Christo Shipkov

Improvement of skin quality after fat grafting: clinical observation and an animal study.

Background: Restoration of volume and contour defects is a challenge in plastic surgery. Autologous fat tissue transfer is gaining increasing popularity in this field. The aim of this study was to investigate the histologic modifications of the skin after fat tissue grafting on an animal model. Methods: Thirty nude mice, divided into three groups, were used in the experiment. All 30 mice received human fat tissue on one side. On the opposite side, 10 mice received nothing (negative control group), 10 mice received cell proliferation medium, and the remaining 10 mice received only subcutaneous tunneling. Eight weeks later, biopsies of the skin and subcutaneous tissue were performed and specimens were analyzed by hematoxylin-phloxin-saffron staining. Dermis thickness was measured. To differentiate human from murine collagen fibers, human and murine collagen type I antibodies were used. The other types of collagen were investigated by immunohistochemistry (immunostaining) using collagen type III, V, and VI antibodies. Results: Fat tissue was found in all animals. Macroscopically, fat tissue presented normal aspects, with abundant peripheral neovascularization. Histologic examination showed abundant extracellular matrix around the injected human fat tissue. This was attributable to increased type I collagen fibers of murine origin as a result of the murine fibroblast stimulation by the grafted human fat tissue. Dermal thickness after fat grafting was significantly greater. This was not attributable to inflammatory reactions, because no modification was detected in our control groups. Conclusions: This study shows that fat tissue grafting stimulates a neosynthesis of collagen fibers at the recipient site and makes the dermis thicker. However, the long-term effects remain undetermined and need further investigation.

Influence of the Recipient Site on the Outcomes of Fat Grafting in Facial Reconstructive Surgery

Background: The purpose of this study was to analyze the role of fat grafting for restoration of facial contour deformities (volumes) in traumatic and malformation cases. Outcomes were evaluated for each facial aesthetic subunit to demonstrate the role of the recipient site. An algorithm for the treatment of facial malformations and traumatic sequelae by subunits, in relation to the results obtained in this study, is proposed. Methods: This retrospective study involved 100 patients treated by structural fat grafting of the facial region. Results were evaluated by a subjective self-evaluation survey (i.e., a questionnaire answered by patients) and an objective assessment by a five-member jury. Each subunit of the face was studied separately. Results were presented separately and compared. Results: The average follow-up period was 23 months. The overall satisfaction rate of patients was 74 percent. The average score for subjective evaluation was 14.5 of 20. The objective score was 13.9 of 20. The results were significantly different depending on the aesthetic subunit of the face. The best results were achieved in the malar (89 percent good results) and lateral cheek areas (84 percent good results). The poorest results were registered for the lower and upper lip areas (34 percent and 31 percent good results, respectively). Minor complications were observed in 3 percent of the cases. Conclusions: Fat tissue grafting is a simple, efficient, and reproducible technique for restoration of facial volumes. In the absence of functional disorders, it is the authors’ first choice in the decision-making process for the treatment of facial soft-tissue deficiencies.

Analysis of a series of autologous fat tissue transfer for lower limb atrophies.

Localized and circumferential atrophies of the lower extremities have been difficult to treat with few simple autologous solutions available. The aim of this study was to analyze the efficacy of fat grafting in lower limb atrophies. There were 20 patients (17 females and 3 males) at an average age of 33 years. Twelve patients had localized and 8 patients circumferential atrophies of various etiologies: traumatic (60%), congenital (25%), and iatrogenic (15%). The average number of fat injections was 1.1 per patient (range 1–2) for localized atrophies and 2.2 per patient (range 1–3) for circumferential atrophies. The average follow-up period was 2 years. The average volume injected at each stage was 79 mL for localized atrophies and 137 mL for circumferential atrophies. In the cases of circumferential atrophies, an average augmentation of 1.9 cm (range 1–6 cm) of the limb perimeter per injection was achieved. The overall satisfaction of the patients was high. Autologous fat grafting is a reliable technique for lower limb atrophies.

Redefining the vascular anatomy and clinical applications of the sartorius muscle and myocutaneous flap.

Background: The sartorius muscle is a superficial thigh muscle with specific anatomical characteristics in terms of shape and vascular supply. Few studies have assessed the vascular supply of the muscle and overlying skin paddle and its potential in reconstructive surgery. The study used three-dimensional, four-dimensional imaging to analyze the segmental vascularity of the muscle, as well as the overlying skin paddle, to define arcs of rotation based on its major pedicles. Methods: Thirty sartorius muscles and the circumferential skin of the thigh were harvested from adult cadavers. Anatomic considerations, such as pedicle number, location, diameter, and length, were recorded. Three-dimensional and four-dimensional computed tomography angiography was used to measure the length of muscle perfused by a single pedicle defined as a major pedicle. Lastly, the area of cutaneous territory supplied by each major pedicle was calculated. Results: The sartorius muscle is supplied by six to eight vascular pedicles. Two clusters of major pedicles (diameter greater than 1.8 mm) were described (proximal and distal), which are located 18 to 25 cm and 35 to 44 cm from the anterior superior iliac spine, respectively. The proximal major pedicle perfuses almost 80 percent of the muscle, and the distal major pedicle perfuses almost 90 percent. The average area of skin perfused was 330 cm2. Conclusions: This study suggests greater anatomical assurance of the potential use of the sartorius muscle and its overlying skin as a local transposition and free flap. The vascular supply of the muscle and skin by two major pedicles allows two pivot points for muscular or musculocutaneous flaps. The various applications for reconstructive surgery based on these arcs of rotation are discussed.

Madelung Disease: On the Morphologic Criteria for Diagnosis and Treatment

To the Editor: We read with great interest the article by Ramos et al, which presents their series of 47 patients (the largest series from a single institution presented in the literature to our knowledge) and a thorough review on the benign symmetric lipomatosis (Madelung disease). As mentioned by Ramos et al, Madelung disease is more common in the Mediterranean population, which can explain the higher incidence of this condition in their series. However, in our clinical practice, we do not see it so commonly, as reported by Ramos et al. Although, benign fat tissue tumors are among the most common tumefactions in the human body, we feel that Madelung disease is not so common. In the National Organization for Rare Disorders (NORD) guide to rare diseases, the Madelung disease is included as a rare disorder and only in the list of differential diagnosis in cases with multiple lipomatosis. Guilemany et al cited an incidence of 1 to 25,000 males. Our impression from the clinical practice is that Madelung disease can be both under or over diagnosed. One of the possible reasons is probably the fact that there are no strict inclusion criteria as to the localization and dimensions in Madelung disease because reports are scarce in the literature. The typical discretion consists of massive lipomatous deposits around the neck, which gave rise to the classic descriptions of lipoma anulare colli, “buffalo hump” and “horse collar.” According to Enzi, Madelung disease is characterized by diffuse, symmetric, painless, nonencapsulated, and irreversible growth of lipomatosis, which has a tendency to recur after surgical treatment. Smith et al also defined the condition as massive fatty deposits, arranged symmetrically around the neck, shoulders, and arms. However, Guilemany et al extended the definition and concluded that the primary manifestation of Madelung disease is a painless, symmetrical adipose deposit situated on the face, neck, shoulders, upper trunk, arms, abdomen, and legs. In the report of Guilemany et al, the legs were also included in the definition. Ramos et al presented a patient (not clear for us whether male or female) with abdominal localization of the lipomatosis without any neck and shoulder manifestations (unless previously operated on). In this sense, should this patient be included in the category of Madelung disease? If we follow the “classic” definition, the answer should be “no,” because there was no upper torso and neck and shoulder localization. On the other hand, should we reserve the term “Madelung disease” only to cases corresponding to the “classic” definition? The answer should be probably negative because the Madelung disease is also called “benign symmetric lipomatosis.” In this latter definition, the localization of the fat deposits is not taken into consideration, which means that abdominal and leg localizations should be included in this group. Sometimes large encapsulated lipomas are called Madelung disease just because they are in the neck region or around the shoulder, as we have seen in our practice. In other cases, large diffuse, nonencapsulated fibromatous deposits are diagnosed as giant lipomas, although they are probably a presentation of Madelung disease. In a recent report, Silistreli et al presented a male patient with abdominal localization of a large nonencapsulated lipomatous mass, which was diagnosed as a giant lipoma. Similar case is reported by Ramos et al, which was diagnosed as Madelung disease. All this illustrates that the question whether a huge lipomatous mass is a Madelung disease and whether to include only patients with neck and upper torso lipomatosis in the category of Madelung disease remains open. May be one of the most significant criteria remains the absence of a capsule in Madelung disease along with its localization, dimensions, accompanying metabolic or endocrine disorders, alcohol abuse, human immunodeficiency virus (HIV), respiratory malignancies. Most of the patients presenting with Madelung disease demand treatment only when the “tumor” is large enough to cause functional disorders (restricted movements, dysphagia, and dyspnea) or leads to aesthetic disturbances. Dermolipectomy and suction-assisted lipectomy (SAL) represent the mainstay of surgical treatment in Madelung disease, which remains the only effective therapeutic option, as underlined by Ramos et al. We consider that both methods have their role if properly used. However, SAL yields less satisfactory results in our hands because of 2 reasons. First, the amount of the fat deposit to be aspirated is commonly too large. Second, the resultant skin redundancy can hardly adapt to the new volume and usually requires skin excision. That is why we also recommend dermolipectomy, with the SAL reserved for cases of smaller volumes and less skin redundancy. As mentioned by Ramos et al, SAL should be considered as well in cases of diffuse deposits where lipectomy would be difficult to perform. We also agree with Ramos et al that the dermolipectomy offers improved exposure, major debulking with better control of noble structures, and better cosmetic result. In our practice, the combination of SAL, followed by dermolipectomy has also yielded satisfactory results. The preliminary SAL reduces the fat volume and renders the dissection and consecutive skin resection easier. Finally, both resected specimens and aspirate from SAL should be subjected to pathologic evaluation to exclude any underlying liposarcoma. We thank Ramos et al for this nice and exhaustive report, which will add further clarification to Madelung disease.

Poland syndrome and breast tumor: a case report and review of the literature.

Poland syndrome is a rare congenital malformation. Hypoplasia of the sternocostal portion of the pectoralis major muscle is the most significant feature and is most frequently associated with homolateral breast hypoplasia. In this article, the authors present a case of bilateral phyllodes tumors in a 28-year-old woman with Poland syndrome and discuss (1) the relationship between the condition and breast cancer, (2) the modes of surveillance in patients with Poland syndrome, and (3) its impact on breast reconstruction.

Distally based adipofascial sural flap for foot and ankle reconstruction.

BACKGROUND this retrospective study of a case series analyzed the results from the application of a distally based adipofascial sural flap for nonweightbearing defects of the foot and ankle. METHODS twenty-eight patients with post-traumatic ankle and foot defects (ten women and 18 men; age range, 17-63 years) underwent surgery between November 1, 2003, and November 30, 2008. Distally based adipofascial sural flaps were used in ten open fractures, 14 soft-tissue post-traumatic defects, and four deep burns. Defects were on the dorsal side of the foot (eight cases), the lateral malleolus (four cases), the medial malleolus and inframalleolar region (four cases), the Achilles tendon region (eight cases), and the anterior surface of the ankle (four cases). Surgical procedures were performed by a single surgeon (A.M.). RESULTS all of the flaps healed uneventfully. There was no partial or total flap loss. All 28 patients walked normally at the time of follow-up. Three delayed healings occurred at the donor site. CONCLUSIONS this is a homogeneous series of lower-limb reconstructions with the distally based adipofascial sural flap, which permits better analysis of the results. This flap has a constant and reliable blood supply. It can be used for the reconstruction of nonweightbearing foot and ankle regions to avoid the bulky volume of the fasciocutaneous flap in this area and to minimize the donor site scar.

New Abdominal Flap Design for Breast Reconstruction in Association with the Thoracoabdominal Flap

Mastectomy for breast cancer has a huge psychological and social impact on patients. That is why breast reconstruction has become an integrated part of the treatment for breast cancer.

Le lambeau nasogénien et le lambeau du buccinateur. Étude anatomique et à propos de 2 cas cliniques

Resume Les auteurs presentent une etude anatomique du lambeau nasogenien et du lambeau de buccinateur sur 12 cadavres. Ils illustrent cette etude par 2 cas cliniques : 1 cas de reconstruction du philtrum avec un lambeau nasogenien a pedicule superieur, 1 cas combinant un lambeau nasogenien a pedicule inferieur et un lambeau du muscle buccinateur a pedicule anterieur ipsilateral.

Pectoralis Major and Pectoralis Minor Muscle Flap for Postpneumonectomy Empyema

The article by Nomori et al. has profoundly impressed us. Plastic and thoracic surgeons often collaborate because the vascularized muscle fl aps are needed for the treatment of empyema. We have observed in our practice cases in which the latissimus dorsi muscle (LDM) was sectioned not only after posterolateral thoracotomy but after lateral thoracotomy as well. It is possible that the sectioning of the LDM not only at posterolateral thoracotomy might be much more frequent than is believed. Since the thoracodorsal vascular pedicle and its hilus lies close to the lateral border of the LDM it can be easily sectioned when performing thoracotomy, the vascularization and, thus, the use of the LDM as a fl ap becoming uncertain. The importance of this fact was pointed out also by Malczewski et al. In treating empyema we have successfully used the LDM, even when sectioned, as a muscle fl ap on its lumbar and intercostal perforants for obliteration of the basal part of the empyema cavity. As mentioned by Nomori et al., the obliteration of the thoracic apex is quite diffi cult. In these cases the pectoral muscles are the closest source for vascularized tissue. Our anatomic studies showed that the vascular pedicle of the pectoral minor muscle (PMi) can be a branch either of the thoracoacromial artery, or a separate branch of the axillary artery or the lateral thoracic artery. In either case this branch lies very close to the primary pedicle of the pectoralis major muscle (the thoracoacromial artery), thus allowing the inclusion of the two muscles in one fl ap. Based on this anatomical study, in January 2000 we used the pectoral major (PMa) and PMi muscles as a single fl ap in a case of postpneumonectomy empyema without bronchopleural fi stula. The patient had undergone pneumonectomy for lung cancer. We performed intrathoracic transposition of the PMa and PMi muscles with simultaneous thoracoplasty. Excellent obliteration of the thoracic apex and the residual pleural cavity to the level of the third rib was achieved. The patient was dismissed on the 21st day without complications. He was free of empyema for 8 months when he presented with renal metastasis from his lung carcinoma. We consider the PMa and PMi muscle fl ap proposed by Nomori et al. as excellent for obliteration of the thoracic apex in empyema patients, with minimal functional and aesthetic donor site deformity.