Joseph H. Dayan

Reverse lymphatic mapping: a new technique for maximizing safety in vascularized lymph node transfer.

Background: The authors introduce the technique of reverse lymphatic mapping for vascularized lymph node transfer. This physiologic technique allows one to identify which lymph nodes drain the trunk as opposed to the extremity, to minimize the risk of iatrogenic lymphedema. Methods: A prospective study of patients undergoing vascularized lymph node transfer using the reverse lymphatic mapping technique was conducted. Patients received technetium injections in the first and second webspaces of the foot and intradermal indocyanine green injections in the lower abdomen. Lymphatic vessels were traced to the lymph nodes draining the lower abdomen that were harvested; a gamma probe was used to localize lymph nodes draining the lower extremity, which were avoided. In cases of vascularized axillary lymph node transfer, technetium was injected into the hand and indocyanine green was injected into the back and lateral chest. Ten-second counts were recorded of the lymph node flap and the sentinel node draining the extremity for comparison. Results: Thirty-five patients underwent vascularized lymph node transfer (19 groin and 16 axillary lymph node transfers) guided by reverse lymphatic mapping. Follow-up time was 1 to 30 months. Mean 10-second count using the gamma probe for all lymph node flaps was 88.6 (SD, 123; median, 39); mean 10-second count of extremity sentinel nodes was 2462 (SD, 2115; median, 2000). On average, 10-second signal strength of the lymph node flap was 6.0 percent that of the extremity sentinel node. Conclusion: Reverse lymphatic mapping guides vascularized lymph node flap harvest based on physiologic drainage patterns of the trunk and limb that may minimize the risk of iatrogenic lymphedema. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The "neosubpectoral" pocket for the correction of symmastia.

Background: Symmastia is a rare but challenging problem to correct. A number of techniques have been proposed, but each has drawbacks in terms of reliability, accuracy, and difficulty. A recently described technique to treat subpectoral symmastia is reported whereby a new pocket is created between the deep surface of the pectoralis major muscle and the anterior surface of the periprosthetic capsule, the boundaries of which are limited by the adherence between the capsule and overlying tissue. The “neosubpectoral” pocket is therefore not a “repair” of the excessively medialized symmastia pocket, but is a new pocket, limited at its perimeter by the patients own tissues rather than by sutures or a patch. Methods: A precise neosubpectoral plane is developed between the pectoralis major and the anterior implant capsule wall, with dissection limited to creating only the space necessary for proper placement of the implant. The technical details of this procedure are described. A chart review was conducted of all patients who underwent symmastia correction using this technique since December of 2003 at Georgetown University Hospital in the practices of Steven Teitelbaum, M.D., and G. Patrick Maxwell, M.D. Results: A total of 23 patients underwent symmastia correction using the neosubpectoral technique. Several of these patients presented for recurrence after failed capsulorrhaphy. There has been no recurrence of symmastia to date in this study. The average follow-up was 22 months. One postoperative hematoma and one seroma occurred. One patient had uncorrected, underdiagnosed inferior malposition from an earlier procedure requiring revision. Conclusions: The neosubpectoral technique is a method for the correction of symmastia that may offer a more efficient, accurate, and effective solution in a single stage. It is an appealing concept that allows for a site change while maintaining the subpectoral position. This procedure is technically straightforward and may offer a reliable means of correcting many other forms of implant malposition and difficult reconstructions.

The influence of brow shape on the perception of facial form and brow aesthetics.

Background: Previous studies have described the ideal shape of the aesthetic brow. These studies were based on fashion models, who typically have ideal oval faces. In people with different facial shapes, makeup artists modify brow shape to give the illusion of an oval shape. The purpose of this investigation was to compare the classically described ideal brow to the modified brow for each facial shape. Methods: The faces of five models were morphed into round, square, oval, and long facial shapes. The eyebrows were digitally removed. A makeup artist drew the brows specifically for each facial shape. In a second set of prints, the brow shape was based on the previously published criteria. Seventy-eight people were asked which face they believed was more aesthetic. Results: There was no significant difference between the classic and the modified eyebrow in the oval or round facial shapes. In the square and long facial shapes, the modified brow was found to be more attractive in 62.7 percent and 58.7 percent of the subjects, which is statistically significant (p < 0.05). Conclusions: The ideal brow may differ from the classic description when applied to the long or square face. In long faces, a flatter brow may give the illusion of fullness. In the square face, an accentuated lateral curvature may help soften the angles of the face. It may be difficult to achieve these modifications surgically, but it is important to be aware of the effect that brow shape has on facial shape.

Complex perineal and groin wound reconstruction using the extended dissection technique of the gracilis flap.

Background: The purpose of this article is to review the applications of the extended-dissection technique of the gracilis flap in a high-risk patient population with complex wounds requiring more coverage than a standard gracilis flap may provide. To our knowledge, this is the first study applying the extended-dissection technique as described by Hasen et al. to pedicled gracilis flaps. Methods: A chart review conducted from 2003 to 2006 identified 19 consecutive patients as having undergone an extended gracilis dissection. Once the pedicle is identified on the medial border of the gracilis, dissection continues proximally, dividing the rich vascular network of perforators to the adductor muscles. The gracilis is then passed beneath the adductor longus and delivered adjacent to the sartorius, where dissection proceeds directly down to the profunda femoris. Results: All reconstructions were successful. There was one complication presenting as a late infection at the donor site. Mean patient age was 66 years and nearly all patients had multiple significant comorbidities, including diabetes, peripheral vascular disease, and/or radiation therapy. Conclusions: The extended-dissection technique for gracilis harvest has significant benefits for use in pedicled flaps, including a greater arc of rotation and no restriction on postoperative ambulation or thigh abduction. These factors are particularly important in the challenging patient population represented in this study and add to the reliability and versatility of the gracilis flap. Anatomical illustrations for technical guidance in this procedure are also provided.

Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction

Background: At present, there are limited data available regarding the use and feasibility of enhanced recovery pathways for patients undergoing microsurgical breast reconstruction. The authors sought to assess patient outcomes before and after the introduction of an enhanced recovery pathway that was adopted at a single cancer center. Methods: A multidisciplinary enhanced recovery pathway was developed for patients undergoing deep inferior epigastric perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction. Core elements of the enhanced recovery pathway included substituting intravenous patient-controlled analgesia with ketorolac and transversus abdominis plane blocks using liposomal bupivacaine, as well as intraoperative goal-directed fluid management. Patients who underwent surgery between April and August of 2015 using the enhanced recovery pathway were compared with a historical control cohort. The primary endpoints were hospital length of stay and total postoperative opioid consumption. Results: In total, 91 consecutive patients were analyzed (enhanced recovery pathway, n = 42; pre–enhanced recovery pathway, n = 49). Mean hospital length of stay was significantly shorter in the enhanced recovery pathway group than in the pre–enhanced recovery pathway group (4.0 days versus 5.0 days; p < 0.0001). Total postoperative morphine equivalent consumption was also lower in the enhanced recovery pathway group (46.0 mg versus 70.5 mg; p = 0.003). There was no difference in the incidence of 30-day complications between the groups (p = 0.6). Conclusion: The adoption of an enhanced recovery pathway for deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced length of stay by 1 day. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Lower Extremity Free Flaps for Breast Reconstruction

Summary: Thigh-based flaps are typically a secondary option for breast reconstruction because of concerns regarding limited tissue volume and donor-site morbidity. In recent years, there have been a number of new techniques and insights that have resulted in greater flexibility and improved outcomes. This article reviews lessons learned from a large collective experience using the following 4 flaps: transverse upper gracilis also known as transverse myocutaneous gracilis, diagonal upper gracilis, profunda artery perforator, and lateral thigh perforator flaps. Flap selection considerations include the patient’s fat distribution and skin laxity, perforator anatomy, and scar location. Pearls to minimize donor-site morbidity include avoiding major lymphatic collectors in the femoral triangle and along the greater saphenous vein and respecting the limits of flap dimension to reduce wound healing complications and distal ischemia. Limited flap volume may be addressed with stacking another flap from the contralateral thigh or primary fat grafting as opposed to overaggressive flap harvest from a single thigh. A detailed review of the benefits and disadvantages of each flap and strategies to improve results is discussed. With careful planning and selection, thigh-based flaps can provide a reliable option patients desiring autologous breast reconstruction.

Computer-generated three-dimensional animation of the mitral valve

OBJECTIVE Three-dimensional motion-capture data offer insight into the mechanical differences of mitral valve function in pathologic states. Although this technique is precise, the resulting time-varying data sets can be both difficult to interpret and visualize. We used a new technique to transform these 3-dimensional ovine numeric analyses into an animated human model of the mitral apparatus that can be deformed into various pathologic states. METHODS In vivo, high-speed, biplane cinefluoroscopic images of tagged ovine mitral apparatus were previously analyzed under normal and pathologic conditions. These studies produced serial 3-dimensional coordinates. By using commercial animation and custom software, animated 3-dimensional models were constructed of the mitral annulus, leaflets, and subvalvular apparatus. The motion data were overlaid onto a detailed model of the human heart, resulting in a dynamic reconstruction. RESULTS Numeric motion-capture data were successfully converted into animated 3-dimensional models of the mitral valve. Structures of interest can be isolated by eliminating adjacent anatomy. The normal and pathophysiologic dynamics of the mitral valve complex can be viewed from any perspective. CONCLUSION This technique provides easy and understandable visualization of the complex and time-varying motion of the mitral apparatus. This technology creates a valuable research and teaching tool for the conceptualization of mitral valve dysfunction and the principles of repair.

Scalp, skull, orbit, and maxilla reconstruction and hair transplantation.

Learning Objectives: After reading this article, the participant should be able to: 1. Discuss the options for reconstruction of scalp, skull, orbit, and maxilla defects. 2. Describe the core principles to obtaining a sound result. Summary: Orbitomaxillary, skull, scalp, and hair restoration covers a broad segment of reconstructive surgery. The purpose of this article is to review considerations in available options for reconstruction, flap selection, relevant anatomy, and potential hazards. Although there are a variety of methods available to treat these complex defects, core principles are presented as a guide to obtaining a sound result specific to the priorities appropriate to an individual patient.

Modern Perforator Flap Imaging with High-Resolution Blood Pool MR Angiography

Advances in microsurgical techniques have improved autologous reconstructions by providing new donor site options while decreasing donor site morbidity. Various preoperative imaging modalities have been studied to assess the relevant vascular anatomic structures, with magnetic resonance (MR) angiography traditionally lagging behind computed tomography (CT) with respect to spatial resolution. Blood pool MR angiography with gadofosveset trisodium, a gadolinium-based contrast agent with extended intravascular retention, has allowed longer multiplanar acquisitions with resultant voxel sizes similar to or smaller than those of CT and with improved signal-to-noise ratio and soft-tissue contrast while maintaining the ability to depict flow with time-resolved imaging. The resultant vascular detail enables precise evaluation of the relevant vascular anatomic structures, including the vessel course, size, and branching pattern, as well as the venous arborization pattern. In addition, any architectural distortion, vessel alteration, or injury from prior surgery can be depicted. The reporting radiologist should be aware of pertinent and incidental findings relevant to the planned surgery and the patients disease so that he or she can assist the microsurgeon in flap design as a member of the multidisciplinary team. Given the lack of ionizing radiation exposure in patients who often have an elevated body mass index, high-spatial-resolution blood pool MR angiography has become the imaging reference standard for the preoperative assessment of perforator flap vascular and soft-tissue morphology in our practice.

Revision of Wise pattern breast reductions with vertical procedures.

AbstractA small percentage of patients who undergo Wise pattern mammaplasties request revisions to address recurrent macromastia or poor breast shape. Reuse of the Wise pattern method at times results in disappointing aesthetic results. Recently, in a series of 15 consecutive patients, we used vertical techniques with glandular reshaping to perform these revisions. Advantages include the ability to significantly improve breast shape and to avoid reopening of potentially problematic inframammary scars. No major complications occurred. Patients have been uniformly pleased with the significant improvement in their breast contour, width, and size. In summary, despite the use of the Wise pattern method for the original procedure, consideration should be given to use vertical techniques for revisions in that they are safe and can better address patient goals. Gratifying results can be achieved.