Modern Innovations in Breast Surgery: Robotic Breast Surgery and Robotic Breast Reconstruction.

Robotic surgery has a history of applications in multiple surgical areas and has been applied in plastic surgery over the past decade. Robotic surgery allows for minimal access incisions and decreased donor site morbidity in breast extirpative surgery, breast reconstruction, and lymphedema surgery. Although a learning curve exists for the use of this technology, it can be safely applied with careful preoperative planning. Robotic nipple-sparing mastectomy may be combined with either robotic alloplastic or robotic autologous reconstruction in the appropriate patient.

The effect of local anaesthetic on delayed bleeding in a epigastric flap model of rats.

OBJECTIVE: Local anaesthetics are often used in plastic surgery practice. Through their mechanism of action, local anaesthetics produce a sympathetic blockage with a subsequent vasodilatation and a resulting local increase of perfusion. The effect of vasodilation of the local anaesthetics causes bleeding locally resulting in haematoma, bruising and/or pain. We present an experimental study of the effects of local anaesthetics on delayed bleeding. METHOD: In this animal study, 36 adult male Wistar rats were divided into four groups of nine animals: lidocaine; lidocaine and epinephrine; bupivacaine; and control. An epigastric flap model was harvested. Local anaesthetics that are frequently used in daily practice were administered in equal amounts to the harvested flap. RESULTS: After 24 hours, the rats were euthanised to collect and measure all coagula under the epigastric flap. No statistically significant differences in relation to the amount of coagulum were found between the groups. CONCLUSION: Our results suggest that proper haemostasis is achieved, there is no difference on the effect of delayed bleeding between the local anaesthetics which are often used.

Microsurgical Tissue Transfer in Breast Reconstruction.

Autologous breast reconstructions have grown in popularity because of their durability, aesthetic outcomes, symmetry, increase in external beam radiotherapy use, and potential aesthetic enhancement at the donor site. Increasing patient expectations for predictable high aesthetic outcomes with minimal complications or need for further procedures has been met by refinement in the use of flaps. The authors' microsurgical breast reconstruction center aims to provide this while delivering efficient service. The deep inferior epigastric flaps form 85% and transverse upper gracilis and profunda artery perforator flaps account for 10%; lumbar artery perforator flaps are a new addition to the authors' armamentarium.

Microsurgical Tissue Transfer in Breast Reconstruction.

Autologous breast reconstructions have grown in popularity because of their durability, aesthetic outcomes, symmetry, increase in external beam radiotherapy use, and potential aesthetic enhancement at the donor site. Increasing patient expectations for predictable high aesthetic outcomes with minimal complications or need for further procedures has been met by refinement in the use of flaps. The authors' microsurgical breast reconstruction center aims to provide this while delivering efficient service. The deep inferior epigastric flaps form 85% and transverse upper gracilis and profunda artery perforator flaps account for 10%; lumbar artery perforator flaps are a new addition to the authors' armamentarium.

Calculation of contraction patterns in rat skin flap model.

INTRODUCTION: In this study rat abdominal skin flaps were observed daily to explain their contraction behavior and a mathematical formula has been developed. METHODS: 24 male rats were used for the study. Abdominal skin flaps based on the inferior epigastric neurovascular bundles were raised. In the first group all flaps were sutured to their donor area without any extra physical or chemical interference. In the second groups steroid was applied under the flaps to change the contraction rate. RESULTS: Contraction rate was significantly higher in necrotic tissues in both groups. A formula was used to correct for the contraction. The corrected results for the seventh day necrotic area percentage measurements were significantly higher than actual measurements. (p = 0.0001). CONCLUSIONS: By using the mathematical formula developed in this study, pre-contraction value of the experimental skin flaps can be achieved and the results can be interpreted more accurately.

Evaluation of scar penetrating neovascularisation in a rat epigastric flap model.

AIM: The aim of this study is to investigate neovascularisation patterns in the presence of scar tissue and to compare the venous vs arterial components of the scar penetrating neovascularisation. METHODS: Forty male Spraque-Dawley Rats, which were divided into four groups, were used for this study. At the beginning of the study a vertical midline abdominal incision was made to all animals. Six weeks after the incisions were made, epigastric flaps based on inferior epigastric vessels were raised. In the first group both left and right epigastric artery and veins were protected. In the second group only the right epigastric artery and vein was protected. In the third group, besides the right epigastric artery and vein, only the left epigastric artery was kept intact. In the fourth group, besides the right epigastric artery and vein, only the left epigastric vein was kept intact. RESULTS: The percentages of necrotic areas on the flaps were statistically evaluated. The percentages of the necrotic areas on the left side of the flaps were significantly higher in the second group (p = 0.0305). Total flap area necrosis was also significantly higher in the second group (p = 0.026). In each group, vessel formations were identified which were extending through the midline scar tissue in the angiographic evaluations. CONCLUSIONS: These results suggest that scar penetrating neovascularisation on an epigastric flap with one sided pedicle, which is supported by a vein or an artery on the contralateral side, can be enough to facilitate the flap circulation.

Perforator flaps--how many perforators are necessary to keep a flap alive?

Perforator flaps are becoming increasingly important in reconstructive microsurgery because of their reduced donor-site morbidity. However, one drawback is partial necrosis caused by vasospasm or inconsistency of delicate perforator vessels. In this study we have evaluated the number and capacity of perforator vessels with respect to the size of a flap, and the influence of vascular endothelial growth factor (VEGF) on the capacity of perforators in a standard animal model. We realised an epigastric perforator flap 4cm×7cm in 36 rats. In 3 control groups (n=6 in each), flaps were raised based on 4, 2, or 1 perforator vessel(s), while all other perforators as well as the epigastric vessels were ligated. In three study groups (n=6 in each), set up in the same way as the control groups, we also injected a single dose of VEGF into the wound area. After one week, all areas of necrosis were assessed planimetrically. We also evaluated the wounds by laser Doppler flowmetry preoperatively and after one week, and by histological and immunohistochemical examination. An increased number of perforators, together with VEGF, was associated with a significant reduction in the areas of necrosis. This observation was particularly true in flaps based on only one perforator. The inclusion of additional perforators has a more important role in the success of a flap than theoretical models suggest. Proangiogenetic factors may improve the viability of perforator flaps.

The influence of different VEGF administration protocols on the perfusion of epigastric flaps in rats.

In this study we investigated the impact of the time at which vascular endothelial growth factor (VEGF) was given on the overall survival of flaps and time of the achievement of full perfusion in the rat epigastric flap model. Epigastric flaps were raised in 144 rats. VEGF was given to 108 rats at different time points. Perioperatively blood flow, velocity, haemoglobin (Hb) concentration, and oxygen saturation were measured non-invasively using laser-Doppler spectrophotometry. On postoperative days 3, 5, 7, or 10, the pedicle of the flap was ligated. One week later, the flap was harvested for immunohistochemical assessment of the density of microvessels. Differences significant from those in the control group were found in all specimens 3 and 5 days after the first operation, whereas no differences in the area of necrosis were detected after 7 and 10 days. Preoperative values of measured Hb (p<0.0001, 95% confidence interval (CI) 0.57 to 1.02), flow (p<0.0001, 95% CI -0.32 to -0.13), and velocity (p<0.0001, 95% CI 0.48 to 1.89) predicted necrosis. After ligation of the pedicle, SO2 (p<0.0001, 95% CI -1.12 to -0.83) and flow (p<0.0001, 95% CI -0.38 to -0.26) were prognostic factors. The topical use of VEGF increases overall survival of flaps and decreases the time needed for a free flap to achieve full perfusion. The time of application of VEGF has no part in the postoperative course. The perfusion of vascularised free flaps in their wound beds was achieved between postoperative days 5 and 7 in the control group and postoperative days 3 and 5 after VEGF had been given.

Pre-expanded epigastric flap cover for ventral hernia following fungal necrotizing fascitis of caesarian section wound: An unusual complication.

INTRODUCTION: Reconstruction of anterior abdominal wall after necrotizing abdominal wall infections is a challenge. MATERIAL AND METHODS: A 35-year-old lady presented with 20 × 18 cm sized defect of the anterior abdominal wall following fungal necrotizing fascitis. The defect was covered by an overlay prolene mesh and the soft tissue deficit was corrected by pre-expanded epigastric flap based on the superior epigastric artery. CONCLUSION: A concerted multi-specialty effort is needed to correct these defects.

Estudo da isquemia e reperfusão em retalhos cutâneos de ratos

INTRODUCTION: Multiple factors have been implicated in the pathogenesis of reperfusion injury in the skin, including the reactive oxygen species. OBJECTIVE: The aim was to evaluate the effect of reperfusion injury in the rat skin flap evaluated by tissue assay for malonyldialdehyde (MDA) and xanthine oxidase (XO). METHODS: 8 Wistar rats were used, between 300-400g weight and two identical epigastric flaps were raised in each animal (control and experiment), the vasculature of one flap was left intact and in the second flap the arterial pedicle was clamped for 16 hours and reperfused for 45 minutes. Skin samples were obtained from each flap after these periods of time and submitted to MDA and XO analysis. RESULTS: Reperfused flaps had significantly increased MDA and XO values compared to the control flaps biopsies. CONCLUSION: The lipid peroxidation levels were higher in the rat epigastric skin flaps subjected to 16 hours of ischemia and 45 minutes of reperfusion.

INTRODUÇÃO: Múltiplos fatores têm sido implicados na patogênese da lesão de isquemia/reperfusão da pele, incluindo as espécies reativas de oxigênio. OBJETIVO: Estudar a lesão de isquemia/reperfusão em retalhos cutâneos de ratos avaliando os níveis teciduais do malonildialdeído (MDA) e xantina oxidase (XO). MÉTODOS: Foram utilizados 8 ratos Wistar, com peso entre 300 - 400g, sendo confeccionados 2 retalhos epigástricos por animal (controle e experimento), um deles submetido à 16h de isquemia (RI) seguida de 45 min de reperfusão (RR) e o outro controle (RC). Foram colhidas 3 biópsias de pele dos retalhos (RC, RI, RR) e encaminhadas para dosagem de MDA e XO. RESULTADOS: A análise bioquímica mostrou aumento significativo dos níveis teciduais de MDA e XO após a reperfusão em relação aos retalhos controles. CONCLUSÃO: Retalhos epigástricos de ratos submetidos à 16h de isquemia e 45min de reperfusão apresentam elevação dos níveis teciduais de MDA e XO, caracterizando a lipoperoxidação da membrana celular.