[Harvesting method of thoracodorsal perforator flap: Adaptation]. / Technique de prélèvement d'un lambeau perforant thoracodorsal : mise au point.

The thoracodorsal artery perforator (TDAP) flap is a reliable method of reconstruction by which the indications were on a constant rise during the last few years. Several surgical variants exist and different harvesting techniques were described. However, with our experience using this flap for substance-loss coverage, we frequently faced a complex and relatively time-consuming pedicle dissection. This brought us to adapt our harvesting technique according to the anatomical situations of the neighboring structures. The purpose of this study is to revisit and adapt the method of the pedicle dissection for the TDAP flap. The conservation of both the nervous network and a section of a circumferential muscular collar with a diameter of two centimeters are the main keys of our study.

Rectus abdominis muscle innervation: an anatomical study with surgical implications in diep flap harvesting.

PURPOSE: To improve the current knowledge of rectus abdominis innervation, so as to identify a safe area where the vascular pedicle should be dissected to reduce the risk of nerve damage during deep inferior epigastric perforator (DIEP) flap harvesting. METHODS: Ten abdominal wall dissections were performed. Perforating arteries were identified and classified into nerve-related perforators and non-nerve-related perforators depending on the presence of nerve branches crossing vessels. The width of rectus abdominis and the distance between perforators and lateral edge of rectus abdominis muscle were measured. In contralateral hemi-abdomen, full-thickness specimens were sampled for microscopical analysis. RESULTS: Nerves enter the rectus sheath piercing the lateral edge (60% of cases) or the posterolateral surface of the sheath (40% of cases). They enter the rectus abdominis muscle at a mean distance of 4.3 cm from the lateral margin of the sheath. Within rectus abdominis, nerves have a mean thickness of 200.3 µm and split into 2-4 sensitive and 2-4 muscular branches. Close relationship between muscular branches and deep inferior epigastric artery perforators were shown. The mean distance between nerve-related perforators and the lateral edge of the rectus abdominis was of 3.26 ± 0.88 cm. The mean distance between non-nerve-related perforators and the lateral edge of the rectus abdominis was of 6.26 ± 0.90 cm. CONCLUSIONS: To spare nerves and reduce donor-site complications, a perforator located beyond an imaginary line of 3.26 ± 0.88 cm far from the lateral edge of rectus abdominis muscle should be included in the DIEP flap.

Anatomy of the pedicled anterolateral thigh flap for phalloplasty in transitioning-males.

Incidence of transexualism and request for neophalloplasty is increasing yielding a current prevalence of trans-male in the USA of 1:2500. Surgeons have explored various techniques to improve desirable outcomes of neophallic construction, decrease the length of surgery, and minimize stigmatizing scars. The anterolateral thigh (ALT) flap is an alternative to the traditional radial forearm flap for patients who do not want a forearm scar. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Anatomy of the donor and recipient sites as well as the surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. The ALT flap is a skin, fat and fascia flap that is usually supplied by the descending branch of the lateral circumflex femoral vessels and the lateral femoral cutaneous nerve. However, variability in neurovascular supply does exist with important clinical implications. In the pedicled surgical procedure, neurovascular supply is left partly attached to the donor site ("pedicle") and simply transposed to the perineum, keeping the pedicle intact as a conduit to supply the tissue with blood and innervation. ALT flap offers clinical advantages of less obvious donor site concealable with clothing, decreased surgical time, preservation of erogenous sensation and vascular supply of the flap without microsurgical anastomosis of nerves and vessels, and good potential for urethroplasty. This surgery may be difficult in patients with thicker skin and more subcutaneous thigh fat. Clin. Anat, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

Donor Distal, Recipient Proximal and Other Personal Perspectives on Nerve Transfers.

This article presents a personal overview of nerve transfers and emphasizes the various factors that contribute to outcome following these surgeries. There is no "one result" for all nerve transfers. The results will vary depending on factors relating to the donor nerve and the recipient nerve, the degree of the surgical difficulty of the specific procedure, and issues relating to preoperative and postoperative rehabilitation. The general issues that influence all nerve injury and recovery, such as age of the patient, comorbidities, and time since injury, pertain to nerve transfers as well.

Donor Activation Focused Rehabilitation Approach: Maximizing Outcomes After Nerve Transfers.

As nerve transfers become the mainstay in treatment of brachial plexus and isolated nerve injuries, the preoperative and postoperative therapy performed to restore motor function requires continued dedication and appreciation. Through the understanding of the general principles of muscle activation and patient education, the therapist has a unique impact on the return of function in patients with nerve injuries. As surgeons continue to develop novel nerve transfers, the perioperative training, education, and implementation of the donor activation focused rehabilitation approach model is critical to ensure successful outcomes.

Analgesic effect of hamstring block after anterior cruciate ligament reconstruction compared with placebo: a prospective randomized trial.

PURPOSE: To evaluate the effect of a hamstring block for postoperative pain management using 20 mL of 0.25% bupivacaine compared with placebo after anterior cruciate ligament (ACL) reconstruction with a hamstring autograft. METHODS: In a 3-month period, 45 patients undergoing ACL reconstruction with a hamstring autograft who all received a femoral nerve block were randomized to receive either 20 mL of 0.25% bupivacaine or 20 mL of saline water administered through a catheter into the donor-site space. The patients and recovery staff were blinded to the treatment. Postoperative donor-site pain was evaluated subjectively by the patients using a pain score (Likert scale from 0 to 10). The pain was registered for each hour in the first 6 hours and thereafter once daily for 8 days. Furthermore, the requirement for postoperative analgesic medicine was registered. RESULTS: The hamstring block group (n = 23) had significantly less pain for each of the first 6 postoperative hours. The pain score was reduced from 4.2 to 2.3 (95% confidence interval, 1.3 to 3.3) (P = .01) in the first hour and from 2.8 to 1.3 (95% confidence interval, 0.6 to 1.9) in the sixth hour, and there was a significantly lower overall requirement for early postoperative fentanyl, reduced from a mean of 58 to 35 µg (P = .02), and morphine, reduced from a mean of 10 to 6 mg (P = .04). After 6 hours, there was no difference in the pain level and use of analgesics between the 2 groups. CONCLUSIONS: With the use of a donor-site block in hamstring ACL reconstruction, the donor-site pain level, as well as the overall requirement for fentanyl and morphine, was significantly reduced in the first 6 postoperative hours. No effect of the donor-site block was seen after 6 hours. LEVEL OF EVIDENCE: Level I, therapeutic, randomized controlled study.

Versatility of lateral cutaneous branches of intercostal vessels and nerves: anatomical study and clinical application.

The use of the intercostal artery perforator (ICAP) flap has recently become popular in reconstructions of the breast, upper arm and trunk. Lateral cutaneous branches (LCBs) are a group of the ICAPs that penetrate the fascia near the middle axillary line. However, reports on its precise anatomy and clinical applications are quite limited. We performed an anatomical study of LCBs using cadavers. Based on the findings, we developed novel clinical application methods as follows: (1) sensate superficial circumflex iliac perforator (SCIP) flap, (2) supercharged SCIP flap, (3) ICAP-based propeller flap (IBPF) and (4) free ICAP flap based on LCB. LCBs have the following advantages: (1) Long pedicles can be obtained in the supine position without risk of pneumothorax. (2) The neurovascular bundle is consistently available, allowing elevation of sensate flaps. (3) Donor-site morbidity is low. Therefore, we believe that LCBs offer a versatile option in reconstructive surgery.