Patrick Tonnard

The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction

This study was undertaken to demonstrate that the deep inferior epigastric perforator (DIEP) flap can provide the well-known advantages of autologous breast reconstruction with lower abdominal tissue while avoiding the abdominal wall complications of the transverse rectus abdominis myocutaneous (TRAM) flap. Eighteen unilateral free DIEP flap breast reconstruction patients were assessed 12-30 months (mean 17.8 months) after surgery. Clinical examination, physical exercises and isokinetic dynamometry were performed preoperatively and two months and one year postoperatively. Intraoperative segmental nerve stimulation, visual evaluation and postoperative CT scans were also used to quantify the damage to the rectus muscle. The 18 patients were then compared with 20 free TRAM flap patients and 20 non-operated controls. Two DIEP flap patients presented with abdominal asymmetry. A limited decrease of trunk flexing strength was noticed but rotatory function was intact. Ten of the TRAM flap patients had umbilical or abdominal asymmetry, bulging or hernias. TRAM flap patients showed a statistically significant reduction in strength to flex and to rotate the upper trunk compared to both the one year postoperative DIEP flap group and the control group. The answers to a questionnaire revealed impairment of activities of daily living for some TRAM flap patients while the activities of all DIEP flap patients were unaffected. Our data demonstrate that the free DIEP flap can limit the surgical damage to the rectus abdominis and oblique muscles to an absolute minimum. We believe it is worthwhile to spend extra operative time, the main disadvantage of this technique, to limit late postoperative weakness of the lower abdominal wall.

Doppler flowmetry in the planning of perforator flaps

Perforator flaps have become the first choice in free flap reconstruction of contour defects or skin and fat replacement in our department. The Deep Inferior Epigastric Perforator (DIEP), the Superior Gluteal Artery Perforator (S-GAP) and the Thoracodorsal Artery Perforator (TAP) flaps are now routinely used. By evaluating the vascular anatomy of these flaps preoperatively, we intend to improve our surgical strategy so that these operative procedures can proceed in a faster and safer way. In this study, the results of the colour Duplex scanning in 50 consecutive DIEP flap patients are reviewed and evaluated for their sensitivity and positive predictive value. Also the preoperative information from unidirectional Doppler flowmetry in 30 S-GAP flaps and 11 TAP flaps is evaluated for its reliability. Due to the variable vascular anatomy of the lower abdominal wall and the dorso-lateral thoracic wall we now prefer using the colour Duplex scanning for planning the DIEP and TAP flaps. The more constant course of the branches of the superior gluteal artery allows us to use the easier and cheaper unidirectional Doppler flowmetry for planning the S-GAP flap.

Nanofat grafting: basic research and clinical applications.

Background: The indications for fat grafting are increasing steadily. In microfat grafting, thin injection cannulas are used. The authors describe their experience of fat injection with even thinner injection needles up to 27 gauge. The fat used for this purpose is processed into “nanofat.” Clinical applications are described. Preliminary results of a study, set up to determine the cellular contents of nanofat, are presented. Methods: Nanofat grafting was performed in 67 cases to correct superficial rhytides, scars, and dark lower eyelids. Three clinical cases are described. In the research study, three fat samples were analyzed. The first sample was a classic lipoaspirate (macrofat). The second sample was microfat, harvested with a multiport small-hole cannula. The third was microfat processed into nanofat. Processing consisted of emulsification and filtering of the lipoaspirate. Fat samples were analyzed for adipocyte viability. Cells from the stromal vascular fraction and the CD34+ subfraction were quantified. The stem cell quality was investigated by culturing the cells in standard and adipogenic media. Results: No viable adipocytes were observed in the nanofat sample. Adipose-derived stem cells were still richly present in the nanofat sample. Cell cultures showed an equal proliferation and differentiation capacity of the stem cells from the three samples. Clinical applications showed remarkable improvements in skin quality 6 months postoperatively. No infections, fat cysts, granulomas, or other unwanted side effects were observed. Conclusions: Nanofat injections might become a new concept in the lipofilling area. In clinical situations, nanofat seems to be suitable for skin rejuvenation purposes.

The versatility of the pudendal thigh fasciocutaneous flap used as an island flap.

The pudendal thigh flap is a sensate fasciocutaneous flap based on the terminal branches of the superficial perineal artery, which is a continuation of the internal pudendal artery. Several authors have reported using this axial patterned flap in a bilateral fashion to reconstruct the vagina, mostly in patients with vaginal atresia. The technique is simple, safe, and reliable, and no stents or dilators are required. The reconstructed vagina has a natural angle and is sensate. The donor site in the groin can be closed primarily with an inconspicuous scar. The distinct advantages of this flap widen its indications to several other pathologies. In this article, the authors report on the bilateral use of the flap to reconstruct a vagina in patients with congenital atresia (n = 8) and after oncological resection (n = 5). Furthermore, the versatility of this island flap is also demonstrated by its use in a unilateral fashion in patients with recurrent or complex rectovaginal fistulas (n = 4) and in two patients with a defect of the posterior urethra in a heavily scarred perineum. All 31 pudendal thigh flaps survived completely. Some wound dehiscence was observed in two patients. Two other patients required a minor correction at the introitus of the vagina. The functional outcome was excellent in all patients, despite the presence of some hair growth in the flaps. This article discusses the expanding indications of this versatile flap and the refinements in operative technique. (Plast. Reconstr. Surg. 107: 719, 2001.)

The MACS-lift short scar rhytidectomy.

The minimal access cranial suspension (MACS) lift, a short scar face lift for the lower and middle third of the face, uses a pure vertical vector, involves no lateral tension, and may be performed with the patient under local anesthesia in 2 to 2.5 hours. According to the authors, the procedure reduces recovery time and morbidity, and results are as stable as more classic, extended face lift techniques.

Optimising Results from Minimal Access Cranial Suspension Lifting (MACS-Lift)

Between November 1999 and February 2005, 450 minimal access cranial suspension (MACS) lifts were performed. Starting with the idea of suspension for sagging soft tissues using permanent purse-string sutures, a new comprehensive approach to facial rejuvenation was developed in which the vertical vector appeared to be essential. The neck is corrected by extended submental liposuction and strong vertical traction on the lateral part of the platysma by means of a first vertical purse-string suture. The volume of the jowls and the cheeks is repositioned in a cranial direction with a second, slightly oblique purse-string suture. The descent of the midface is corrected by suspending the malar fat pad in a nearly vertical direction. In 23 cases (5.1%), the result in the neck was unsatisfactory, and additional work had to be done secondarily, or in later cases, primarily. The problem that appeared was unsatisfactory correction of platysmal bands (resolved with an additional anterior cervicoplasty) or vertical skin folds that appeared in the infralobular region (corrected with an additional posterior cervicoplasty). This article describes two ancillary procedures that, although not frequently necessary, can optimise the result of MACS lifting.

Septum-based mammaplasty: a surgical technique based on Würinger's septum for breast reduction

Background: During the past 7 years, the senior author (M.H.) has been performing septum-based mammaplasty. The aim of this article is to report the safety and ease of breast shaping by using this technique. Methods: A series of 110 consecutive patients underwent septum-based breast reduction performed by a single surgeon. This technique uses a lateral or medial pedicle based on Würingers horizontal septum, which carries the main nerve supply to the nipple in addition to intercostal perforators. Results: Mean nipple-to-sternal notch distance was 33 cm (range, 22 to 45 cm). Mean resection was 658 g (range, 160 to 1980 g). Nipple elevation was 9 cm on average (range, 3 to 17 cm). A retroareolar hematoma occurred in three breasts. Total areola necrosis occurred in one breast (0.5 percent) as a result of an infection in a diabetic patient. Limited wound dehiscence occurred in 15 breasts (7.7 percent). A secondary scar revision was needed in 10 patients (9 percent). One patient required a revision. Conclusions: Based on a well-vascularized and constant anatomical septum, a septum-based pedicle is safe, even in large breasts. This technique is safe and demonstrates ease of pedicle shaping and breast remodeling in patients undergoing reduction mammaplasty.

The antecubital fasciocutaneous island flap for elbow coverage.

Soft-tissue defects in the area of the periolecranon may be a source of concern to the reconstructive surgeon who aims for durable protection with a minimum of drawbacks. Lamberty and Cormack described the antecubital fasciocutaneous flap both as a local transposition and as a free flap. The island version of this flap enables a single-stage transfer of thin, pliable, sensitive skin into the region of the periolecranon Without further scarring around the defect. In general, most of the donor site can be closed primarily together with a small, full-sheet, split-thickness skin graft on the remaining skin defect on the volar surface of the distal forearm. An additional advantage of this flap is the rather straightforward dissection with minimal repercussion on the forearm contour. An anatomic overview as well as 4 patients are described to illustrate the appealing features of this fasciocutaneous flap.Van Landuyt K, De Cordier BC, Monstrey SJ, Blondeel PN, Tonnard P, Verpaele A, Matton G. The antecubital fasciocutaneous island flap for elbow coverage.

Revascularisation by ingrowth of a free flap: Fact or fiction?

Revascularisation of a critically ischaemic extremity by means of a free flap occurs through the development of vascular connections at the free flap‐surrounding tissue interface. Three clinical cases are presented showing that in the particular situation of free tissue reconstruction of an ischaemic limb, vascular connections develop which are able at least partially to supply the free flap after occlusion of its arterial pedicle. One other case demonstrates similar vascular connections by angiography

Short scar face lift.

Daniel C. Baker, MD Foad Nahai, MD Hamid Massiha, MD Patrick Tonnard, MD Dr. Baker: The first patient is a 48-year-old fashion consultant who wants to correct her neck and jowl laxity (Figure 1). Although her hair is quite short, she is planning to let it grow and wear it up off her face. Many of her friends and clients have undergone face lift surgery and have significant scars behind their ears; she would like to avoid this. Dr. Massiha, how would you treat this patient? Figure 1 This 48-year-old fashion consultant is requesting correction of her neck and jowl laxity. Dr. Massiha: She has some asymmetry, and the right side of her face is smaller than the left. The asymmetry may require another procedure, such as fat grafting. She has a type 1 or 2 deformity1 and would be an ideal candidate for a short scar face lift. Dr. Baker: Would you do a SMAS flap, plication, or some type of suspension technique? Dr. Massiha: I would dissect the SMAS and platysma as one unit and pull it up. Whatever SMAS is in excess, I would remove. I would treat the left side more aggressively than the right, and maybe that would improve the asymmetry. I like using a SMAS platysma unit, but if I could not dissect the cheek part of the SMAS because it was too thin or too thick, I would create a skin flap in the upper part of the face and blend it with the SMAS platysma flap of the lower face, namely below the level of the lips inferiorly. Dr. Baker: Dr. Nahai, the submental area seems a little full. How would you address that? Dr. Nahai: I agree with Dr. Massiha that this woman would be a good candidate for a short scar …