Georg M. Huemer

The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection.

Background: The transverse musculocutaneous gracilis (TMG) flap has received little attention in the literature as a valuable alternative source of donor tissue in the setting of breast reconstruction. The authors give an in-depth review of their experience with breast reconstruction using the TMG flap. Methods: A retrospective review of 111 patients treated with a TMG flap for breast reconstruction in an immediate or a delayed setting between August of 2002 and July of 2007 was undertaken. Of these, 26 patients underwent bilateral reconstruction and 68 underwent unilateral reconstruction, and 17 patients underwent reconstruction unilaterally with a double TMG flap. Patient age ranged between 24 and 65 years (mean, 37 years). Results: Twelve patients had to be taken back to the operating room because of flap-related problems and nine patients underwent successful revision microsurgically, resulting in three complete flap losses in a series of 111 patients with 154 transplanted TMG flaps. Partial flap loss was encountered in two patients, whereas fat tissue necrosis was managed conservatively in six patients. Donor-site morbidity was an advantage of this flap, with a concealed scar and minimal contour irregularities of the thigh, even in unilateral harvest. Complications included delayed wound healing (n = 10), hematoma (n = 5), and transient sensory deficit over the posterior thigh (n = 49). Conclusions: The TMG flap is more than an alternative to the deep inferior epigastric perforator (DIEP) flap in microsurgical breast reconstruction in selected patients. In certain indications, such as bilateral reconstructions, it possibly surpasses the DIEP flap because of a better concealed donor scar and easier harvest.

Oncoplastic Techniques Allow Breast-Conserving Treatment in Centrally Located Breast Cancers

Background: Operative techniques for oncoplastic reconstruction combine oncologic extirpation of the tumor with immediate reconstruction of breast shape and symmetry. These techniques are increasingly being used for breast-conservation therapy of centrally located breast carcinomas. The goal of this study was to provide an overview of the various surgical options for oncoplastic treatment of central breast carcinomas. Methods: From September of 1998 through January of 2005, 31 women (median age, 61 years) were treated for 32 centrally located breast carcinomas by breast-conserving therapy. There were 27 invasive tumors (median size, 13.5 mm), and five patients had ductal carcinoma in situ (median size, 39.6 mm). One patient received chemotherapy preoperatively for tumor reduction. A total of 11 patients had a positive lymph-node status, and 21 patients had a free sentinel node. Results: The various surgical techniques included a central lumpectomy with direct closure (n = 6), central lumpectomy with inverted T-closure (n = 2), a circumareolar, Benelli-type closure (n = 2), a modified Grisotti-flap closure (n = 9), and a mammaplasty-type closure with an inferiorly based pedicle (n = 13). In 27 patients, a contralateral procedure was undertaken (bilateral carcinoma or symmetrizing mammaplasty). Two patients required a secondary mastectomy because of ductal carcinoma in situ with positive surgical margins in the final histology. They were treated by immediate reconstruction with an implant and a pedicled myocutaneous latissimus dorsi flap, respectively. In a median follow-up of 33.8 months, there were no local recurrences in the remaining breast or axilla, but two patients developed distant metastases. Conclusions: Breast carcinoma of small size that occurs in a central location can be safely treated oncologically by breast conservation therapy. The use of various oncoplastic techniques yields very satisfactory aesthetic results.

Comparison of the effectiveness of gene therapy with transforming growth factor-β or extracorporal shock wave therapy to reduce ischemic necrosis in an epigastric skin flap model in rats

The induction of neoangiogenesis by exogenous growth factors in failing skin flaps has recently yielded promising results. Gene transfer with virus vectors has been introduced as a highly capable route of administration for growth factors, such as vascular endothelial growth factor or fibroblast growth factor. Extracorporal shock waves (ESW) deliver energy by means of high amplitudes of sound to the target tissue and have been shown to induce angiogenesis. We compared the effectiveness of gene therapy with adenovirus‐mediated transforming growth factor‐β (TGF‐β) and ESW therapy to treat ischemically challenged epigastric skin flaps in a rat model. Thirty male Sprague‐Dawley rats were divided into three groups of 10 each with an 8 × 8 cm epigastric skin flap. Rats received either subdermal injections of adenovirus (Ad) encoding TGF‐β (108 pfu) or ESW treatment with 750 impulses at 0.15 mJ/mm2. The third group received no treatment and served as a control group. Flap viability was evaluated after 7 days and digital images of the epigastric flaps were taken and areas of necrotic zones relative to total flap surface area calculated. Histologic evaluation and increased angiogenesis were confirmed by CD31 immunohistochemistry. Overall, there was a significant increase in mean percent surviving area in the Ad‐TGF‐β group and the ESW group compared to the control group (ESW group: 97.7 ± 1.8% vs. Ad‐TGF‐β: 90.3 ± 4.0% and control group: 82.6 ± 4.3%; p < 0.05). Furthermore, in the ESW group mean percent surviving areas were significantly larger than in the Ad‐TGF‐β group (ESW group: 97.7 ± 1.8% vs. Ad‐TGF‐β: 90.3 ± 4.0%; p < 0.05). Flap vascularization was increased by Ad‐TGF‐β and ESW with numerous vessels, however, there was no significant difference between the two treatment groups. We conclude that treatment with ESW enhances epigastric skin flap survival significantly more than Ad‐TGF‐β treatment and thus represents a modality that is feasible, cost‐effective, and less invasive compared to gene therapy with growth factors to improve blood supply to ischemic tissue.

Improved dorsal random-pattern skin flap survival in rats with a topically applied combination of nonivamide and nicoboxil

The effects of a topically applied combination of nonivamide and nicoboxil in improving skin perfusion and preventing distal flap necrosis were tested in a random-pattern dorsal skin flap model. Forty male Wistar rats were randomized into two groups (n = 20), and a standardized dorsal random-pattern skin flap was raised on each rat. Animals in the experimental group were treated with the topically applied drug combination four times per day for 6 days, whereas in the control group only a placebo ointment was applied each time. Skin flap viability was evaluated on day 7, and the extent of skin flap necrosis was compared between the two groups. The topically applied combination of nonivamide and nicoboxil resulted in a statistically significant decrease in skin flap necrosis, compared with the control group (mean percentage of skin flap necrosis in the nonivamide/nicoboxil-treated group, 22.6 +/- 6.0 percent; control group, 36.8 +/- 4.3 percent; p< 0.05). The topical combination of nonivamide and nicoboxil was effective in reducing ischemic necrosis in failing random-pattern skin flaps in this rat model. The results of this study suggest that such a topical drug application might have significant effects in the reduction of ischemic necrosis in the distal parts of skin flaps, and this treatment might also have applications as prophylactic therapy for risky skin flaps.

Indications, outcomes, and complications of pedicled propeller perforator flaps for upper body defects: a systematic review.

Background The aim of this investigation was to systematically review the current literature to provide the best data for indications, outcomes, survival, and complication rates of pedicled propeller perforator flaps for upper body defects. Methods A comprehensive literature review for articles published from January 1991 to December 2011 was performed using the PubMed, Medline, and Cochrane Databases. Articles without available full-text, single case reports or papers with excessive missing data were excluded. Papers reporting pedicle-perforator (propeller) flaps used for lower extremity reconstruction were excluded from meta-analysis. Results From the initial 1,736 studies our search yielded, 343 studies qualified for the second stage of selection. Of 117 full-text reports screened, 41 studies, met the definitive inclusion and exclusion criteria. Of the selected 41 articles, 26 were case series, original papers or retrospective reviews and were included, whereas 15 were case report papers and therefore were excluded. Two hundred ninety-five propeller flaps were reported to have been used in a total of 283 patients. Indications include repair of trauma-induced injuries, post-trauma revision surgery, cancer resection, chronic infection, pressure sores, and chronic ulcers with a major complication rate (3.3%) comparable to that of free flaps. No specific exclusion criteria for the procedure were presented in the studies reviewed. Conclusions Pedicled propeller flaps are a versatile and safe reconstructive option that are easy and quick to raise and that provide unlimited clinical solutions because of the theoretical possibility of harvesting them based on any perforator chosen among those classified in the body.

Pulsatile perfused porcine coronary arteries for microvascular training.

Microsurgery is today an established technique in specialties such as plastic surgery, neurosurgery, and trauma surgery. However, specialized training is a prerequisite for mastering anastomosis of small-diameter vessels or coaptation of nerves in the operating room. The training should be as realistic as possible and thus, laboratory animals such as the rat are preferably used as a substitute. In an attempt to minimize the use of living animals without jeopardizing a realistic training setting, we developed a pulsatile perfused porcine coronary artery model for microsurgical education. The training model consists of a membrane pump that generates a pulsatile flow within a coronary artery of a porcine heart. The pump is commercially available with a dimension of approximately 130 × 100 × 60 mm and a weight of 190 g. The pump is energized by 220 B and the motor is run on a transformed power of approximately 12 V (range, 1.5–12 V). Different fluids from simple saline solution to theoretically whole blood can be used for perfusion. The membrane pump proved to be very reliable during microvascular training because of its convenient size and wide range of feed rate providing a very realistic training setting. A maximum fluid output of 850 mL/min can be achieved. The pump has a high acceptance in microsurgical trainees evaluated by questionnaires during several microsurgical courses. The pulsatile perfused porcine coronary artery system for microsurgical training enables the trainee to work under the most realistic training settings. It proved to be a valuable tool during microsurgical education, reducing the costs and sparing living laboratory animals. Thus, we can recommend this system to anyone who is involved in training and teaching microsurgical skills.

Immediate reconstruction of the nipple/areola complex in oncoplastic surgery after central quadrantectomy.

Background:Oncoplastic surgery adds valuable techniques for breast-conservation therapy that allows for wide excisions and prevents breast deformities. However, no such technique has addressed loss of the nipple/areola complex (NAC) after central lumpectomy. We present a simple and effective technique for immediate reconstruction of the NAC after such loss due to tumorectomy. Methods:After central tumorectomy, a local tissue flap is created above the defect to restore the nipple. Then the neonipple is carried on a superior-based, dermoglandular pedicle to its new position, similar to breast reduction surgery. The operation is continued with resection of redundant tissue lateral to the pedicle for optimal breast shape. From the discarded breast tissue, a full-thickness skin graft is harvested and used to reconstruct the areola. The contralateral breast is treated with a usual mammaplasty and tailored to the specific needs of the opposite side. Results:Nine patients with central tumors of the breast were treated in this fashion at our institution. In all patients, the aesthetic result was good to excellent. In 1 patient, there was delayed wound healing of the full-thickness skin graft for the areola, which healed by secondary intention. Conclusion:The presented technique is easily achieved and produced excellent results after breast-conservation surgery. It will expand the armamentarium of oncoplastic surgery to meet central defects with loss of the nipple/areola complex.

Central quadrantectomy with resection of the nipple-areola complex compared with mastectomy in patients with retroareolar breast cancer.

Abstract:  Appropriate surgery in women with retroareolar breast cancer should allow resection of the cancer with wide free margins and an acceptable cosmetic result. The aim of this study was to compare breast conservation surgery (BCS) to mastectomy for treatment of retroareolar breast cancer. In a prospective nonrandomized study, 69 women with retroareolar breast cancers underwent either central quadrantectomy (n = 33) with complete removal of the nipple‐areola complex or mastectomy (n = 36). Two of 33 (6%) patients scheduled for BCS had a secondary mastectomy and immediate reconstruction due to involved margins. After a median follow‐up of 42 month (range 17–99 months) in the BCS group and 43 months (range 16–118 months) in the mastectomy group local and regional recurrences as well as systemic disease were comparable between both groups. The postoperative cosmetic result after BCS as evaluated by the patients was rated as excellent in 80% and good in 20% with no poor result. BCS followed by radiation therapy is a feasible alternative to mastectomy in patients with retroareolar breast cancer.

A new siamese flap for breast reconstruction : The combined infragluteal- transverse myocutaneous gracilis muscle flap

Breast reconstruction has become an integral part of the multidisciplinary treatment regimen for breast carcinoma. The use of autologous tissue is considered the standard and the microsurgical transfer of tissue its favored method. Compared with conventional breast reconstruction methods such as pedicled flaps with or without prostheses, the microsurgical free flap enables the surgeon to perform better tailoring of the tissue to the needs of the recipient site. Several free flaps suitable for breast reconstruction have been presented in recent years, such as the transverse rectus abdominis musculocutaneous flap,1 the deep inferior epigastric perforator flap,2 the superficial inferior epigastric artery flap,3 the superior and inferior gluteal flap with or without muscle,4–6 the myocutaneous gracilis flap,7 and the anterolateral thigh flap.8 Constant effort to minimize donor-site morbidity is the driving force in searching for new options in breast reconstruction. The most frequently used donor site for a free flap in breast reconstruction is the lower abdomen. The reasons for and advantages of this donor site are the large quantity of available tissue, which is especially desirable in patients with large breasts, and the limited postoperative morbidity, together with a primary closure of the defect and the concealed donor scar in the lower abdomen, making it most acceptable in female individuals. However, in some cases, this donor site is contraindicated because of inadequate softtissue bulk, previous abdominoplasty, or abdominal scars. The back (free latissimus dorsi flap) or the gluteal region (inferior or superior gluteal artery perforator flap) does not necessarily offer a good alternative in these selected cases. In 1992, Yousif et al. reported for the first time the use of the musculocutaneous gracilis flap with a transverse orientation of the skin island (transverse myocutaneous gracilis flap) in one breast reconstruction case.7 In our institution, we have been using this flap in head and neck and trauma reconstruction9 and recently in breast reconstruction.10 The objective of this report is to present a new compound “Siamese”11–13 flap for breast reconstruction from the medial upper thigh and lower buttock region that provides the reconstructive surgeon with a large amount of tissue together with a concealed donor area other than the lower abdomen.

Restoration of the gluteal fold by a deepithelialized skin flap: Preliminary observations

BackgroundThe gluteal fold represents an important aspect of the gluteal region. Destruction of this anatomic landmark as a consequence of trauma or tissue harvest can result in an aesthetically disturbing disfigurement. A technique for reconstruction of the gluteal fold and preliminary results are presented.MethodsThe newly formed gluteal fold is created by fixation of a deepithelialized skin flap to the periosteum of the tuber ischiadicum.ResultsThe operative procedure is quick and easy to apply. The method is used mainly for patients with a distorted gluteal fold after tissue harvest for breast reconstruction. However, it also can be used after trauma such as that associated with burn injuries. In all patients, reconstruction of the gluteal fold yielded aesthetically pleasing and reliable results with high patient satisfaction.ConclusionsThe authors present a simple and effective technique for reconstruction of the gluteal fold by a deepithelialized skin flap. The technique is applicable for patients who have lost their natural gluteal sulcus, with a resultant altered buttock shape, after trauma or other causes.