André Salval

Current indications for and comparative analysis of three different types of latissimus dorsi flaps.

BACKGROUND Free tissue transfer with lower abdominal flaps for autologous breast reconstruction is not suitable for all patients. The latissimus dorsi (LD) musculocutaneous flap is an alternative, effective method for both immediate and delayed breast reconstruction. OBJECTIVES The authors assess their experience with LD flaps for breast reconstruction, including indications for patient selection, donor site choice, aesthetic outcomes, complications, and patient satisfaction. METHODS Charts for all patients who underwent breast reconstruction with one of three types of LD myocutaneous flaps during a three-year period at a single institution were retrospectively reviewed. Patients (n = 82) were divided into three groups: (1) 35 patients received a standard LD myocutaneous flap with implant, (2) 18 patients underwent a muscle sparing LD flap procedure with implant, and (3) 29 patients had an autologous LD flap. A questionnaire was administered to assess flap and donor site complications, aesthetic outcomes, patient satisfaction, and shoulder function. RESULTS Flap complications occurred in 13 patients (15%). Donor site complications occurred in 24 patients (28%), mostly consisting of back seroma with the autologous LD flap. There was no significant difference in shoulder range of motion or muscle strength between the operated and unoperated sides. Patient satisfaction was high in all three study groups. CONCLUSIONS The LD is a safe, versatile, and reproducible technique for breast reconstruction. The procedure benefits from ease of flap harvesting and setting and may provide satisfactory results in diverse patients, including those for whom an abdominal flap is neither indicated nor feasible. .

Human adipose‐derived stem cells: isolation, characterization and applications in surgery

Penelope Jones,* RN, ICU Cert, Grad Dip Epi Karin Leder,† MBBS, FRACP, PhD, MPH Ian J. Woolley,*‡§ MBBS, FRACP Paul Cameron,*§ FRACP, FRCPA, PhD Denis Spelman,*† MBBS, FRACP, FRCPA, MPH *Infectious Diseases Unit, The Alfred Hospital; Departments of †Epidemiology and Preventive Medicine and §Medicine, Monash University, and ‡Department of Infectious Diseases, Monash Medical Centre, Melbourne, Victoria, Australia

Autologous latissimus dorsi flap as an alternative to free abdomen-based flap for breast reconstruction in the morbidly obese.

ence of levator aponeurosis, there were no published studies using elastin stain to identify the levator aponeurosis before our study. We presented our abstract at the 2008 American Society of Ophthalmic Plastic and Reconstructive Surgery fall meeting, and Dr. Marcet’s study was not begun until after that time. We would like to emphasize that we support the notion that the amount of Müller muscle resection does indeed impact the upper eyelid height but that additional mechanisms are occurring to elevate the eyelid in a Müller muscle-conjunctival resection—specifically, advancement of the levator aponeurosis, including plication and sometimes, as in our study, imbrication. While performing numerous external müllerectomy procedures, there is great variability in the appearance of Müller muscle and levator aponeurosis and levator palpebrae superioris with regard to the fatty infiltration and strength. Strictly observing an established algorithm in terms of amount of Müller muscle resection is sometimes not enough to achieve the proper eyelid height desired. The surgeon must sometimes directly plicate and imbricate the levator aponeurosis to obtain the target lid height. While performing external müllerectomy procedures and Hughes flaps, we have observed that the attachments between the levator aponeurosis and the Müller muscle have a range of looseness, with some being extremely more difficult than others to separate. As with intraocular lens calculations, each surgeon must customize his or her formula or algorithm to his or her surgical technique, because the most important goal is to achieve good eyelid height, contour, and symmetry—and, it is hoped, a satisfied patient. DOI: 10.1097/PRS.0b013e31823aefb1

Impending Facial Skin Necrosis and Ocular Involvement After Dermal Filler Injection: A Case Report

AbstractDemand for non-surgical rejuvenating procedure is constantly increasing due to the aging population, increasing expense of aesthetics and beauty procedures, introduction of new applications and rising demand for noninvasive aesthetic procedures over surgical procedures. Skin necrosis is a rare but severe potential complication. It is caused by impediment of the blood supply to the skin area by compression and/or obstruction of the vessel with filler material, and/or direct injury to the vessel. We report the case of a young patient who presented an acute and severe complication after a dermal filler injection by an unlicensed therapist. High-dose corticosteroids i.v. therapy among others helped in the process of healing. Skin necrosis left the patient with a full thickness scar on the forehead region. Dermal fillers are to be considered safe only when handled by trained doctors. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Sternalis Muscle: An Uncommon Finding During Aesthetic Breast Surgery

The sternalis muscle is an uncommon anatomic variant of the chest wall musculature. It was first reported in Anatomes Elenchus Accuratissimus in 1604.1,2 Few reports of this muscle have appeared in the literature, and there is debate about its anatomic origin, insertions, function, and innervations. Reported as an inconstant finding in Netter’s Atlas ,3 the sternalis muscle is described as an analogous muscle that develops along with the rectus abdominis muscle but resorbs when chest development occurs during intrauterine life. Over the years, anatomists have coined a number of terms to refer to the sternalis muscle, such as the accessorius ad rectum and the parasternal, pectoris rectus , or praesternalis muscle .4 The sternalis is an accessory muscle that can originate from the upper sternum and the infraclavicular region, which inserts upon the anterior pectoral fascia, the lower ribs, the costal cartilages, the sheath of the rectus abdominis muscle, and the aponeurosis of the abdominal external oblique muscle. An adipose tissue layer can be interposed between the pectoralis major and sternalis muscles. Some anatomists consider the sternalis a rudiment of the panniculus carnosus in humans.5 Existence of the sternalis muscle varies between the sexes and among ethnic groups; it is reported in …

Ultrasound-Guided Thoracic Wall Nerve Blocks to Reduce Postoperative Pain and Eliminate Opioid Consumption in Patients Undergoing Implant-Based Breast Reconstruction.

Sir: W had the great pleasure of reading the interesting article by Shah et al. entitled “Thoracic Intercostal Nerve Blocks Reduce Opioid Consumption and Length of Stay in Patients Undergoing Implant-Based Breast Reconstruction,”1 and we congratulate the authors on their thoughtful study. Implant-based breast reconstruction is the most popular and most commonly performed method of reconstruction in patients undergoing mastectomy and breast reconstruction. It is extremely important to enhance the comfort of these patients, and to reach this aim, the authors described their experience with intraoperative thoracic intercostal nerve blocks, investigating postoperative pain control and length of hospital stay. Regarding this topic, we would like to report our experience with a different method of ultrasound-guided thoracic wall nerve block to overcome this issue that enabled us not only to reduce the consumption of opioids but to abandon them completely, eliminating the unwanted side effects. The pectoral nerve (Pecs) block is a technique described by Blanco et al.2–4 and consists of an interfascial plane block where local anesthetic is injected into the plane between the pectoralis major muscle and the pectoralis minor muscle (Pecs I block) and above the serratus anterior muscle at the third rib (Pecs II block) with the aid of a linear ultrasound probe. These novel techniques attempt to block the pectoral; intercostobrachial; third, fourth, fifth, and sixth intercostal; and long thoracic nerves (Figs. 1 and 2). Fig. 1. Image of the probe position and needle direction dur-

Breast Reshaping with Dermaglandular Flaps After Giant Lipoma Removal: Versatility of Oncoplastic Techniques

Lipomas of the breast are benign lesions that do not raise great interest in the literature and their incidence is unclear. They usually are small, benign soft tissue tumors of fat cells that can be treated by simple excision. Although lipoma is a banal condition, it often causes diagnostic and therapeutic uncertainty. The first reason for this is the normal fatty composition of the breast. Second, it may be difficult to distinguish a lipoma from other benign or malignant lumps. This report presents a rare case involving giant lipoma of the breast that compromised most of the mass of the breast. After resection, the remaining breast was reshaped using multiple dermaglandular flaps to restore the breast mound, and contralateral breast mammaplasty was performed for symmetry. This case is a good illustration of the oncoplastic reconstruction options available after wide local excision.

Thoracodorsal Artery Perforator Flap for Partial Breast Reconstruction

The popularity of breast conservation therapy (BCT) for the management of women with breast cancer continues to rise. Numerous techniques exist, either at the time of resection or following radiation therapy, and the decision of which to use depends on breast size, tumor size, and tumor location. Women with unfavorable defects will often benefit from volume replacement technique, such as pedicled perforator flaps. The thoracodorsal artery perforator (TDAP) flap is a versatile tool in reconstructive surgery and its use in breast reconstruction is becoming increasingly popular.

Chest Wall Reconstruction for Locally Advanced Breast Cancer with Abdominal Perforator Flap

Locally advanced breast cancer continues to be a significant problem in developing countries and common breast cancer presentation worldwide. Surgical resection in these situations produces large defects that may not be suitable for primary closure. Surgical management of these large wounds includes skin grafts, local cutaneous flaps, omental flaps, musculocutaneous and perforator flaps. Before planning and performing a chest wall reconstruction with either the conventional muscle/musculocutaneous or perforator flaps, an exact analysis should be made of the existing defect.

Innervation of Latissimus Dorsi Flap in Breast Reconstruction: To Sever or Not the Thoracodorsal Nerve?

Latissimus dorsi flap for breast reconstruction has maintained a strong popularity because of its relative simplicity of harvesting combined with reliable and consistent flap vascularity, the ability to provide additional prosthetic coverage, and the lack of requiring microsurgical skills. The latissimus dorsi flap can be an alternative option for both immediate and delayed reconstructions, even without implants, as purely autogenous tissue, and several variations of this flap have been described with a wide range of skin paddle designs and orientation.