Rafael G. Jakubietz

Different preparation methods to obtain platelet components as a source of growth factors for local application

BACKGROUND: Autologous platelet components were recently used as part of tissue‐engineering strategies in oral and maxillofacial surgery. Various preparation methods were investigated to define standardized blood bank components and to collect data on the growth factor content of human platelets before and after storage.

The 180-Degree Perforator-Based Propeller Flap for Soft Tissue Coverage of the Distal, Lower Extremity : A New Method to Achieve Reliable Coverage of the Distal Lower Extremity With a Local, Fasciocutaneous Perforator Flap

Background:Traumatic and nontraumatic defects of the distal third of the tibia are challenging in regard to soft tissue coverage. While local, pedicled fasciocutaneous perforator flaps allow adequate coverage, the donor site often requires skin grafting. When a local perforator flap is designed as a 180-degree propeller flap, an excellent esthetic result and direct closure of the donor site can be achieved, with minimal morbidity. Methods:Eight patients with defects in the malleolar region were treated with 180-degree propeller flaps based on perforators from the tibial and peroneal vessels. Results:One partial flap loss was encountered in an insulin-dependent diabetic. Partial superficial epidermolysis was encountered in 2 cases and healed without further interventions. No other complications were encountered. All patients returned to full ambulation within 8 weeks. Conclusion:The 180-degree propeller flap is an elegant and versatile method to achieve soft tissue coverage with local tissue in defects of the distal tibia. Contrary to other local perforator flaps, this specific design facilitates direct closure of the donor site. As only local, thin tissue is used, no interference with normal shoe wear occurs. Even in older patients, this flap has proven to be a reliable option.

A contoured locking plate for distal fibular fractures in osteoporotic bone: A biomechanical cadaver study

OBJECTIVE Fixation of ankle fractures in elderly patients is associated with reduced stability conditioned by osteoporotic bone. Therefore, fixation with implants providing improved biomechanical features could allow a more functional treatment, diminish implant failure and avoid consequences of immobilisation. MATERIALS AND METHODS In the actual study, we evaluated a lateral conventional contoured plate with a locking contoured plate stabilising experimentally induced distal fibular fractures in human cadavers from elderly. Ankle fractures were induced by the supination-external rotation mechanism according to Lauge-Hansen. Stage II fractures (AO 44-B1) were fixed with the 2 contoured plates and a torque to failure test was performed. Bone mineral density (BMD) was measured by quantitative computed tomography to correlate the parameters of the biomechanical experiments with bone quality. RESULTS The locking plate showed a higher torque to failure, angle at failure, and maximal torque compared to the conventional plate. In contrast to the nonlocking system, fixation with the locking plate was independent of BMD. CONCLUSION Fixation of distal fibular fractures in osteoporotic bone with the contoured locking plate may be advantageous as compared to the nonlocking contoured plate. The locking plate with improved biomechanical attributes may allow a more functional treatment, reduce complications and consequences of immobilisation.

The Limited Scar Mastopexy: Current Concepts and Approaches to Correct Breast Ptosis

The literature on short scar mastopexy was reviewed, with a focus on the different techniques. Currently four techniques have been described: the periareolar, the vertical, the inverted-T, and the L-shaped scar. The different techniques were evaluated with regard to patient selection, operative techniques, scar length, and complications. A large number of techniques have been published for minimal ptosis, whereas for significant ptosis, the number of surgical options is limited. It is evident that limited scar techniques can be applied to all grades of ptosis, but there is no one technique that can satisfactorily correct all degrees of ptosis. Plastic surgeons should weigh the advantages and limitations of each technique to correctly address breast ptosis. This article reviews an algorithmic approach to correct all degrees of ptosis with mastopexy.

The distally based adipofascial sural artery flap: faster, safer, and easier? A long-term comparison of the fasciocutaneous and adipofascial method in a multimorbid patient population.

Background: Complex wounds of the distal third of the leg are challenging to treat. Despite free tissue transfer, local pedicled flaps such as the distally pedicled sural artery flap remain a valuable option. Methods: The authors conducted a retrospective comparison of the classical harvesting technique of the sural artery flap with a simplified method without a skin island. Results: We report on 148 patients who were treated with 104 adipofascial flaps and 44 fasciocutaneus flaps from 1997 to 2010. The adipofascial group showed a shorter operative time and a better aesthetic outcome. Complications did not differ in this multimorbid patient group. Conclusions: With a simple modification, the distally based sural artery flap is easier and faster to perform. The study shows that the adipofascial flap is as safe as the classic version, with the advantage of an improved donor-site appearance. Therefore, the described technique is a valuable tool in cases where free tissue transfer is not suitable. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Breast Augmentation: Cancer Concerns and Mammography-A Literature Review.

There has been a longstanding concern about whether there is an association between breast cancer and breast implants. This concern has served as the stimulus for many studies. Although there are data to support both sides, after our critical review of the literature, several conclusions can be drawn. (1) Augmented patients are not at a greater risk than the nonaugmented population for developing breast cancer. (2) Early detection of occult cancer is possible in augmented patients. (3) Submuscular placement allows for greater mammographic visualization. (4) Eklund views (displacement techniques) should be used when obtaining mammograms in augmented patients and should be interpreted by radiologists experienced in the evaluation of augmented patients. (5) Silicone and saline implants demonstrate the same radiodensity on mammograms; neither is superior to the other. (6) The current recommendations for getting screening/preoperative mammograms are no different for augmented patients, although the ultimate decision lies with each surgeon and patient.

Subfascial directionality of perforators of the distal lower extremity: an anatomic study regarding selection of perforators for 180-degree propeller flaps.

BackgroundThe 180-degree propeller flaps allow closure of soft-tissue defects of the distal lower extremity. In addition to twist, the pedicle is often subject to additional kinking which increases proportionally to the angle at which the perforator pierces through the fascia. This study evaluates the directionality of the perforators at the fascial level to guide in the selection process of the best perforator. Material and MethodsPerforators were identified in the lower extremities of 16 fresh cadavers. The angle of fascial perforation was measured. Perforators were grouped according to source vessel and location. Results were analyzed statistically regarding angle of fascial perforation along the source vessel and region. ResultsA total of 324 perforators were identified. Distal perforators pierced the fascia at a significantly greater angle than in the proximal and middle segment of the peroneal and anterior tibial vessels (P < 0.005). Perforators originating from the posterior tibial artery pierced the fascia at less acute angles distally. When grouped according to the region of the perforators, no significant difference was found between perforators from all source vessels in the proximal region of the distal lower extremity. Even distally, perforators from the posterior tibial artery traveled almost perpendicular (P < 0.005). ConclusionPerforators traveling in a near perpendicular manner are ideal to serve as a pedicle for 180-degree propeller flaps as solely the twist has to be distributed along the vessel. The posterior tibial artery was the source to perforators with the most constant, near-perpendicular course, predisposing them for use in 180-degree propeller flaps.

Breast reduction by liposuction in females.

BackgroundBreast reduction by liposuction alone is an appealing technique that has failed to gain widespread acceptance. Despite numerous studies on liposuction, the majority of surgeons remain skeptical. This study aimed to review the indication and limitations of this procedure.MethodsTwo groups of patients that qualify for this procedure can be defined. However, the aesthetic result will be pleasing only for young patients. For elderly patients, liposuction breast reduction will simply achieve a weight reduction of the breast without improving the shape.ResultsUniversally good liposuction results for breast weight reduction and elevation of the nipple–areolar complex are reported. Improvement in breast shape and correction of ptosis cannot be achieved for elderly patients. Young patients with a preoperatively pleasing breast shape can expect a preservation of the shape with the benefit of minimal scarring.ConclusionLiposuction breast reduction is appealing due to selective removal of fat, ease of the procedure, and minimal scarring. The main disadvantage is that a correction of shape and ptosis is not possible with liposuction, and only young patients can expect an aesthetically pleasing result. Elderly patients may benefit from faster recovery times, a less invasive procedure, and low costs. The application of a new technique to a cancer-prone organ represents a potentially serious medicolegal issue because follow-up imaging may be impaired and a possible spread of cancer cells cannot be ruled out. Despite its technical appeal, breast reduction by liposuction alone mandates a cautious approach.

Reconstruction of pressure sores with perforator-based propeller flaps.

Perforator flaps have been successfully used for reconstruction of pressure sores. Although V-Y advancement flaps approximate debrided wound edges, perforator-based propeller flaps allow rotation of healthy tissue into the defect. Perforator-based propeller flaps were planned in 13 patients. Seven pressure sores were over the sacrum, five over the ischial tuberosity, and one on the tip of the scapula. Three patients were paraplegic, six were bedridden, and five were ambulatory. In three patients, no perforators were found. In 10 patients, propeller flaps were transferred. In two patients, total flap necrosis occurred, which was reconstructed with local advancement flaps. In two cases, a wound dehiscence occurred and had to be revised. One hematoma required evacuation. No further complications were noted. No recurrence at the flap site occurred. Local perforator flaps allow closure of pressure sores without harvesting muscle. The propeller version has the added benefit of transferring tissue from a distant site, avoiding reapproximation of original wound edges. Twisting of the pedicle may cause torsion and venous obstruction. This can be avoided by dissecting a pedicle of at least 3 cm. Propeller flaps are a safe option for soft tissue reconstruction of pressure sores.

Suture material for flexor tendon repair: 3-0 V-Loc versus 3-0 Stratafix in a biomechanical comparison ex vivo

BackgroundBarbed suture material offers the possibility of knotless flexor tendon repair, as suggested in an increasing number of biomechanical studies. There are currently two different absorbable barbed suture products available, V-Loc™ and Stratafix™, and both have not been compared to each other with regard to flexor tendon repair. The purpose of this study was to evaluate both suture materials for primary stability under static and cyclic loading in a biomechanical ex vivo model.MethodsForty fresh porcine flexor digitorum profundus tendons were randomized in two groups. A four-strand modified Kessler suture technique was used to repair the tendon either with a 3-0 V-Loc™ or 3-0 Stratafix™ without a knot. Parameters of interest were mode of failure, 2-mm gap formation force, displacement, stiffness and maximum load under static and cyclic testing.ResultsThe maximum load was 42.3 ± 7.2 for the Stratafix™ group and 50.7 ± 8.8 N for the V-Loc™ group. Thus, the ultimate tensile strength was significantly higher for V-Loc™ (p < 0.05). The 2-mm gap occurred at 24.8 ± 2.04 N in the Stratafix™ group in comparison to 26.5 ± 2.12 N in the V-Loc™ group (n.s.). Displacement was 2.65 ± 0.56 mm in the V-Loc™ group and 2.71 ± 0.59 mm in the Stratafix™ group (n.s.). Stiffness was 4.24 ± 0.68 (N/mm) in the V-Loc™ group and 3.85 ± 0.55 (N/mm) the Stratafix™ group (n.s.). Those measured differences were not significant.ConclusionV-Loc™ demonstrates a higher maximum load in tendon reconstruction. The differences in 2-mm gap formation force, displacement and stiffness were not significant. Hereby, the V-Loc™ has an advantage when used as unidirectional barbed suture for knotless flexor tendon repair.