Breast reconstruction with a transverse abdominal island flap

A rectus abdominis musculocutaneous island flap for breast reconstruction following mastectomy is presented. The vascular anatomy of the abdominal wall has been clinically studied in patients undergoing abdominal lipectomy. Cadaver dissections are shown, demonstrating the anatomy, arc of rotation, and design alternatives of the rectus abdominis flap. The surgical technique is demonstrated and representative patients are shown.

The transverse abdominal island flap: part I. Indications, contraindications, results, and complications

The transverse abdominal island flap is not just another myocutaneous flap. Although it derives its blood supply from myocutaneous perforators, the portion of the skin and fat that overlies muscle comprises only about 20% of its surface. The surface area of the flap by far exceeds the surface area of the entire muscle that carries it. Its hemodynamics are more complicated than usual and consist of delicate communications between the superior and inferior deep epigastric systems and the deep and superficial epigastric systems across the midline. Its use in breast reconstruction has been as exciting as it is complex. We describe our experience with 60 consecutive patients and 65 transverse abdominal island flaps.

The "reverse" latissimus dorsi muscle and musculocutaneous flap: anatomical and clinical considerations

A "reverse," posteriorly based transposition of a latissimus dorsi musculocutaneous flap on its segmental blood supply is presented. This adds new possibilities to this versatile and reliable musculocutaneous unit. The variable modes of blood supply to the musculocutaneous units are discussed, and the question of the strategic vascular and neurosympathetic delays are raised.

The flexor digitorum brevis muscle island pedicle flap: a new dimension in heel reconstruction

A modality is presented by which the flexor digitorum brevis muscle, with or without its overlying skin, can be transposed for soft tissue coverage of the heel area. Surgical anatomy, cadaver dissection, operative technique, and our clinical experience in six patients are presented.

Clinical trials of amniotic membranes in burn wound care

Four test conditions of increasing complexity were used to evaluate the clinical efficacy of amniotic membranes as biologic dressings on donor sites and burn wounds in children. These were the clean-skin donor-site wound, the uncontaminated shallow partial-thickness burn wound, the bed of freshly excised full-thickness wounds, and the granulating surface of colonized burn wounds. The rate of epithelialization under amniotic membranes was the same as that under 5% scarlet red ointment or 0.5% silver nitrate solution dressings. Preservation of a healthy excised wound bed and maintenance of a low bacterial count in contaminated wounds paralleled the experience with human allograft dressings despite technical difficulties and the absence of vascularization of amniotic membrane and its fragile structure. Tentative conclusions are drawn as to the mechanisms by which biologic dressings exert their beneficial effects.

Benefits and Limitations of Macrotextured Breast Implants and Consensus Recommendations for Optimizing Their Effectiveness

Implant texture is an important factor influencing implant selection for breast augmentation. Natrelle Biocell implants are characterized by macrotextured shell surfaces containing irregularly arranged concavities with large open-pore diameters and depths. These properties facilitate adhesion of the implant to the surrounding tissue, thereby promoting implant immobilization. Relative to implants with other surfaces, macrotextured implants offer low rates of capsular contracture; low rates of malposition, rotation, and rippling; and high rates of patient satisfaction. However, macrotextured implants are associated with a slightly higher risk of double capsule and late seroma. The surgeon can minimize these risks with straightforward techniques that encourage tissue adhesion. This report presents experience-based recommendations to optimize the effectiveness of Biocell anatomic implants. The authors discuss the application of best practices to all aspects of the breast implantation process, from implant selection and surgical planning to operative technique and postoperative management. LEVEL OF EVIDENCE 3.

Comparative double blind clinical study on round versus shaped cohesive gel implants

BACKGROUND

Highly cohesive round or shaped implants are used today by most plastic surgeons performing breast augmentation outside North America.

OBJECTIVES

This study was conducted to (1) compare aesthetic outcomes of round versus shaped implants in breast augmentation by defining the preferences of the general female population and plastic surgeons towards two groups of augmented breasts (implanted with either round or shaped devices); and (2) to determine whether or not plastic surgeons could identify the type of implant used in each patient based on the postoperative appearance.

METHODS

The study surveyed 30 breast augmentation patients, 15 with shaped implants and 15 with round devices. Two cohort categories evaluated the postoperative photographs of the patients: the first group comprised 235 female lay respondents and the second group included 11 male plastic surgeons. The lay respondents were asked to score breast beauty and naturalness, and to assess the upper pole. The plastic surgeons were asked similar questions and were additionally asked to try to identify the implant type.

RESULTS

With respect to "breast beauty," both respondent categories scored round and shaped implant patients similarly. With regard to "naturalness," both groups scored round implant patients significantly higher (P < .001). Concerning upper pole assessment, the round implant group was scored higher and better than the shaped implant group (P < .001). The plastic surgeons' correct identification rate was 64% for round implants, and 47% for shaped implants.

CONCLUSIONS

We believe that in the hands of an experienced surgeon who takes all soft tissue variables into consideration, the aesthetic result may not be differentiable when using round versus shaped implants in well-selected patients.

Cellular Optimization of Nanofat: Comparison of Two Nanofat Processing Devices in Terms of Cell Count and Viability

Background

Nanofat was introduced by Tonnard and Verpaele in 2013. Their initial observations in intradermal applications showed improvement in the appearance of the skin. Since then, a number of Nanofat devices have been introduced. The cellular content in the processing of Nanofat is not the same in every device, yet the cellular composition is responsible for the biologic action of Nanofat. The authors sought to find a different means to produce a matrix rich Nanofat to optimize the cellular content.

Objectives

The primary objective of this study was to compare cell counts, cultures, and cell viabilities produced by LipocubeNano (Lipocube, Inc., London, UK) in comparison to Tulip’s NanoTransfer (Tulip Medical, San Diego, CA) processing methods.

Methods

Twenty milliliters of fat were harvested from 10 patients in order to test two methods of Nanofat production. Ten milliliters of fat were used to assess each method and, after the final product was obtained, enzymatic digestion for stromal vascular fraction (SVF) isolation was performed. A Muse Flow-cytometer was used to measure cell counts and cell viabilities, cell cultures were performed, and cell images were taken with a florescent microscope.

Results

The LipocubeNano was shown to be superior to Tulip’s NanoTransfer system of progressive downsizing with final filtering, which appeared to trap more fibrous tissue leading to lower amounts of SVF. LipocubeNano resulted in higher cell counts (2.24 × 10⁶/cc), whereas Tulip’s NanoTransfer method resulted in a lower cell count at 1.44 × 10⁶/cc. Cell viability was the same (96.05%) in both groups.

Conclusions

Nanofat from LipocubeNano has a higher regenerative cell count and more SVF cells than the other common mechanical method of Nanofat processing. This new means of mechanical processing preserves more matrix, optimizing the cellular content of the Nanofat, thus having potentially a higher regenerative effect.

Level of Evidence: 5

Meningomyelocele closure with distally based latissimus dorsi flap

Our experience with the distally based latissimus dorsi flap in 12 patients (7 primary closures and 5 secondary procedures) indicates that it is an extremely reliable and useful flap in this setting. It provides coverage of the dural repair with viable soft tissues under a minimum of tension. The suture lines are distant from the dural closure, the donor defect closes primarily, and in the event of a complete failure, the contralateral latissimus dorsi remains available. In those cases of meningomyelocele where direct primary closure is not possible, we view this as the procedure of choice.

Ultrasonically assisted lipectomy in aesthetic breast surgery

A case report of a young patient with marked asymmetry treated successfully with ultrasonically assisted lipectomy with a good functional cosmetic result, undetectable scars, and mammographic control and showing no ill-effect on the breast parenchyma is presented. Further studies and follow-up are needed to confirm the value and advisability of using ultrasonic energy in the female breast.

Combined erbium:YAG laser resurfacing and face lifting

Facial aging occurs secondary to gravity-induced tissue ptosis and photoaging. Combined face lifting and carbon dioxide laser resurfacing provides a comprehensive one-stage approach to facial rejuvenation but is condemned by many plastic surgeons due to the nonspecific thermal effects of the laser and risk of skin necrosis. Newer high-energy erbium:YAG lasers allow precise tissue ablation with minimal thermal effect. In this study, various facial rejuvenation techniques were combined with simultaneous erbium:YAG laser resurfacing to assess results and complications. A total of 257 patients from Florida, Melbourne, Australia, and Tel Aviv, Israel, underwent combined erbium:YAG laser resurfacing and surgical facial rejuvenation. Various face-lift methods were used, including endoscopic, deep plane, and subcutaneous. Simultaneous, full-facial laser resurfacing was performed using a variety of erbium:YAG lasers. It was found that combined laser resurfacing and face lifting was successful in greater than 95 percent of patients with minimal morbidity. Two patients (1 percent) (both heavy smokers) developed small areas of skin necrosis that healed with minor pigment changes. Five patients (2 percent) developed synechia that was treated with no residual effect. Two additional patients (1 percent) developed temporary ectropion. There were no other cases of scarring, infection, or cosmetically obvious hypopigmentation. Although larger studies are necessary, it seems that the lack of thermal injury from the erbium:YAG laser makes it possible to safely perform laser resurfacing with surgical facial rejuvenation in nonsmokers. However, the authors caution that familiarity with the nuances of erbium:YAG laser resurfacing be obtained before performing combined laser resurfacing and face lifting.

The subperiosteal bicoronal approach to total facelifting: the DMAS--deep musculoaponeurotic system

Craniofacial surgery, developed by Paul Tessier, has shown that subperiosteal undermining and lifting of the soft tissues of the upper two-thirds of the face results in an excellent and long-lasting rejuvenated look to the entire face. The result is significantly more durable and longer lasting than the classic subcutaneous facelift reinforced with SMAS plication, transposition, and shortening. The authors--three surgeons working independently--are convinced that we have entered a new era in facelift procedures. We decided to combine our experiences which total 250 patients with followups of 6 months to 6 years.

Surgical management of heel ulcers--a comprehensive approach

Reconstruction of the ankle, heel, and foot remains a challenging, often frustrating problem for surgeon and patient alike. Little local soft tissue is available for the reconstruction, and often the underlying disorder precludes use of some procedures. The ankle and the heel are vital musculoskeletal structures, responsible for shock absorption, weight-bearing, and locomotion, and their dysfunction inflicts discomfort and disability on the individual that commonly lasts many months or even over a year. Soft tissue defects on the weight-bearing versus the nonweight-bearing surfaces present two quite different problems. Many surgical modalities, beginning with a skin graft and ending with microvascular transplantation of sensile tissues, are now available to the reconstructive surgeon for resurfacing the sole of the foot. We present a classification of heel ulcers based on their etiology, location, size, and the status of the peripheral circulation; offer new operative modalities and update the operations already available; and suggest an orderly approach to selecting an operation for reconstructing the foot.

Bilateral cleft lip repair: "putting it all together"

The surgical repair of the bilateral cleft lip should take into consideration restoration of normal anatomy throughout the lip. If it is well done, it contributes to both form and function. A composite technique is presented here, with additions taking advantage of all tissues and based on this principle. Preoperative orthodontic preparation is used to achieve more satisfactory spatial relationships when appropriate and to permit a one-stage repair without lip adhesions. The technical aspects are clearly outlined and supported by case presentations. The technique saves all tissue; avoids tightness; provides good muscular function; constructs a labial sulcus providing for proper movement of the lip; provides good nasal sills and floors; is adaptable to complete or incomplete clefts; can be easily revised or used for secondary revisions in other cases, and so on.

Pancreaticoduodenal artery aneurysm simulating carcinoma of the head of the pancreas

Aneurysms of the pancreaticoduodenal arcades, although uncommon, may rupture and produce symptoms similar to those of pancreatic carcinoma. We describe one patient with a ruptured interior pancreaticoduodenal artery aneurysm and a large hematoma in the pancreatic head. He had a three-week history of painless jaundice. Angiography was essential in establishing the diagnosis and defining a vascular road map preoperatively. The surgical management involved resection of the aneurysm and vascular reconstruction.

Brow lift for the correction of visual field impairment

BACKGROUND

Eyebrow ptosis and hooding gives the eye a sad, heavy look that often disturbs the visual field.

OBJECTIVE

A direct extended scalpel-shaped brow lift is proposed to correct this functional and aesthetic disfigurement. This manuscript reviews our experience with the presented technique and evaluates the clinical results in the light of ongoing concerns regarding the appearance of the postoperative scar. In addition, the indications and patient selection criteria are elaborated.

METHODS

An incision was made along the superior border of the brow, extending laterally and downward, often within a "crow's feet" crease. The upper border of the incision joined the 2 extremities of the skin outline of the lower incision in a gentle convex curve. The general outline of the incision resembled the shape of a No. 20 scalpel blade, in which the maximal width is located laterally at the temple "crow's feet" area.

RESULTS

Fourteen patients, including 8 males (48-74 yrs of age) and 6 females (67-71 yrs of age) underwent this procedure. The surgical scar was hardly noticeable after 6 to 9 months, and often fell within a preexisting crow's feet crease. Elimination of some of the crow's feet occurred in all the patients. Subjective and objective functional relief with respect to the vision field and the heavy-feeling brow and satisfaction with the aesthetic result were reported by all patients.

CONCLUSIONS

The most appropriate candidates for the direct extended scalpel-shaped brow lift are patients older than 50 years of age, with eyebrow ptosis accompanied with lateral hooding, well developed crow's feet, and forehead skin laxity; long, dense eyebrows, and low transverse forehead wrinkles aid in concealment of the scar.

Meshed Acellular Dermal Matrix in Immediate Prepectoral Implant-based Breast Reconstruction

Prepectoral implant placement has many potential advantages in immediate breast reconstruction. Acellular dermal matrices (ADMs) are commonly used in these surgeries. ADM meshing may enhance integration, decrease seroma and infection rates, and reduce surgical costs.

METHODS

This was a retrospective, single-center study of 49 women (71 breasts) undergoing immediate, prepectoral, implant-based breast reconstruction with 2:1 meshed, bovine-derived ADM (SurgiMend). Outcomes were compared against those of 77 patients (105 breasts) undergoing a similar procedure but with partial subpectoral implant placement.

RESULTS

In the prepectoral group, the mean age was 49.1 years and mean body mass index was 24.7 kg/m². There were no significant differences in baseline characteristics versus the partial subpectoral control group. Mean follow-up was 18.6 months (prepectoral) and 21.3 months (partial subpectoral). Mean time to drain removal was reduced in the prepectoral group (6.5 versus 8.5 days; P < 0.001). Rates of minor and major complications with prepectoral implant placement were 15.5% and 11.3%, respectively - similar to partial subpectoral placement (15.2% and 14.3%) (overall P = 0.690). Capsular contracture and explantation were associated with radiation therapy, and rates were similar between groups.

CONCLUSIONS

Prepectoral implant placement with meshed ADM is a safe and reproducible alternative to partial muscle coverage with meshed ADM. Recovery may be easier and animation deformity avoided. It could therefore become the standard of care for implant-based breast reconstruction.

The subperiosteal lift

The subperiosteal lift developed by Tessier is a technique for rejuvenating the face and emphasizing beauty. It is performed using two approaches: intraoral and bicoronal or precapillary. It entails a total subperiosteal undermining of the face beginning 2 cm over the orbits and continuing on the orbital rims, the zygomatic arches, and the malar bones. This allows total lifting of the soft tissues of the face (DMAS, deep musculo aponeurotic system). The lateral and vertical traction allows elevation of the superior two thirds of the face, eyebrows, and cheeks. Lifting pulls up from the forehead to the mandibular line. The fixation of the superficial layer of the temporal aponeurosis in traction to the upper part also has an effect on tissue elevation. The best candidates for this procedure are women in their late 30s or early 40s but can be used on those from 30 to 50 and more. It is highly specialized operation which requires substantial surgical experience both in selecting the patient and in execution.

Aesthetic breast surgery: consulting for the future--proposals for improving doctor-patient interactions

This report summarizes the opinions advanced by an international panel of acknowledged expert plastic surgeons convened to discuss women's attitudes about aesthetic breast surgery. To inform the discussions, a survey was undertaken to explore women's attitudes and opinions. The survey showed that significant numbers of women take the initial steps but do not proceed to surgery. This represents a failure to meet the needs of many women who stand to benefit from surgery. It also represents a waste of resources. Cost and fear are important factors, but a crucial consideration for women is whether they can find a surgeon they can trust. The panel recommends using standard consultation procedures, ensuring good clinic organization, managing expectations, dispelling myths, and providing adequate patient education to build trust and contribute to the successful treatment of women who desire breast surgery.

Potential problems with the transverse rectus abdominis myocutaneous flap in breast reconstruction and how to avoid them

The transverse rectus abdominis myocutaneous flap offers a versatile and reliable technique of repair provided certain anatomical, physiological and surgical principles are closely followed. The operative technique and technical details are described and discussed.