Betul Gozel Ulusal

Breast reconstruction using the entire transverse abdominal adipocutaneous flap based on unilateral superficial or deep inferior epigastric vessels.

Background: Among various alternatives for autologous breast reconstruction, the superficial inferior epigastric artery abdominal flap provides the least donor-site morbidity, as dissection of the rectus abdominis sheath and muscle is not required. However, because of inconsistencies in the existence and size of the superficial inferior epigastric artery, its use is limited. In addition, whether the perfusion from the superficial system is adequate across the midline is still a question to be answered. Methods: Over a period of 16 months, the authors performed a total of 44 breast reconstructions using either the deep inferior epigastric artery perforator flap (n = 30) or the superficial inferior epigastric artery flap (n = 14). In all cases, the superficial inferior epigastric artery system was explored first and used as the pedicle if the diameter of the available vessels was larger than 1 mm. If the vessels were unavailable or the diameters were smaller than 1 mm, the deep inferior epigastric artery and vein were used as the pedicle. The diameter of the superficial inferior epigastric artery ranged between 0.8 and 3.0 mm, and the mean pedicle length was 6 cm. The superficial inferior epigastric artery was not available in 21 cases (48 percent), and in nine cases (20 percent) the diameter was smaller than 1 mm. In six cases where the superficial inferior epigastric artery was judged to be appropriate, laser Doppler study was performed perioperatively to assess the perfusion of each zone (I through IV) from the deep and superficial systems consecutively. In all cases, the superficial and deep systems ipsilateral to the defect were dissected. During inset, zone IV was not discarded routinely, and 92.3 percent and 86.7 percent of the harvested superficial inferior epigastric artery flap and deep inferior epigastric artery perforator flap, respectively, were used. Results: The flap survival rates were 93 and 100 percent in the superficial inferior epigastric artery and deep inferior epigastric artery perforator groups, respectively. Adequate perfusion of all zones from the superficial system was documented by laser Doppler flowmetry, and the perfusion rates were comparable to the deep system. Conclusions: The entire abdominal adipocutaneous flap based on the unilateral superficial inferior epigastric artery is as reliable as one based on the deep inferior epigastric artery perforator flap. As a result, initially, the superficial inferior epigastric artery flap should be explored, as it provides less donor-site morbidity. A sizable superficial artery and vein is sufficiently safe for microsurgical transfer, similar to the deep inferior epigastric system.

Free lateral arm flap for 1-stage reconstruction of soft tissue and composite defects of the hand: A retrospective analysis of 118 cases.

In this article, the long-term outcomes of hand defects after 1-stage reconstruction with lateral arm flap were retrospectively analyzed in a large series. Between the years 1990 and 2004, 118 traumatic hand defects were reconstructed using lateral arm fasciocutaneous flap (n = 104), lateral arm fascial flap (n = 6), and composite lateral arm flap (n = 8) in Chang Gung Memorial Hospital. There were 22 females and 96 males with an average age of 32.5 ± 13.3 years. The mean follow-up period was 17 ± 6.2 months. The overall success rate was 97.5%. The cosmetic outcomes were satisfactory and only 16.1% of the patients required debulking. The functional recovery of the hand contractures secondary to crush injury were generally associated with poor results. In the composite flap group, reconstruction of the extensor tendons with triceps tendon yielded limitation in tendon excursion and poor functional results. However, complete bone healing without complication was uniformly detected in all cases. Lateral arm fasciocutaneous flap endured secondary interventions well and no complications regarding wound healing was encountered.

Comparisons of resource costs and success rates between immediate and delayed breast reconstruction using DIEP or SIEA flaps under a well-controlled clinical trial.

Background: Every year many patients diagnosed with breast cancer are subjected to mastectomy. Some of them choose to undergo breast reconstruction to restore their body image. Immediate or delayed reconstruction is possible, depending on medical, financial, and emotional considerations. High success rate and cost-effectiveness are two important factors that may guide decision making in the management plan. The objective of this study was to compare the resource costs and success rates of immediate and delayed breast reconstructions using either deep inferior epigastric perforator (DIEP) or superficial inferior epigastric artery (SIEA) flaps. The resource cost is referred to as the cost of operation and hospitalization. Methods: From September of 2000 through August of 2001, 42 patients underwent immediate (n = 21) or delayed (n = 21) unilateral breast reconstruction using either a DIEP (n = 30) or SIEA (n = 12) flap by one surgeon. Results: There were no statistical differences in resource costs, success, and complication rates between DIEP and SIEA flaps in both the immediate and delayed breast reconstruction groups. Conclusions: Using either a DIEP or SIEA flap as the autologous tissue, delayed breast reconstruction is as cost-effective as immediate reconstruction.

Establishing a composite auricle allotransplantation model in rats: introduction to transplantation of facial subunits.

Background: Allografts from cadaveric sources may be an alternative for replacing the missing auricle. In this report, the technical aspects of orthotopic composite auricle allotransplantation and an effective short-term immunosuppression protocol in a rat model are described. Methods: A total of seven transplantations were performed in the experimental group. The donors were Brown Norway (RT1n) rats and the recipients were Lewis (RT11) rats. In the pilot study, 11 isotransplantations (Lewis to Lewis) were performed in either heterotopic (n = 4) or orthotopic (n = 7) locations to establish the surgical technique. Composite auricle allografts were harvested and transplanted based on the posterior facial vein, the external carotid artery, and the great auricular nerve. A plastic square mold sutured over the transplants was used to prevent mechanical trauma to the transplants. Cyclosporine A initiated as 16 mg/kg/day for 2 weeks and tapered to a dosage of 8 mg/kg/day for another 2 weeks was the only immunosuppression regimen. Results: All allografts survived with perfect viability for the follow-up period of 30 days. There were no signs of rejection, infection, or graft-versus-host disease, although significant weight loss was observed resulting from the immunosuppressive treatment. However, signs of rejection started 4 to 6 days after cessation of the cyclosporine A treatment, including edema, localized epidermal desquamation, and erythema formation that eventually progressed to necrosis within 11 to 14 days. The histologic outcomes were well correlated with the macroscopic appearance. Conclusions: It is feasible to elevate and transplant the composite auricle in rats as a single neurosensorial facial subunit. A tapered dose of cyclosporine A from 16 mg/kg to 8 mg/kg allows maintaining allograft survival for 30 days across a strong major histocompatibility complex barrier. This model is reliable and reproducible and has the potential to be used for future immunologic studies to prevent or to induce transplantation tolerance.

Using the descending branch of the lateral femoral circumflex vessel as a source of two independent flaps.

Background: Simultaneous reconstruction of two separate defects by two free flaps is time consuming and often requires two donor sites. The anterior and lateral aspect of the thigh is an ideal donor site for free tissue harvest without incurring significant morbidity. In this article, the authors describe their recently developed technique that allows for harvesting two independent fasciocutaneous free flaps from the same descending branch of lateral circumflex femoral vessel as a new clinical application of the versatile anterolateral thigh flap. Methods: A total of eight flaps were developed from left thighs of four patients. There were two male and two female patients, with a mean age of 42.0 years. The defects were either on the lower extremity (n = 2) or in the oral cavity (n = 2). Each anterolateral aspect of the thigh was used to develop two perforator flaps, based on one perforator each. The anterolateral thigh flap was elevated in the standard manner based on at least two cutaneous vessels of the descending branch of the lateral circumflex femoral artery. The skin flaps were tailored to the recipient site requirement and the main descending branches of the lateral femoral circumflex vessels were divided in between to be used as the pedicle of both flaps. The mean flap dimensions ranged from 2.5 × 4 cm to 8 × 12 cm (mean, 5 × 8 cm). The mean operation time was 11 hours 30 minutes. The mean length of the pedicle was 9 cm (ranged, 8 to 11 cm). The mean external diameter of the descending branch in the mid thigh and where it joined to the lateral circumflex femoral artery was 1.75 mm and 3 mm, respectively. Three donor sites were closed directly and one was grafted. Results: All flaps survived completely. No complications were encountered. Donor-site morbidity was negligible. Hospitalization averaged 9.9 ± 1.7 days. Conclusion: Two fasciocutaneous flaps based on independent skin vessels can be reliably harvested from the same descending branch of the lateral femoral circumflex artery for simultaneous reconstruction of two separate defects.

Simultaneous endoscope-assisted contralateral breast augmentation with implants in patients undergoing postmastectomy breast reconstruction with abdominal flaps.

Background: Unilateral breast reconstruction after mastectomy provides the challenge of achieving symmetry with the opposite side. Reduction mastopexy is a common balancing procedure for the contralateral breast used to achieve pleasing and symmetrical breasts. Although symmetry is the ultimate goal, some women have a hypoplastic and/or ptotic contralateral breast, and the recreation of this shape would therefore not be desirable. Methods: From April of 2000 to April of 2005, a total of 158 patients underwent postmastectomy breast reconstruction using either free deep inferior epigastric perforator flaps (n = 142) or superficial inferior epigastric artery flaps (n = 16) at Chang Gung Memorial Hospital. Of the 158 patients, 19 (12.0 percent) underwent endoscope-assisted placement of implants into the contralateral breast at the same surgical stage to form a more pleasing breast mound. Mean patient age was 46.1 ± 7.6 years. All patients had a slender body habitus, with small to medium-sized breasts. Saline-filled implants were placed in a submuscular position with the assistance of endoscopy. Five different incisions for access were used: transaxillary (n = 6), Port-A-Cath catheter scar (n = 4), inframammary (n = 1), biopsy scar (n = 1), and transmidline (n = 7). Results: The success rate was 100 percent, with complete survival of the 19 flaps. In three patients, revision procedures were carried out at 12 to 44 months’ follow-up because of implant leakage, capsular contracture, and nipple ptosis (one patient each). The remaining patients were highly satisfied with the cosmetic result, and symmetry was achieved, with soft, natural appearing breasts during the follow-up period of 29.2 ± 16.9 months. The transmidline approach was superior to the other routes, because no additional scar was produced and access was easier. Conclusions: Contralateral breast augmentation at the same stage with deep inferior epigastric perforator or superficial inferior epigastric artery flap surgery can be performed with high success rates and poses no surgical risks or morbidity to patients. The combined procedure does not significantly extend the time of operation, and aesthetically pleasing results and symmetry can be achieved and sustained over the long term.

Anatomical and technical aspects of harvesting the auricle as a neurovascular facial subunit transplant in humans.

Background: Auricular transplants from cadaveric sources may be a viable alternative for difficult auricular reconstruction once immunologic problems are largely solved. The authors report on the neurovascular anatomy and technical details of harvesting the auricle as a single facial subunit. Methods: Nine auricles were studied in latex-injected (n = 5) and fresh cadaveric heads (n = 4). In latex-injected heads, dissection in the neck and auricular region and microdissection within the substance of the auricle were performed under loupe magnification. The arterial network was exposed and measurements were taken, including the size, length, and diameters of vessels. The number of branches supplying the entire auricle was noted. Methylene blue dye was injected into fresh cadaveric heads through the posterior auricular (n = 2) or superficial temporal arteries (n = 2) to assess the territory supplied by each arterial system. Results: Dye injected into the superficial temporal artery stained the upper two-thirds of the anterior and posterior auricular regions; all anterior cartilaginous eminences, except the antitragus, were homogenously stained. Dye injected into the posterior auricular artery stained the lobule, posterior auricular skin, and the depressed anterior auricular regions, including the cavum conchae, scapha, and triangular fossa. Neither the superficial temporal nor the posterior auricular arteries could adequately nourish the entire auricle as single pedicles. The auriculotemporal and great auricular nerves can be included in the transplant for sensation. The temporoparietal scalp can also be reliably included to meet reconstructive requirements. Conclusions: The auricle can be reliably elevated as a transplant when nourished by both the superficial temporal and posterior auricular arterial systems. The external jugular vein and external carotid artery can therefore be used as the vascular pedicle for auricular transplantation.

Allograft Mass as a Possible Contributing Factor to the Skin Transplant Outcome

BACKGROUND A composite tissue consists of tissues derived from ectoderm and mesoderm typically containing skin, fat, muscle, nerves, lymph nodes, bone, bone marrow or any combination of these. Solid organ transplants possessing larger allograft mass were reported to survive better. As for the vascularized composite tissues however, thus far no study has comparatively studied the survival of grafts possessing different tissue burdens. The purpose of this study was to explore the effect of transplanted tissue burden and tissue type on survival of skin element of composite tissues. MATERIALS AND METHODS Forty-five transplantations were performed using four different vascularized composite tissue allotransplantation models. The survival periods and rejection severity of the skin parts of the transplants were compared by histological, immunological, and macroscopic evaluation: (a) under no immunosuppressive treatment (control group) (n = 21); (b) after 1 week of Cyclosporine (CsA) treatment (16 mg/kg) (experimental group) (n = 24). Total rejection was defined as necrosis of >90% of the skin flaps. Histopathologic evaluation and flow cytometric analysis to detect chimerism rates in the blood was performed in the CsA treated animals on day 18. RESULTS The differences of mean survival times between and within the experimental and control groups were statistically significant (P < 0.05). Histopathological outcomes showed lower rejection grades in skin allografts transplanted with a higher tissue burden. Total CD4+ and CD8+ T-cell chimerism rates were less than 1% in isolated skin transplant groups and ranged from 6.1 to 33.5% in skin flaps transplanted with the entire hindlimb or a part of it. CONCLUSION The transplanted tissue burden as well as the tissue type can be an important factor for the skin transplant outcome.

The advantages of free tissue transfer in the treatment of posttraumatic stiff knee

Background: Open fractures of the distal femur involving the joint, surrounding ligament, and soft tissues are among the worst types of injuries that may eventually lead to stiff knee. Release procedures have been described as the common treatment option for posttraumatic stiff knee. However, the importance of simultaneously applied free flaps to replace the pliable soft tissue around the knee joint has not been discussed previously. Methods: Between 1996 and 2002, nine patients with posttraumatic severe stiff knees were operated on. All patients underwent release procedures, such as scar removal, quadricepsplasty, tendon lengthening, and/or capsulotomy. In addition, free tissue transfers were performed at the same stage as the release procedures to cover the resultant soft-tissue defects or carried out at a secondary stage because of wound-healing problems. The mean follow-up period was 38 months. Results: Complete flap survival was 100 percent. There were no infection or wound-healing problems following free tissue transfer. After satisfactory rehabilitation, acceptable range of motion was regained. Conclusion: Surgical reconstruction of the posttraumatic stiff knee becomes more straightforward with the use of free flaps to cover soft-tissue defects, providing remarkable advantages for postoperative rehabilitation.

Long-term outcomes of composite auricle as a neurosensorial facial subunit allotransplant.

A total of 22 composite auricle transplantations were performed in allogeneic experimental (group I, n = 10), allogeneic control (group IIa, n = 5), and isogeneic control (group IIb, n = 7) groups. Allotransplantations were carried out across major histocompatibility complex barrier from Lewis Brown Norway rats to Lewis rats. Isotransplantations were performed between Lewis rats. Group II group received no treatment. Allotransplant recipients in group I were immunosupressed by tapered dose of cyclosporine A for 100 days. Then the treatment was discontinued and immunologic, histopathologic, and clinic assessments including neurosensory recovery were carried out. Group IIa rejected their allografts within 7 to 9 days. All 10 animals from group I and 6 animals from group IIb survived for 100 days without infection, illness, signs of rejection, and graft versus host disease. Satisfactory sensory recovery was attained. Suppressed mixed lymphocyte reaction reactivity under CsA treatment was increased 10 days after cessation of the treatment. CD4-positive/RT1Ac and CD8-positive/RT1Ac chimeric cell rates were detected as 0.9% and 1.2% respectively at day 100.