Advances in autogenous breast reconstruction: the role of preoperative perforator mapping.
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Adult↗
Biomedical subjects
Moustapha Hamdi
Publications and source records attributed to Moustapha Hamdi.
The versatility of the inter-costal artery perforator (ICAP) flaps.
INTRODUCTION: Anatomy and classification of intercostal perforator flaps in addition to our experience with will be demonstrated for different indications. MATERIAL AND METHODS: The intercostal vessels form an arcade between the aorta and the internal mammary vessels. Different pedicled perforator flaps can be raised on this neurovascular bundle to cover defects on the trunk. They are classified as following: dorsal intercostal artery perforator flap (DICAP); lateral intercostal artery perforator (LICAP); and anterior intercostal artery perforator (AICAP) flap. RESULTS: Between 2001 and 2004, 20 pedicled (ICAP) flaps were harvested in 16 patients. The indications were: immediate partial breast reconstruction in eight patients who had a quadrantectomy for breast cancer; midline back and sternal defects in three patients who had radical excisions for a dermatofibrosarcoma or malignant melanoma; and autologous breast augmentation (four bilateral and one unilateral flap) in five post-bariatric-surgery patients. The average flap dimension was 18 x 8 cm(2) (range 8 x 5-24 x 12 cm(2)). There were two DICAP flaps, two (AICAP) flaps and 16 (LICAP) flaps. All but two flaps were based on one perforator. Mean harvesting time was 45min for a single flap. Bilateral breast augmentation with LICAP flap necessitated longer operative time (range 2-3h) depending whether it was combined or not with mastopoexy. Complete flaps survival was obtained. All donor sites were closed primarily. CONCLUSION: The (ICAP) flaps provide valuable options in breast surgery; and for challenging defects on the trunk without sacrifice of the underlying muscle.
Adolescent↗
Adipose tissue induction in vivo.
Engineering adipogenic tissue in vivo requires the concomitant induction of angiogenesis to generate a stable long-term three-dimensional construct. Histioconductive tissue engineering strategies have been used. The disadvantage of using biodegradable scaffolds is a delayed angiogenic induction resulting in ischemic necrosis of the central cell population in the scaffold. We evaluated an histioinductive approach for adipose tissue engineering by combining essential key components for adipogenic induction: (1) a precursor cell source, (2) a vascular pedicle, (3) a supportive matrix, and (4) a chamber to preserve space for the new tissue to develop. We observed concomitant adipogenic and angiogenic induction after 6 weeks in three-dimensional adipose tissue constructs.
Adipose Tissue↗
Donor-site morbidity of the radial forearm free flap after 125 phalloplasties in gender identity disorder.
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Adult↗
The versatile DIEP flap: its use in lower extremity reconstruction.
The deep inferior epigastric perforator (DIEP) flap gained widespread popularity as a free flap in breast reconstruction. It is also a versatile and reliable supply of a large amount of skin and soft-tissue, which can be used in other types of reconstruction. We present 25 consecutive cases (28 DIEP flaps) performed in our service during the past 5 years for different indications in lower extremity aesthetic and functional reconstruction, both as pedicled or free flaps. The amount of tissue provided, its reliable vascular supply and long and adequately sized pedicles, together with its limited donor-site morbidity make it a useful alternative free flap.
Abdomen↗
Free perforator flaps in children.
BACKGROUND: Raising perforator flaps is said to be a tedious procedure. The benefits, however, are great. In adults, perforator flaps have proved their usefulness and reliability in various clinical situations. In children, donor sites for free flaps are particularly scarce because of the need for a long and reliable vascular pedicle of sufficient size. There is also the need to minimize donor-site morbidity from aesthetic, functional, and psychological perspectives. METHODS: The authors present a series of 23 consecutive free perforator flaps performed by the first author in 20 children; ages at the time of operation ranged from premature (born at 28 weeks) to 16 years (mean age, 7 years 5 months). Three children presented with upper limb defects; the remaining 17 children sustained major soft-tissue defects of the lower limb. All the lesions necessitated extensive coverage with a free flap. Flaps used in this series included nine deep inferior epigastric artery perforator flaps, seven thoracodorsal artery perforator flaps, and seven compound ("chimera") thoracodorsal artery perforator flaps. RESULTS: All flaps but one were successful. With a follow-up of up to 7 years, the results in this series compare favorably with those of perforator flaps in adults or pediatric free flaps in the literature. CONCLUSIONS: In children, as in adults, perforator flaps are a valuable alternative to the traditional muscle or myocutaneous free flap. Because of the added advantage of reducing donor-site morbidity, perforator flaps have become the authors' preferred option in reconstructive cases in children.
Adolescent↗
Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals.
LEARNING OBJECTIVES: After studying this article, the participant should be able to discuss: 1. The terminology related to male-to-female gender dysphoria. 2. The different theories regarding cause, epidemiology, and treatment of gender dysphoria. 3. The surgical goals of sex reassignment surgery in male-to-female transsexualism. 4. The surgical techniques available for sex reassignment surgery in male-to-female transsexualism. BACKGROUND: Gender identity disorder (previously "transsexualism") is the term used for individuals who show a strong and persistent cross-gender identification and a persistent discomfort with their anatomical sex, as manifested by a preoccupation with getting rid of one's sex characteristics, or the belief of being born in the wrong sex. Since 1978, the Harry Benjamin International Gender Dysphoria Association (in honor of Dr. Harry Benjamin, one of the first physicians who made many clinicians aware of the potential benefits of sex reassignment surgery) has played a major role in the research and treatment of gender identity disorder, publishing the Standards of Care for Gender Dysphoric Persons. METHODS: The authors performed an overview of the terminology related to male-to-female gender identity disorder; the different theories regarding cause, epidemiology, and treatment; the goals expected; and the surgical technique available for sex reassignment surgery in male-to-female transsexualism. RESULTS: Surgical techniques available for sex reassignment surgery in male-to-female transsexualism, with advantages and disadvantages offered by each technique, are reviewed. Other feminizing nongenital operative interventions are also examined. CONCLUSIONS: This review describes recent etiopathogenetic theories and actual guidelines on the treatment of the gender identity disorder in male-to-female transsexuals; the penile-scrotal skin flap technique is considered the state of the art for vaginoplasty in male-to-female transsexuals, whereas other techniques (rectosigmoid flap, local flaps, and isolated skin grafts) should be considered only in secondary cases. As techniques in vaginoplasty become more refined, more emphasis is being placed on aesthetic outcomes by both surgeons and patients.
Clitoris↗
Rehabilitation of burn injured patients following lightning and electrical trauma.
Electrical burn injuries are complicated because of damage to many structures including: blood vessels, muscles, nerves, tendons, bone and skin. Surgeons must confront many problems such as wound healing coverage, scarring, loss of nerve and tendons, progressive joint stiffness and amputation. The goals of burn therapists are to achieve wound healing, functional recovery, and good cosmetic results. Rehabilitation is both preventive and therapeutic and is a fundamental part of managing these patients. In this article, rehabilitation is discussed with emphasis on the following: pain management, wound coverage, positioning, splinting, and exercises (range-of-motion and ambulation). The treatment and prevention of hypertrophic scarring is evaluated. Finally, the use of engineering and assistive technologies for rehabilitation of the electrical burn injured patient is discussed. Successful management of electrical burn injured patients involves communication among the different burn specialists, such as surgeons, anesthesiologists, neurologists, nurses, and kinesitherapists; engineers from the garments/prostheses companies; psychologists; and the patient him/herself.
Burns, Electric↗
A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity.
Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.
Adolescent↗
Algorithm in choosing recipient vessels for perforator free flap in breast reconstruction: the role of the internal mammary perforators.
INTRODUCTION: Although the internal mammary (IM) vessels are our first choice as recipient vessels for free flap breast reconstruction, attempts to reduce surgical morbidity led us to adopt an algorithm when choosing recipient vessels. MATERIALS AND METHODS: The IM vessels give direct perforators to the breast. They can be found either superficial or deep to the pectoralis major muscle. If they are of a reasonable calibre they can be considered as recipient vessels. When the perforators are not suitable, the IM vessels are used for the microanastomosis. This protocol was adopted for our patients between June 1999 and December 2002. RESULTS: Breast reconstruction with free flaps was performed on 298 patients with perforator flaps. IM and thoracodorsal (TD) vessels are used in 88% and 3% of cases, respectively. IM perforators were successfully used in 30 cases (9%). The IM perforators used were located at the level of the second and third intercostal space in nine (30%) and 21 (70%) cases, respectively. The average diameters of those perforators were 1 mm (0.5-1.3 mm) for the artery and 1.7 mm (1-3 mm) for the vein. CONCLUSIONS: The IM perforators can be used as recipient vessels for free flaps. This spares the IM vessels for eventual cardiac bypass surgery, avoiding recipient site morbidity and decreasing the postoperative discomfort.
Algorithms↗
Pedicled perforator flaps in breast reconstruction: a new concept.
INTRODUCTION: Pedicled perforator flaps have not been widely described for the breast. The aim of this study is to report our clinical experience with pedicled perforator flaps in breast reconstruction. MATERIAL AND METHODS: Between May 2000 and May 2003, pedicled perforator flaps were used in 31 patients. The indications were immediate partial breast reconstruction and thoracic reconstruction for carcinomatous mastitis or tumour recurrence. Perforators were identified by Doppler preoperatively. The Doppler-located thoracodorsal artery perforator (TDAP) or another perforator such as the intercostal artery perforator (ICAP) was looked for. If the perforators had good calibers, the flaps were then based solely on these perforators. If the perforators were tiny but pulsating, the TDAP flap was harvested as a muscle-sparing latissimus dorsi type I (MS-LD I) with a small piece of muscle (4x2 cm) included to protect the perforators. If the perforators were not-pulsating, a larger segment of the LD muscle was incorporated to include the maximum of perforators (MS-LD II flap). The nerve that innervates the rest of the LD muscle was always spared. If most of the LD was included in the flap, the flap was then classified as MS-LD III. RESULTS: The mean flap dimensions were 20x8 cm. Using this algorithm, the TDAP flap was harvested in 18 cases and the ICAP flap in three cases. In addition, there were 10 MS-LD flaps with a variable amount of muscle. In addition, one parascapular flap was dissected. A successful flap transfer was achieved in all but three patients, in whom limited partial necrosis occurred. Seroma was not encountered at the donor sites of the perforator flaps (0%) compared to four (40%) after a MS-LD flap. CONCLUSION: Our results show that pedicled perforator flaps are additional options for breast surgery and that they may be used whenever an adequate perforator can be found. This technique is safe and reliable if the algorithm described is used when choosing a flap.
Adult↗
Aesthetic and functional considerations in the reconstruction of large skin defects with free flaps.
Free flaps can be used effectively in the primary reconstruction of large defects after resection of large tumors. The ultimate goal is radical excision of tumors and achievement of primary wound healing with a single procedure and long-term local control of disease. Although this can be obtained with the use of free tissue transfer, patients often seek more aesthetic results. Therefore, refinements of reconstructive techniques with minimal functional donor site morbidity are now the gold standard in our practice.
Esthetics↗
What exactly was wrong with the Trilucent breast implants? A unifying hypothesis.
Trilucent soybean oil-filled breast implants were initially announced as the ultimate prostheses for breast augmentation. However, after an increasing number of reports of local complications and hazardous metabolites attributable to lipid oxidation, first the United Kingdom Medical Devices Agency and later the Belgian National Ministry of Health urged all plastic surgeons to contact their patients and advise them to have the implants removed and, if desired, replaced with another type of prosthesis. In our plastic surgery department, 13 patients received bilateral implants with triglyceride-filled prostheses between February and July of 1996, for primary breast augmentation or replacement of previously implanted prostheses. For 12 of those 13 patients, the prostheses have been explanted, because of unilateral breast enlargement attributable to a ruptured prosthesis for five patients and following the recommendation of the Belgian National Ministry of Health for the other seven patients. Before explantation, all patients underwent standard clinical examinations, with assessments of breast shape, volume, and firmness. Blood analyses were performed, with a special focus on liver enzymes, as were urinalyses. Magnetic resonance imaging scans were obtained before explantation; for two patients, the scans revealed a fluid level separating two liquid layers in an intact prosthesis. This is the first report of such a finding. The removed implants were examined for any damage or shell deterioration and for changes in color and viscosity, the weights and volumes were measured and compared with the initial values for the implanted prostheses, and complete biochemical analyses of the accumulated fluid in cases of ruptured prostheses and of the filler material in cases of intact prostheses were performed. This small but well-documented series illustrates the multitude of problems associated with triglyceride-filled implants, including bleeding of the triglyceride filler; shell deterioration, as indicated by a loss of texture and extreme fragility of the implant (with rupture or delamination with a simple finger touch); an increase in osmotic pressure exerted by the degraded filler material; progressive weakening of the outer silicone shell, with influx of plasma proteins of up to 750 kDa, eventually resulting in rupture of the prosthesis; a lack of oxidative stability and the formation of toxic oxidation products; a lack of biocompatibility, with the formation of insoluble organic soap-like material; and a pronounced inflammatory reaction. It is concluded that the sequential and/or simultaneous occurrence of (1) implant bleeding, (2) lipid infiltration of the silicone elastomer, and (3) inflammation attributable to oxidation products provides an overall explanation or unifying hypothesis for the wide variety of adverse events related to soybean oil-filled implants.
Biocompatible Materials↗
Bilateral autogenous breast reconstruction using perforator free flaps: a single center's experience.
The authors present a single center's experience in bilateral breast reconstruction using perforator free flaps. The aim of this study was to show their indications, surgical technique, and results. A series of 53 patients underwent this procedure between February of 1996 and October of 2002. The surgical procedures were performed on patients with bilateral breast cancer (11 patients), patients with unilateral breast cancer and contralateral prophylactic mastectomy (22 patients), patients who had undergone bilateral prophylactic mastectomy (18 patients), a patient with Poland's syndrome, and a patient whose aesthetic breast augmentation had failed. Primary and secondary bilateral breast reconstructions were done in 18 and four patients, respectively. Eighteen patients who had earlier undergone breast reconstruction with implants had a tertiary breast reconstruction. Combined reconstruction (primary with secondary and primary with tertiary reconstruction) was done in 13 patients. Ninety-eight deep inferior epigastric perforator flaps and eight superior gluteal artery perforator flaps were used. The average operative time was 10 hours (range, 8 to 14.5 hours) for the simultaneous bilateral reconstruction. Total flap necrosis occurred in two cases (one deep inferior epigastric perforator flap and one superior gluteal artery perforator flap). Partial flap necrosis was not encountered, and fat necrosis was found in one deep inferior epigastric perforator flap (1 percent). Two pulmonary infections, one deep vein thrombosis, and one cardiac arrhythmia occurred as postoperative complications. The mean hospital stay was 9 days (range, 6 to 20 days). Abdominal bulging was reported in one patient. There were no recurrent disease or cancer manifestations, with an average follow-up of 3.5 years. This series clearly shows that perforator flaps are reliable and useful tools for bilateral breast reconstruction. This technique decreases the donor-site morbidity and offers an excellent aesthetic and long-term outcome and high patient satisfaction.
Adult↗
Autologous breast augmentation by pedicled perforator flaps.
A technique is described for autologous breast augmentation based on perforator flaps of the lateral chest wall. Raising these flaps as perforator flaps implies minimal donor site morbidity; however, the price to pay is a scar underneath the armpit extending from the lateral end of the inframammary fold onto the back. This scar can be relatively well hidden underneath the arm and in the brassiere. Indications depend on the aversion of the patient against prostheses and the extent of available tissue versus the desired augmentation. As typical indications, we would consider the occasional developmental asymmetry, autologous augmentation after contralateral breast reconstruction, or contour surgery in the bariatric patient.
Adult↗
Evaluation of nipple-areola complex sensitivity after the latero-central glandular pedicle technique in breast reduction.
INTRODUCTION: Previous anatomical and clinical studies have shown that nipple-areola sensitivity decreased significantly after conventional superior and inferior pedicle technique for 3-6 months postoperatively. We found it necessary to modify our techniques in breast reduction to achieve a better outcome regarding breast sensation. Since 1999, we have been using a new technique of breast reduction with a latero-central glandular pedicle. The pedicle for the nipple-areola is based on a horizontal septum and it is designed to incorporate the anterior ramus of the lateral branch of the fourth inter-costal nerve and perforator vessels. Using this technique, a prospective study was conducted in order to quantitatively assess the nipple-areola sensitivity. MATERIAL AND METHODS: The sensitivity of the nipple-areola complex (NAC) was evaluated in 20 consecutive patients undergoing breast reduction with the septum-based lateral pedicle technique. The sensitivity was assessed preoperatively, 2 weeks and 3 months postoperatively by the same examiner. The nipple and four cardinal points of the areola were tested. Pressure thresholds were measured with Semmes-Weinstein monofilaments, temperature sensitivity with hot (40 degrees C) and cold (4 degrees C) metal probes and vibratory thresholds with the Biothesiometer. Average sensation of the areola was calculated by means of the four areas tested. RESULTS: Average values of different patterns of sensitivity decreased significantly on the tested areola 2 weeks postoperatively. Three months postoperatively, pressure and vibration values were statistically comparable in averages to preoperative values (nipple: 46.2+/-3.8 versus 34.6+/-2.2 g/mm2 and 6.4+/-1.2 versus 3.7+/-1 micron; areola: 57.4+/-5.7 versus 49+/-6.8 g/mm2 and 6.7+/-1.2 versus 3.1+/-0.6 micron). Concerning the ability to recognise temperature, 27.5 and 20% of patients could not distinguish between cold and hot 3 months after surgery, on the nipple and the areola, respectively. Numbness was found only on two NAC despite the significant decrease of sensitivity after 2 weeks. This may be attributed to postoperative oedema or neuropraxia. CONCLUSION: Our results showed that using the latero-central glandular pedicle technique preserves the sensitivity of the NAC.
Adolescent↗
The latero-central glandular pedicle technique for breast reduction.
The relatively high number of complications and disadvantages of the conventional techniques in breast reduction combined with our expertise in restoring sensation in breast reconstructive procedures, led to the development of a new technique that was crystallised from the traditional techniques and is able to overcome most of their disadvantages. The key issue of the technique is that the nipple is vascularised and innervated on a column of glandular tissue that remains in contact in its posterior part with the pectoralis muscle and its perforators and in its lateral aspect to the lateral pillar of breast tissue. Due to the ptosis that develops during the process of hypertrophy, this column will gain sufficient length to be turned upwards into the new position of the nipple. Resection of glandular tissue is performed cranially, medial and inferior to this column. Undermining of the skin is reduced to an absolute minimum and glandular resections are always performed in the shape of a wedge. In this way, undermining of the breast gland over the pectoralis muscle is avoided. The glandular pedicles are sutured together after loosely fitting the glandular cone with the nipple into its new position. The long term results of the first 68 cases were reviewed and compared to our experience with the superior dermal pedicle technique combined with the vertical scar as described by Lassus and later by Lejour. Due to increased vascularisation of the nipple-areolar complex (NAC), wound complications were markedly reduced with the new technique. Sensation in the NAC was preserved in almost all cases. There was a high satisfaction about the obtained aesthetical results in regard to shape and volume. Increased viability of the NAC, a reduced rate of wound complications and preservation of sensation in NAC are the main advantages of this technique. Additionally, flattening of the NAC is avoided by the support by glandular tissue behind the NAC that improves projection and hereby the aesthetic conic appearance of both breast and nipple.
Adult↗
Perforator flap terminology: update 2002.
The first terminology consensus on perforator flaps, reached in 2001, was reviewed and further simplified following the Sixth International Course on Perforator Flaps.
Humans↗