Jörg Dabernig

The anatomic and radiologic basis of the circumflex scapular artery perforator flap

Microsurgical development has recently focused upon the perforator paradigm and primary thinning. Existing perforator flaps may require intramuscular dissection or lack reliable surface markings, whereas traditional scapular/parascapular flaps have low donor morbidity and reliable anatomy, but can be excessively bulky. Clinical application of a new flap based on a perforator from the circumflex scapular axis (CSA) has recently been published, but the vessels anatomy has not been adequately characterized. The CSA was dissected in 115 sites in 69 cadavers. The number, external vessel diameter, and site of origin of perforators were measured relative to the CSA bifurcation. Color Doppler ultrasound was used to delineate the CSA and its perforators bilaterally in 40 volunteers. The number, origin relative to CSA bifurcation, diameter, length, and flow velocity of cutaneous perforators were determined. A CSA perforator was always present, running into the subdermal plexus, arising within 2.4 cm of the bifurcation. Cadaver studies: mean perforator diameter, 1.3 mm (SD, 0.66); 13% arose at bifurcation, 36% arose proximal (mean, 1.1 mm; SD, 0.63), and 52% distal to bifurcation (mean, 1.5 mm; SD, 0.88). Ultrasound: mean perforator diameter, 1.18 mm (SD, 0.41); mean flow velocity, 16.3 cm/s (SD, 3.65); perforator arose in 36% proximal, in 40% distal to bifurcation, and in 24% from the bifurcation. We definitively describe the anatomy of the perforator from the circumflex scapular artery upon which a new flap has been based. Its origin and dimensions are anatomically and radiologically reliable. The flap has certain potential benefits over existing perforator flaps.

Applied anatomy of the latissimus dorsi free flap for refinement in one-stage facial reanimation *

BACKGROUND The face can be reanimated after long-term paralysis by free microneurovascular tissue transfer. Flaps from gracilis and pectoralis minor usually require a two-stage procedure with a cross-face nerve graft. Latissimus dorsi has a much longer muscular nerve, the thoracodorsal nerve, which could avoid the need for a second cross-face nerve graft. Our hypothesis is that the neurovascular pedicles of small segments of latissimus dorsi would be long enough to reach the opposite side of the face and to provide a reliable blood and nerve supply to the flaps. METHOD To test this hypothesis the thoracodorsal pedicle and its primary branches were dissected in eleven embalmed cadavers. The segmental vessels and nerves were then traced in a series of simulated flaps approximately 8-10 cm × 2-3 cm by micro-dissection, tissue clearing and histology. RESULTS The thoracodorsal pedicle is 10-14 cm long to where it enters the muscle, and with intra-muscular dissection small chimeric muscle segments 8-10 cm × 2-3 cm can be raised with a clearly defined neurovascular supply. Using micro-dissection the neurovascular pedicle can be lengthened to reach across the face. Segmental arteries and nerves extended to the distal end of all the flaps examined. Artery, vein and nerve run together and are of substantial diameter. CONCLUSION Small muscle segments of latissimus dorsi can be raised on long neurovascular pedicles. The vessels and nerves are substantial and the likelihood of surgical complications such as flap necrosis and functional disuse on transplantation appear low. Although in our opinion the use of cross-face nerve grafts and transfer of smaller muscle flaps remains the gold standard in facial reanimation in straightforward cases, the micro-dissected latissimus dorsi flap is a useful option in complex cases of facial reanimation. CLINICAL APPLICATION Facial reanimation using micro-dissected segments of latissimus dorsi has been performed in four complex cases of facial paralysis.

Nasal tip reconstruction of the nose with composite ear-helix free flap.

To the Editor: We applaud the authors of the recent publication, “The Impact of Breast Reconstruction on the Oncologic Efficacy of Radiation Therapy: A Retrospective Analysis,” (Nahabedian and Momen. Ann Plast Surg. 2008;60:244 – 250) for attempting to address the important issue of whether or not postmastectomy reconstruction has a detrimental effect on the surveillance and/or progression of breast cancer recurrence. Current evidence would suggest that the performance of postmastectomy implant and/or autogenous tissue reconstruction is oncologically safe. This paper, however, appears to be making a statement that contradicts current thinking. The authors suggest that “tumor recurrence and patient demise may be increased when radiation therapy is performed following breast reconstruction.” Such a significant statement could potentially affect current practices and the standard of care for breast cancer patients. It follows that such a statement must be based on only the highest level of evidence possible. After examination of the data presented in this paper, we would challenge the authors by suggesting that their conclusions are not justified for the following reasons. Firstly, the rate of locoregional breast cancer recurrence in ‘all-comers’ in this study is alarmingly high. Recurrence rates for the total cohort in this series—all of whom underwent mastectomy and postmastectomy radiotherapy (PMRT)—were reported as 19.8%, “of which 27% was when radiation followed reconstruction and 14.9% when radiation preceded reconstruction.” This is a concerning finding. By contrast, a 2005 Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) subset analysis of postmastectomy patients with 4 or more positive lymph nodes demonstrated a 5-year locoregional recurrence rate (LRR) of 11.6% with the use of PMRT. Among patients with 1-3 positive lymph nodes, the 5-year LRR was 4.0% with PMRT. This discrepancy suggests that the current study patients many have had other clinicopathologic risk factors putting them at extremely high risk of recurrence, and/or the treatment of their primary disease was inadequate. Secondly, while the authors conclude that the incidence of tumor recurrence and death appears to be increased when radiation is performed following reconstruction, significant noncomparability exists between subgroups of patients. For example, the raw data presented suggests that the 2 groups (those who are radiated before reconstruction and those who were radiated after reconstruction) may differ with respect to stage of disease and the proportion of patients who received chemotherapy. In addition, the authors do not tell us how many patients in each group had other potential risk factors for recurrent disease such as number of positive lymph nodes, margin status, tumor ER/PR positivity, lymphovascular invasion, extracapsular extension, etc. Finally, while the authors acknowledged that the peak incidence of local recurrence is reported to occur during the second year after primary breast cancer treatment, the mean follow-up was reported as 26.4 months. This suggests that a large proportion of patients had less that 2 years of follow-up. In addition, length of follow-up was not recorded for each subgroup of patients (ie, those radiated before reconstruction or those radiated after reconstruction) so it is unclear whether follow-up was comparable between these patient cohorts. Perhaps more importantly, however, the statistical analysis performed here needs to be clarified. We would argue that in general, logistic regression analysis should not be used when evaluating ‘censored’ data (ie, individuals are followed for different lengths of time or their follow-up is incomplete) because such analysis does not take time or length of follow-up into account. Instead, when the data is censored, survival analysis should be performed. We would strongly advise the authors to re-analyze their data using the appropriate statistical techniques and to work in collaboration with an oncologic surgeon. We certainly agree that the oncologic safety of postmastectomy reconstruction should be evaluated and urge the authors to apply increased scientific rigor to their current evaluation. Colleen M. McCarthy, MD, MS Peter G. Cordeiro, MD Joseph J. Disa, MD Babak J. Mehrara, MD Andrea L. Pusic, MD, MHS Memorial Sloan Kettering Cancer Center New York, NY

Prevention of Paediatric Ring Avulsions – A Cadaveric Study

Finger ring avulsion injuries can be functionally, cosmetically and emotionally devastating for the patient. This cadaveric study assessed a simple way to prevent ring avulsion injuries. Fresh cadaver fingers were used to test the incidence of avulsion injury with ordinary rings and when a single slot was cut in the ring. Intact rings mostly produced significant digital injuries, while the rings with slots did not.

The reversed dermis flap in a homodigital or cross finger manner for soft tissue reconstruction in dorsal finger defects.

To the Editor: The VAC machine is commonly used to enhance granulation tissue of difficult wounds. We recently used the VAC machine to enhance the adherence of cutaneous flaps to their beds. Case 1: A 45-year-old presented with infected gluteal silicone implants (inserted via midline incision for augmentation). Following removal of implants and intravenous antibiotics, the infection was controlled. The cavities created by the implants were irrigated daily but the cutaneous flaps failed to stick to their beds. A VAC machine was applied to the open incision site and the flaps became adherent within a few days. The open incision was left to heal by secondary intension. Case 2: A 20-year-old girl presented with an infected scalp expander. Following removal of the expander and intravenous antibiotics, the infection was controlled. The raised scalp flap failed to stick to its bed. A VAC machine was applied to the open incision and the flap became adherent within a few days. In both these cases, we believe that negative pressure created by the VAC machine enhanced adherence of the flaps to their beds.

Juvenile gigantomastia of extreme magnitude: a case report.

A 12-year-old girl from Togo was admitted for treatment of progressive bilateral breast enlargement of extreme magnitude. Her parents first noted abnormal breast growth about 6 months before admission. During this period, the girl’s body weight increased from 35 to 60 kg. Breast enlargement started almost simultaneously with menarche. The patient did not have a history of illness, specific breast, or development of irregularities. Medical histories of the known relatives were inconspicuous concerning malignant diseases or breast disorders. Upon clinical examination, the patient had massive bilateral enlargement of the breasts. Nipple position was below hip joint level. Both breasts showed multiple cutaneous ulcerations (Figs. 1–3). Palpation showed firm-tissue quality with edema, dilated venous vessels but no detectable tumor formations. Hormonal levels of -HCG, serum estradiol, progesterone, prolactin, thyroid stimulating hormone, growth hormone, Luteinizing hormone, follicle stimulating hormone, and testosterone were detected but showed no distinctive feature. The patient had never been on any medication. CT-scan showed no evidence of tumor or pituitary gland abnormities. One day after admission, the patient underwent radical subcutaneous mastectomy. Breast reconstruction with deepithelialized breast skin flaps and free NAC transplant were performed. Weight of the resected tissue was 20 kg in total (Fig. 4). Histologic examination showed nodular proliferation of glandular breast tissue with edematous fibrous stroma and focal lactational changes (Figs. 5,6). There was no evidence of malignant tissue transformation. The patient was followed up 1 and 2 years after the operation was carried out. The breasts showed acceptable breast shape without evidence of recurrence although the patient gained 20 kg of body weight (Figs. 7–10).

Re: use of a dorsal adipofascial flap for reconstruction of large volar finger defects.

Dear Sir, The dorsal adipo-fascial flap (Tremolada et al., 1998), taken from the proximal phalangeal segment of the finger (Fig 1), can be used to reconstruct defects on the palmar surface of the same finger. This homodigital flap, based on dorsal branches of the main digital artery, provides a thin layer of well-vascularised tissue capable of covering relatively large defects (up to half the circumference of the finger) on the palmar surface of the finger in a single-stage procedure. It is useful to cover vital structures, such as the exposed flexor tendon, with minimal donor site morbidity.

Pedicled pubic phalloplasty in females with gender dysphoria

Concerning the management of the nine patients reported by Pepper et al. , the diagnostic and therapeutic criteria for managing suspected lymphoceles were neither defined nor standardised. Some patients were actively treated, others not, but the criteria on which these decision were based are unclear. Thus an evaluation of the chosen strategies is impossible. Also, the case number of nine lymphoceles, apart from representing a gross underestimation of the true incidence of lymphoceles, would be rather small for determining ‘the best method of diagnosis and treatment’.