| 1. |
- Acosta, Rafael, et al.
(author)
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A Clinical Review of 9 Years of Free Perforator Flap Breast Reconstructions : An Analysis of 675 Flaps and the Influence of New Techniques on Clinical Practice
- 2011
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In: Journal of reconstructive microsurgery. - : Georg Thieme Verlag KG. - 0743-684X .- 1098-8947. ; 27:2, s. 91-98
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Research review (peer-reviewed)abstract
- The aim of this study is to review our 9-year experience with deep inferior epigastric perforator (DIEP) breast reconstructions to help others more easily overcome the pitfalls we experienced. A chart review was conducted for all 543 patients who had 622 DIEP breast reconstructions in our clinic between January 2000 and January 2009. In this time, there were an additional 28 superior gluteal artery perforator and 25 superficial inferior epigastric artery reconstructions, bringing the total free flap reconstructions to 675. In the early years, the success rate was 90.7%, the average operative time was 7 hours and 18 minutes, and the complication rate was 33.3%; these have improved to 98.2%, 4 hours and 8 minutes, and 19.3%, respectively. We describe our selection criteria, preoperative vascular mapping, surgical techniques, and postoperative monitoring as they relate to these improvements in outcome, operative time, and complications. The DIEP flap is a safe and reliable option in breast reconstructions. By acquiring experience with the flap and introducing new and improving existing techniques we have improved the ease of the procedure and the success rate and have shortened the operative time.
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| 2. |
- Acosta, Rafael, et al.
(author)
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Performing two DIEP flaps in a working day : an achievable and reproducible practice
- 2010
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In: Journal of Plastic, Reconstructive and Aesthetic Surgery. - : Elsevier BV. - 1748-6815. ; 63:4, s. 648-654
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Journal article (peer-reviewed)abstract
- Background: While the deep inferior epigastric artery perforator (DIEP) flap is a reliable technique for autologous breast reconstruction, the meticulous dissection of perforators may require lengthy operative times. In our unit, we have performed 600 free flaps for breast reconstruction over 8 years and have reduced operative times with a combination of preoperative computed tomographic angiography (CTA), various anastomotic techniques and the Cook-Swartz implantable Doppler probe for perfusion monitoring. We sought to assess the feasibility of performing two DIEP flaps within the working hours of a single day. Methods: A review of 101 consecutive patients undergoing DIEP flap breast reconstruction in a 12-month period was performed, comparing one DIEP flap per day (n=43) to two DIEP flaps per day (n=58). Complications, outcomes and techniques used were critically analysed. For cases of two DIEP flaps per day, a comparison was made between the use of two separate operating theatres (n=44) and a single consecutive theatre (n=14). Results: Complications did not increase when two DIEP flaps were performed in a single working day. The use of vascular closure staple (VCS) sutures and ring couplers resulted in statistically significant reductions in anastomotic times. The use of two separate theatres for performing two DIEP flaps resulted in a reduction of 59 min in operative time per case (p=0.004). Conclusion: Two DIEP flaps can be safely and routinely performed within the hours of a single working day. By minimising operative times, these techniques can improve productivity and substantially decrease surgeon fatigue.
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| 3. |
- Audolfsson, Thorir, et al.
(author)
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Nerve Transfers for Facial Transplantation : a cadaveric study for motor and sensory restoration
- 2013
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In: Plastic and reconstructive surgery (1963). - 0032-1052 .- 1529-4242. ; 131:6, s. 1231-1240
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Journal article (peer-reviewed)abstract
- BACKGROUNDRestoration of facial animation and sensation are highly important for the outcome after facial allotransplantation. The identification of healthy nerves for neurotization, through recipient to donor nerve coaptation, is of particular importance for successful nerve regeneration within the allograft. However, due to the severity of the initial injury and resultant scar formation, a lack of healthy nerve stumps in the recipient is a commonly encountered problem. In this study, we evaluate the technical feasibility of performing nerve transfers in facial transplantation for both sensory and motor neurotization.METHODSFifteen fresh cadaver heads were used in this study. The study was divided in two parts. First, the technical feasibility of nerve transfer from the cervical plexus (CP) to the mental nerve (MN) and the masseter nerve (MaN) to the buccal branches of the facial nerve (BBFN) was assessed. Next, we performed nerve transfers in simulated face transplants to describe the surgical technique focusing on sensory restoration of the midface and upper lip by neurotization of the infraorbital nerve (ION), sensory restoration of the lower lip by neurotization of the MN, and smile reanimation by neurotization of the BBFN.RESULTSIn all specimens coaptation of at least one of branches of the CP to the mental nerve was possible as well as between the masseter nerve to the buccal branch of the facial nerve. In simulated face transplant procedures nerve transfers of the supraorbital nerve (SON) to the infraorbital nerve (ION), cervical plexus branches to the mental nerve, and masseter nerve to facial nerve are all technically possible.CONCLUSIONNerve transfers are a technically feasible option that could theoretically be used in face transplantation either as a primary nerve reconstruction when there are no available healthy nerves, or as a secondary procedure for enhancement of functional outcomes. The supraorbital nerve, branches of the cervical plexus and the masseter nerve are nerves usually located out of the zone of injury and can be selected as neurotizers for the infraorbital nerve, mental nerve and buccal branch of the facial nerve respectively.
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| 4. |
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| 5. |
- Darcy, Catharine M., et al.
(author)
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Surgical technique : The intercostal space approach to the internal mammary vessels in 463 microvascular breast reconstructions
- 2011
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In: Journal of Plastic, Reconstructive and Aesthetic Surgery. - : Elsevier BV. - 1748-6815. ; 64:1, s. 58-62
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Journal article (peer-reviewed)abstract
- The internal mammary vessels are one of the most frequently used recipient sites for microsurgical free-flap breast reconstruction, and an accepted technique to expose these vessels involves removal of a segment of costal cartilage of the rib. However, in some patients, cartilage removal may result in a visible medial chest-wall depression that requires corrective procedures. We, therefore, use an intercostal space approach to the internal mammary vessels, as there is minimal disturbance of the costal cartilage with this technique. We have developed and performed our technique over an 8-year period in 463 microvascular breast reconstructions, and present it here as it contains modifications not previously described that may be of interest to other surgeons. There was no serious morbidity associated with the intercostal space approach, the internal mammary vessels were reliably and safely exposed in all these cases and the flap success rate was 95.8%.
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| 6. |
- Enajat, Morteza, et al.
(author)
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Aesthetic Refinements and Reoperative Procedures Following 370 Consecutive DIEP and SIEA Flap Breast Reconstructions : Important Considerations for Patient Consent
- 2010
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In: Aesthetic Plastic Surgery. - : Springer Science and Business Media LLC. - 0364-216X .- 1432-5241. ; 34:3, s. 306-312
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Journal article (peer-reviewed)abstract
- Breast reconstruction often requires multiple operations. In addition to potential complications requiring reoperation, additional procedures are frequently essential in order to complete the reconstructive process, with aesthetic outcome and breast symmetry shown to be the most important factors in patient satisfaction. Despite the importance of these reoperations in decision-making and the consent process, a thorough review of the need for such operations has not been definitively explored. A review of 370 consecutive autologous breast reconstructions (326 patients) was undertaken, comprising 365 deep inferior epigastric artery perforator (DIEP) flaps and 5 superficial inferior epigastric artery (SIEA) flaps. The need for additional procedures for either complications or aesthetic refinement following initial breast reconstruction was assessed. Overall, there was an average of 1.06 additional interventions for every patient carried out after primary reconstructive surgery. Of 326 patients, 46 underwent early postoperative operations for surgical complications (0.17 additional operations per patient as a consequence of complications). Procedures for aesthetic refinement included those performed on the reconstructed breast, contralateral breast, or abdominal donor site. Procedures for aesthetic refinement included nipple reconstruction, nipple-areola complex tattooing, dog-ear correction, liposuction, lipofilling, scar revision, mastopexy, and reduction mammaplasty. While DIEP flap surgery for breast reconstruction provides favorable results, patients frequently require additional procedures to improve aesthetic outcomes. The need for reoperation is an important part of the consent process prior to reconstructive surgery, and patients should recognize the likelihood of at least one additional procedure following initial reconstruction.
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| 7. |
- Enajat, Morteza, et al.
(author)
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How long are fasciocutaneous flaps dependant on their vascular pedicle : A unique case of SIEA flap survival
- 2010
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In: Journal of Plastic, Reconstructive and Aesthetic Surgery. - : Elsevier BV. - 1748-6815. ; 63:4, s. E347-E350
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Journal article (peer-reviewed)abstract
- Background: While it has long been held that muscle flaps maintain their dependency on their vascular pedicle for the long term, fasciocutaneous flaps have been less well investigated. Recent studies of the deep inferior epigastric artery perforator (DIEP) flap have suggested that these flaps may maintain long term dependence on their vascular pedicles for survival. There is no literature concerning these effects in the superficial inferior epigastric artery (SIEA) flap. Case report: We describe a unique case in which the pedicle of a superficial inferior epigastric artery (SIEA) flap for breast reconstruction was avulsed 11 days postoperatively, with the flap surviving on its inferior wound edge alone. Conclusion: Fasciocutaneous flaps may lose dependency on their vascular pedicles in the short term following transfer, developing alternative pathways for vascular supply and ultimately survival. A conservative approach early in the course of flap compromise due to perforator ligation or avulsion, in cases where immediate re-anastomosis may not be feasible, is thus supported.
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| 8. |
- Lorenzo, Andres Rodriguez, et al.
(author)
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Acute transfer of superficial radial nerve to the medial nerve : Case Report
- 2012
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In: Annals of Plastic Surgery. - 0148-7043 .- 1536-3708. ; 69:5, s. 547-549
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Journal article (peer-reviewed)abstract
- Distal nerve transfers have proven to be an important addition to the armamentarium for reconstruction of peripheral nerve injuries. As new nerve transfer procedures are developed, the indications for their use continue to broaden. We report a case of a 77 year-old male who had a 9 centimeters long gap of the median nerve after suffering from an avulsion injury to his right forearm. This was successfully treated by transferring superficial radial nerve to the median nerve at the carpal tunnel level, thus restoring thumb, index and first web sensation. Our report emphasizes that nerve transfers in the emergency setting may be the treatment of first choice in cases were conventional nerve grafting is known to result in poorer outcomes such as in long nerve gaps or in the elderly patient population.
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| 9. |
- Rodriguez-Lorenzo, Andres, et al.
(author)
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Superficial peroneal and sural nerve transfer to tibial nerve for restoration of plantar sensation after complex injuries of the tibial nerve: cadaver feasibility study.
- 2011
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In: Journal of plastic, reconstructive & aesthetic surgery : JPRAS. - : Elsevier BV. - 1878-0539 .- 1748-6815. ; 64:11, s. 1512-6
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Journal article (peer-reviewed)abstract
- Nerve reconstruction following lower-extremity nerve injuries usually leads to worse outcomes in comparison with upper-extremity injuries due to the long distances of nerve regeneration. This study was performed to consider the clinical application of distal nerve transfer for the treatment of long gaps of the tibial nerve (TN) and in established compartment syndrome. It aimed to determine the anatomic suitability of transferring the sural nerve (SN) in combination with the superficial peroneal nerve (SPN) to the TN at the level of the tarsal tunnel for restoration of plantar sensation.Nine fresh above-knee amputated limbs were dissected with the aid of loupe magnification. We focussed on the detailed anatomy of the course of the SN and the SPN from its emergence proximally at the knee level to the foot. Two different regions, suprafascial and subfascial, were described for each nerve. The maximum length of dissection and the length of the nerves in each region were measured. In all dissections, we assessed the feasibility of directly transferring the SN and SPN to the TN at the level of the tarsal tunnel.The average length of the course of the SN was 20.6 cm (SD ± 2.3 cm) subfascially and 16.4 cm (SD ± 0.9 cm) suprafascially. For the SPN, the average length was 19.4 cm (SD ± 1.9 cm) subfascially and 18 cm (SD ± 2.5 cm) suprafascially. The point of emergence of the nerve from the subfascial course to the suprafascial course was defined as the pivot point for its transfer to the TN. Both the SN and the SPN reached the TN comfortably at the level of the tarsal tunnel, allowing direct co-aptation.Distal nerve transfer using the SN in combination with the SPN is an anatomically reliable procedure, being a potential alternative to the use of nerve grafts in reconstruction of long gaps of the TN. In addition, selected patients with compartment syndrome may also benefit from this transfer to restore plantar sensation.
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| 10. |
- Rodriguez Lorenzo, Andres, et al.
(author)
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Supraorbitary to infraorbitary nerve transfer for restoration of midface sensation in face transplantation : cadaver feasibility study
- 2012
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In: Microsurgery. - : Wiley. - 0738-1085 .- 1098-2752. ; 32:4, s. 309-313
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Journal article (peer-reviewed)abstract
- Background: The collected experience from facial allotransplantations has shown that the recovery of sensory function of the face graft is unpredictable. Unavailability of healthy donor nerves, especially in central face defects may contribute to this fact. Herein, the technical feasibility of transferring the supraorbitary nerve (SO) to the infraorbitary nerve (IO) in a model of central facial transplantation was investigated. Methods: Five heads from fresh cadavers were dissected with the aid of 3× loupe magnification. Measurements of the maximum length of dissection of the SO nerve through a supraciliary incision and the IO nerve from the skin of the facial flap to the infraorbital foramen were performed. The distance between supraorbital and infraorbital foramens and the calibers of both nerves were also measured. In all dissections, we simulated a central allotransplantation procedure and assessed the feasibility of directly transferring the SO to the IO nerve. Results: The average maximum length of dissection for the IO and SO nerve was 1.4 ± 0.3 cm and 4.5 ± 1.0 cm, respectively. The average distance between the infraorbital and supraorbital foramina was 4.6 ± 0.3 cm. The average calibers of the nerves were of 1.1 ± 0.2 mm for the SO nerve and 2.9 ± 0.4 mm for the IO nerve. We were able to perform tension-free SO to IO nerve coaptations in all specimens. Conclusion: SO to IO nerve transfer is an anatomically feasible procedure in central facial allotransplantation. This technique could be used to improve the restoration of midfacial sensation by the use of a healthy recipient nerve in case of the recipient IO nerves are not available secondary to high-energy trauma.
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