Dermal Flap Research Articles

Preventing Suture Extrusion and Recurrence in Mustarde and Furnas Otoplasties by Using Laterally Based Postauricular Dermal Flap, Long-Term Results.

Prominent ear deformity (PD) is an unacceptable condition of pinna that affects 5% of the population and is associated with emotional stress, behavioral disturbances, and social restrictions in relationships. Conchal hypertrphy, inadequate formation of antihelical fold, earlobe placement ahead than it should be, or various combinations of these changes are main characteristics of PD. Many surgical techniques have been described for the PD.The authors' aim was to present laterally based postauricular dermal flap combination with cartilage-sparing methods and effectiveness of this technique in suture extrusion prevention and reducing the rate of recurrence with long-term results. Forty-one patients had bilateral and 6 patients had unilateral PD, a total of 47 patients with a mean age of 14.48 were operated by using this combined procedure. A laterally based supraperichondrial dermal flap was prepared from a deepithelized elliptical postauricular incision. Mustarde and Furnas suture techniques were used solely for PD correction. The dissected laterally based dermal flap was fixed to the mastoid bone with sutures in stretched position after reshaping the auricular cartilage with sutures. The average helix-mastoid distance was (mm) 16.28 ± 2.36, concha-mastoid angle was 25.71 ± 0.96° on 12-month measurements. The helix-mastoid distance showed an increase of 1 to 3 mm, in the concha-mastoid angle measurements of 1° to 2°. Statistically significant changes were observed between the average preoperative, postoperative 1. month, postoperative 12. month helix-mastoid distances (mm), and month concha-mastoid angle (°) measurements (P = 0.0001). The laterally based postauricular dermal flap technique is an effective method to prevent suture extrusion and recurrence which are the most important complications of otoplasty procedure and easy to apply.

Abstract: Adipofascial Flap Versus ADM: An Intraoperative Selection Algorithm for Implant Coverage in Immediate Breast Reconstruction

PURPOSE: Acellular dermal matrix (ADM) has gained popularity1 to enhance lower pole coverage in immediate implant or expander reconstruction. Advantages of ADM include improved rapid reconstruction, postoperative expander filling and lower capsular contracture. Potential trade-offs include higher seroma, infection2,3 and cost. Alternatives for implant coverage include local fascial flaps and inferior dermal flaps as autologous options in select patients.4,5 Given the controversy about the use of ADM, this study provides an intraoperative algorithm for its selective use and review of clinical outcomes in two-stage immediate breast reconstruction. METHODS: A 2 year retrospective chart review of women who underwent the first-stage of two-stage immediate tissue expander reconstruction following skin-sparing mastectomy by two senior surgeons. Patients who had an inferior dermal flap were excluded. Patients were divided into two groups: Group 1 was reconstructed with ADM as an adjunct, and group 2 had a local adipofascial flap. Primary outcomes measures included intraoperative and first visit expander-fill volume, time to reach final fill volume, expansion ratios and clinic visits. Secondary outcome measures included the size of expander, pain during inpatient stay, and complications. RESULTS: 84 patients (148 expanders) were included: group 1 (ADM) had 41 patients (72 breasts) and group 2 (No ADM) had 43 patients (76 breasts). There were no statistical differences in patient demographics, mastectomy weight (P=0.10), and expander placement plane. There were no significant differences between the two groups of tissue expanders for intraoperative expansion volume (P=0.15), total expansion volume (P=0.28), and number of inflations required (P=0.18). Multivariate models adjusted for expander placement and postoperative radiation demonstrated that ADM patients had 0.13 higher expansion ratio intra-operatively (P=0.02) and at the first postoperative fill (P=0.001), but this did not differ significantly for final expansion volumes (P=0.58). There were 10 complications, 6 in the ADM and 4 in the no ADM groups. Complications were treated conservatively except two patients who had previous radiotherapy and requiring explantation for infection (ADM, N=1) and mastectomy skin flap necrosis (No ADM, N=1). CONCLUSION: We provide an anatomical and simple surgical approach to successfully assess and perform adipofascial flaps for implant coverage. Autologous adipofascial tissue, if present, can provide reliable comparable coverage to the inferior pole of the implant with no increased morbidity, complications, and comparable outcomes and can have a beneficial cost reduction. REFERENCES: 1. Gurunluoglu R, Gurunluoglu A, Williams SA, Tebockhorst S. Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010. Ann Plast Surg. 2013;70(1):103–10. 2. Antony AK, McCarthy CM, Cordeiro PG, et al. Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications. Plast Reconstr Surg. 2010;125(6):1606–14. 3. Berry T, Brooks S, Sydow N, et al. Complication rates of radiation on tissue expander and autologous tissue breast reconstruction. Ann Surg Oncol. 2010;17 Suppl 3:202–10. 4. Saint-Cyr M, Dauwe P, Wong C, Thakar H, Nagarkar P, Rohrich RJ. Use of the serratus anterior fascia flap for expander coverage in breast reconstruction. Plast Reconstr Surg. 2010;125(4):1057–64. 5. Kijima Y, Yoshinaka H, Owaki T, Funasako Y, Aikou T. Immediate reconstruction using inframammary adipofascial flap of the anterior rectus sheath after partial mastectomy. Am J Surg. 2007;193(6):789–91.

Abstract: Nail Bed Defect Reconstruction Using Thenar Fascia Flap and Nail Bed Graft

INTRODUCTION: Split-thickness nail bed graft is the most preferred treatment option for covering nail bed defects.1 However, full-thickness loss of nail bed soft tissue precludes direct graft placement because there is no vascular wound bed for the graft to take.2 To cover such exposed distal phalanx and provide a graft bed, we used thin thenar fascial flaps. In this case series, we present our approach to such refractory defects using a two-stage operation. MATERIALS AND METHODS: Between 2014 and 2016, thenar fascial flaps and nail bed grafts were used in five patients. All the patients had full-thickness nail bed defects due to machines or door jamming incidents, and the sizes of the defects were more than half of the whole nail bed. We designed the flaps as general thenar flaps, performed suprafascial dissection, and elevated the dermal flaps proximally. We then performed subfascial dissection over the thenar muscle from the proximal to the distal direction and turned over the only fascial layer and inset onto the defects. After 2 weeks, the flap was divided, and a split-thickness nail bed graft was taken from the big toe. Tie-over dressings were performed, and the donor sites closed primarily. RESULTS: All flaps survived completely, and all split-thickness nail bed grafts were well taken. The mean follow-up period was 11 months. Nail growth was observed to the end of the distal nail bed without non-adherence, and the overall shape of the new nail was symmetrical to the corresponding finger nail of the contralateral hand. Cosmetic outcomes were excellent. The big toe nail showed partial non-adherence initially, but improved with time. None of the patients experienced any other complications. CONCLUSION: Full-thickness nail bed defects, especially with bony exposures, are difficult to operate with satisfactory results. The thenar fascia flap is extremely thin, yet performs admirably as a wound bed for split-thickness nail bed grafts. Morbidity is minimal at both the thenar and great toe donor sites. Functional and cosmetic outcomes are excellent. It could be an excellent treatment option for these kinds of cases. REFERENCES: 1. Brown RE, Zook EG, Russell RC. Fingertip reconstruction with flaps and nail bed grafts. J Hand Surg Am. 1999 Mar;24(2):345–51. 2. Zook EG. Anatomy and physiology of the perionychium. Hand Clin. 2002 Nov;18(4):553–9

A Revision Restoring Projection after Nipple Reconstruction by Burying Four Triangular Dermal Flaps

BackgroundNumerous techniques have been used to achieve long-term projection of the nipple following nipple-areola reconstruction. However, the reconstructed nipple loses projection over time. We describe a technique that uses local flaps to improve the lost projection of reconstructed nipples.MethodsBetween November 2013 and March 2015, nine patients (11 nipples) underwent revisional nipple reconstruction for lost projection. Only C–H nipple reconstructions were included in this study. The medical history of each patient was reviewed and photographs were taken in front and lateral views. All patients attended routine follow-up visits. Deepithelialized triangular flaps were made on all four sides of the nipple and buried in the opposite corners in order to augment the volume of the nipple. Anchoring sutures were used to attach each triangular flap on the side opposite their point of origin, and the resulting defects were closed directly.ResultsThis procedure was used successfully in nine patients (11 nipples). Adequate projection was achieved in all patients and no complications occurred. The average nipple height was 3 mm before operation, 7 mm one day after operation, 5 mm at the six-month follow-up, and 5 mm at the 12-month follow-up. The average nipple-areolar angle was 164° before the operation, 111° one day after the operation, 130° at the six-month follow-up, and 133° at the 12-month follow-up.ConclusionsThe method described provides a solution to the loss of projection in reconstructed nipples. We recommend this technique because it leads to better projection, greater volume, and a more natural shape.

The role of autografts in the treatment of complicated incisional hernias

Complicated incisional hernias (at least one time recurrent and/or multilocular and/or infected synthetic mesh) still represent a significant problem. Presentation of operating techniques desribed so far, as well as publication of a novel procedure and results invented by the authors. Between 01/2011 and 09/2015, 41 patients with recurrent and/or infected incisional hernias with or without entero- and subcutaneous fistulas were operated using the method of the s.c. double-layer autologous tension free dermal flap technique. An accurate follow-up method and a continuous registration of the results was conducted in case of every patient. The body mass index (BMI) and presence of diabetes mellitus (DM) were distinguished factors out of the patients' clinical data. Surgical complications, bulking or laxity, recurrence and the patients' satisfactory index - among other things - were recorded considering the procedure. Patients' clinical data and results: Average age was 59.2 years (13 male / 28 female) in the cohort. 1, 2, 3 times recurrent incisional hernias had 12, 23, 6 patients, respectively. Average BMI was 32,1 kg/m2. 12 patients were treated with type II diabetes. 13 patients had entero- or subcutaneous fistulas and/or infected synthetic meshes at the time of operations. Average follow-up time was 32 months (2-58 months). Seroma formation was registered in 13 cases (31.7%). Fistula formation was registered in one case (2.4%). Bulking formation or laxity was observed in 3 patients (7.3%) and recurrence was noticed in 3 patients (7.3%), 13, 17 and 19 months later in the postoperative period. All the entero- and subcutaneous fistulas developed prior to the last procedure were completely healed. There was no lethal outcome. The method developed by the authors is recommended and suitable for the solution to complicated and/or infected incisional abdominal wall hernias especially in cases of obese (BMI ≥ 25 kg/m(2)) and diabetic, high risk patients. After acquiring the precise operative technique, the method is safe, feasible and it comes along with lower complication and recurrence rate, compared to other applied and well established ones. Further clinical trials need to be conducted in the future in order to be evaluated definetely this procedure.

Pseudogramma polyacanthacomplex (Serranidae, tribe Grammistini): DNA barcoding results lead to the discovery of three cryptic species, including two new species from French Polynesia.

The Pseudogramma polyacantha species complex was found to harbor cryptic taxonomic diversity with three similar, but genetically divergent, species previously hidden in the complex. The true Pseudogramma polyacantha occurs from French Polynesia to South Africa and has modally 19 (many with 20) segmented dorsal-fin rays, modally 16 segmented anal-fin rays, a relatively short lateral line, no dermal flap or small tentacle dorsally on eye, and extensive scalation on the interorbital, suborbital and dentary. Pseudogramma brederi (previously synonymized with P. polyacantha) is recognized as a valid species occurring from Hawaii to Mauritius and having modally 21 segmented dorsal-fin rays, modally 17 segmented anal-fin rays, a relatively long lateral line, no dermal flap or small tentacle dorsally on eye, and relatively well-developed scalation on the interorbital, suborbital and dentary. Pseudogramma galzini n. sp. is described as a new species known only from French Polynesia and having modally 22 segmented dorsal-fin rays, modally 17 segmented anal-fin rays, a relatively long lateral line, no dermal flap or small tentacle dorsally on eye, and limited scalation on the interorbital, suborbital and dentary. Pseudogramma paucilepis n. sp. is described as a new species known only from French Polynesia and having 20 segmented dorsal-fin rays, modally 16 segmented anal-fin rays, a relatively long lateral line, no dermal flap or small tentacle dorsally on eye, and relatively reduced scalation on the interorbital, suborbital and dentary. A mtDNA COI analysis including all available Pseudogramma sequences shows well-supported genetic divergence between the two new species and among congeners.

Accordion-style pedicle suspension in inferocentral pedicled mammoplasty

Objective: In breast reduction surgery, while the primary objective may appear to be decreasing the breast volume, the ultimate goal is to achieve symmetrical, appealing, and sustainable breast cosmesis. To circumvent late-term ptosis following inferior pedicle mammoplasty, methods such as pedicle suspension to the ribs, support with dermal flaps and grafts, and the use of some alloplastic materials have been proposed. This paper presents a method of folding and fixing the inferocentral pedicle on itself and the underlying pectoral fascia.Methods: Inferocentral pedicled, inverted T-scar reduction mammoplasties were performed on 50 patients from June 2009 to June 2014. The inferocentral pedicle, which was kept narrow and long, instead of the conventional inferior-based pyramidal design, was folded over its de-epithelialised surfaces in an accordion fashion and sutured. The confection was then sutured to the pectoral fascia by its lateral and superior borders for long-term preservation of breast moulding.Results: In inferocentral breast reduction, the quest for a method that achieves appealing and lasting pyramidal breast shape continues.Conclusions: This technique is regarded as a simple and effective method for achieving good short- and long-term results for patients being considered for moderate and advanced breast reduction.

Breast reduction: personal technique.

Macromastia is a health problem that requires the coordination of surgical and medical specialists. Goals of reduction mammaplasty are to alleviate physical, emotional and psychosocial discomforts and to restore a conical-shaped breast, maintaining scars as short as possible. We report our approach for reduction mammaplasty with superior pedicle. Our method combines advantages of round block with vertical scar, using a dermal flap that is fixed to the new mammary crease. We analyzed skin and glandular resection customizing the mammaplasty. The dermal flap works against the weight of residual tissue, maintaining the crease at the desired position with a natural result. Benefits are an excellent projection, short scar, suitable reshaping and patient satisfaction. This technique can be used for mild to severe hypertrophy with various degrees of ptosis. It results in a successful aesthetic outcome with minimal scarring, suitable breast remodeling and natural long-lasting projection.

Nipple reconstruction after implant-based breast reconstruction in radiated patients: A new safe dermal flap

After implant-based breast reconstruction, the nipple reconstruction technique must be carefully chosen, especially in patients with a history of radiotherapy. When the contralateral nipple is not available, using a classical dermal-fat local flap may lead to the implant exposure, and consequently, removal. We describe here a simple nipple reconstruction technique, using a strictly dermal local flap and evaluate its complication rate. All patients who underwent our technique for nipple reconstruction between January 2012 and April 2015 were included in this retrospective study. We described our surgical technique and noted the occurrence of postoperative complications. Forty-nine nipples, in 47 patients with a history of radiotherapy, were reconstructed with our technique. The mean age was 53 years old (range 27-78 years old). The average time between radiotherapy and nipple reconstruction was 42.5 months (range from 4.6 to 274.8 months). The mean follow-up was 30.9 months (range from 6 to 47 months). No implant exposure occurred. Regarding the nipple flap, two partial flap loss and one infection occurred, the whole complication rate was 6.1%. Regarding nipple projection, it was quite low (between 2 and 5mm) after 6 months, but remained stable. Our strictly dermal local flap technique for nipple reconstruction is a safe procedure and represents a good alternative to composite contralateral nipple graft in irradiated patients with an implant-based reconstructed breast.

Four flap suspension technique for prevention of bottoming out after breast reduction.

PurposeBottoming-out deformity is accepted as the most important disadvantage of inferior pedicle breast reduction. For prevention of this deformity, different techniques are used in combination with inferior pedicle. In this study, we aimed to prevent bottoming-out deformity by producing an internal bra effect through combination of inferior pedicle technique with 2 superior and 2 inferior dermal flaps that were raised from each side of the pedicle.MethodsThirteen patients whose medical records became available during the follow-up period at Ankara Training and Research Hospital from January 2010 to January 2015 were included in this study. We retrospectively obtained patient medical records including demographic characteristics and clinical data. Superior dermal flaps were planned on both sides of the pedicle 2 cm inferior to the lower border of areola and inferior dermal flaps were planned 6 cm inferior to the superior dermal flaps. The superior and inferior dermal flaps were secured to the periosteum of the 2nd and 4th ribs respectively with permanent sutures.ResultsPreoperatively, the average distance between the inframammary fold and areola was 13.9 cm (range, 11-18 cm). The average amount of breast parenchymal resection was 745 g (range, 612-1,496 g). The average distance between the inframammary fold and the lower border of the areola was 7.9 cm (range, 7.5-9 cm) on the postoperative first-year measurements.ConclusionIn conclusion, according to our study, suspension technique to prevent bottoming-out deformity is associated with an easier technique without the need for alloplastic or allogenic materials. Since fixation is performed to the ribs instead of soft tissues like the pectoral fascia or muscle, we believe that this fixation is more long lasting and can be an effective alternative to other suspension techniques.

Use of double-layer autologous dermal flap in the treatment of recurrent and/or infected incisional hernias: presentation of the surgical technique and the results of 1-year follow-up-a prospective, consecutive cohort study.

The difficulties of treating recurrent and/or infected incisional hernias are well known in surgical practice. Several surgical techniques and various types of grafts are available for surgeons. This study presents a new surgical technique option together with the results of the 1-year follow-up. The primary aim of the study is to present the surgical technique of the procedure suitable for the treatment of recurrent and/or infected incisional hernias. The secondary aim is to determine the recurrence rate and analyse the surgical complications. The tertiary aim is to present the quality of life test results performed 3, 6 and 12months after the surgery. The authors evaluated the results of 36 recurrent and/or infected incisional hernia surgeries (11 men, average age 60.6years; 25 women, average age 58.9years) performed with their own surgical method in the framework of a tightly controlled, prospective, interventional and observational consecutive cohort study conducted between 1 January 2011 and 31 December 2013 at a university surgical department. The study evaluates the results of the 1-year follow-up period. All 36 patients had at least one recurrence of abdominal wall hernia; 12 of them also had concurrent infection of the synthetic graft and a complicating fistula. The mean BMI was 31.82kg/m(2) (25.2-43.5kg/m(2)). The average size of the abdominal wall defect was 145.9cm(2) (59-275cm(2)). The abdominal wall reconstruction was performed using an autologous, double-layer dermal flap. The grafts, which had been inserted during previous surgeries, were removed completely. The autologous dermal tissue was prepared using the flap harvested during dermolipectomy. The reconstruction was achieved using a tension-free technique. The essence of the abdominal wall reconstruction is the completion of the abdominal wall defect by a double-layer autologous dermal flap. The original abdominal wall defect was not closed by direct sutures. The quality of the prepared dermal flap was histologically evaluated. IAPMS (intra-abdominal pressure monitoring set) was applied to verify intra-abdominal pressure in the post-operative period. The result of the surgeries was assessed using a quality of life questionnaire. No recurrence of the abdominal wall hernia was registered during the 1-year follow-up period. Abdominal bulking was observed in case of three patients (8.3%). Wound infection occurred in one patient (2.77%) and skin dehiscence in two patients (5.55%). Haematoma was registered in case of one patient (2.77%) on the fifth post-operative day. Seroma formation occurred in case of eight patients (22.22%), which required percutaneous tapping. A fistula formation was observed in one patient (2.77%) 45days after the surgery. The intra-abdominal pressure remained moderately elevated during the early post-operative period (9.65-5.76mmHg on post-operative days 1 and 5). Reoperation was performed in one case due to haematoma. No fatality occurred. The 1-year recurrence rate in case of the abdominal wall reconstruction using double-layer autologous dermal flap is favourable. Being compliant with the surgical technique developed, the procedure is safe to perform. The number of surgical site infections and fistula formations is low. Based on the questionnaires evaluated, all patients would choose this method instead of the previous reconstruction(s). The method is cost-effective. Based on the results, this procedure is feasible for the treatment of recurrent and/or infected abdominal wall, incisional ventral hernias in obese "high risk" patients.

Management of vascular crisis of free flaps after reconstruction of head and neck defects caused by tumor resection

To discuss the management of vascular crisis of free flaps after reconstruction of head and neck defects caused by tumor resection. A total of 259 cases of free flap reconstruction performed in the Cancer Hospital of Chinese Academy of Medical Sciences from 2010 to 2013 were retrospectively analyzed, including 89 cases of anterolateral thigh flaps, 48 cases of radial forearm flaps, 46 free fibula flaps, 5 cases of inferior epigastric artery perforator flaps, 5 cases of free latissimus dorsi flaps, one case of lateral arm flap, and one case of medial femoral flap. The surveillance frequency of free flaps was q1h on post-operative day (POD) 1, q2h on POD 2 and 3, and q4h after POD 3. Vascular crises were reviewed for analysis. The incidence rate of vascular crisis was 8.1% (21/259), with 15 males and 6 females. The average age was 54.8 years old (17-68), and the average time of vascular crisis was 100.8 h post-operation (3-432). There were 7 cases of free jejunum flaps and 14 dermal free flaps. Seven of these 21 cases with vascular crisis were rescued by surgery. The success rate of salvage surgery within 72 hours from the primary operation was 54.5% (6/11), significantly higher than that of salvage surgery performed later than 72 hours from primary operation (10.0%, 1/10, P=0.043). There were 14 cases of flap necrosis, two of which died of local infection. Early detection of vascular crisis can effectively improve the success rate of salvage, so as to avoid the serious consequences caused by free flap necrosis.

Skin-reducing mastectomy and immediate breast reconstruction in patients with macromastia.

IntroductionIn women with macromastia, a type IV skin sparing mastectomy is often required to achieve an aesthetically pleasing reconstruction. The introduction of “skin-reducing mastectomy”, which inserts a permanent prosthetic device into a large pouch made by the pectoralis major muscle and an inferior pedicle dermal flap, allows the surgeon to achieve a safe oncologic result plus a cosmetically satisfying reconstruction.ObjectiveWe report here our experience with the skin-reducing mastectomy with the aim of emphasizing the problems associated with the technique.Materials and methodA study was conduced from April 2009 to November 2012, 74 patients with breast cancer were selected then received a skin-reducing mastectomy. The enrolled women satisfied the criteria of Nava. Statistical analysis was conduced to estimate the significance of the outcome results and complication rate.ResultA total of 88 SRMs were performed and the outcomes were as follows: excellent in 34 patients, good in 21, and poor in 8. We recorded 25 % of adverse events and statistic helped us to identify patient related factors whose can increase the complications onset.ConclusionSkin-reducing mastectomy is an indispensable procedure to treat cancer in large and pendulous breasts.The correct patient selection is mandatory to reduce the not negligible complication risk. Skin reducing mastectomy when is well conduced allow to obtain good results with patient satisfaction but, like other breast-conserving surgeries, in some case is not the ultimate solution, because it may require some revisions to maintain the optimum results.To day it be consider relatively safe in selected patient and the gold standard in macormastia immediate reconstruction.

AB024. The penile dermal flap* for defect reconstruction in Peyronie’s disease (PD) deformities

ObjectiveGenerally speaking, historically, two main types of surgical treatments have been used to straighten penis deformity in Peyronie’s disease (PD)*: viz. (I) plication procedures; and (II) assorted graft materials to close defects in the tunica albuginea after plaque/deformity excision/release. Many different techniques have been described under each category. Curiously, flaps* (cf. free grafts), which are widely used in many other surgical applications, have hardly been tried in PD. The first description of a pedicled, epidermis-free, dermal penile skin flap for covering the tunica albuginea defect after plaque incision/excision in PD was made by this author in 1992 at the Milan ISSM meeting. In 1994, at the Singapore ISSM meeting, the penile dermal flap operation was awarded the ISSM’s prestigious biennial Herbert Newman award for best paper in original clinical research in the field of sexual health. In this talk, attention is drawn to the biological and cost advantages of having and using biological auto flaps, and it’s operative technique, advantages and long term results. S. KRISHNAMURTI: ‘Penile dermal flap for defect reconstruction in Peyronie’s disease: operative technique and four years’ experience in 17 patients.’ Int J Impotence Res (1995) 7, 195-208.’ In this presentation, the operative technique in both, circumcised and uncircumcised Peyronie’s disease patients will be shown with slides and videos.MethodsOperative technique video and PPT slides to be shown.ResultsPresented in body of talk.ConclusionsWhen available, simple, autologous local pedicled flap ideal material for PD defect closure.

Clinical efficacy of correction of inverted nipples with an improved periductal dermofibrous flap of twisting and locking principles

Objective To explore effect of modified surgical method for correcting inverted nipple. Methods Eight patients with 15 sides of inverted nipple were collected. Three dermal flaps were designed in the position of 2, 6 and 10 o'clock of the areola, respectively. Subcutaneous tunnels were created among the flaps. The distal parts of dermal flaps were incised and transferred into basal part of another flap in a clockwise direction or counterclockwise direction. The secondary wounds were closed and the neck of nipple was constricted. In the surgical procedure, the mammary duct was kept intact. Results Eight cases of patients with 15 sides of inverted nipples received the modified surgical treatment were followed up for 12-36 months postoperatively. The results of six cases of patients with 11 sides were satisfied and two cases of patients with 4 sides recurred. In all cases the incisions were healed primarily, no nipple necrosis and infection, no blood supply and sensory disorders. Conclusions This surgical procedure not only provides a double support for eversion of nipple but keeps the breast duct intact as well. It is an ideal method for taking account of the nipple shape and function correction. Key words: Inverted nipple; Breast duct; Areola; Dermofibrous flaps

Adaptive body patterning, three-dimensional skin morphology and camouflage measures of the slender filefish Monacanthus tuckeri on a Caribbean coral reef.

The slender filefish is a master of adaptive camouflage and can change its appearance within 1-3 seconds. Videos and photographs of this animal's cryptic body patterning and behavior were collected in situ under natural light on a Caribbean coral reef. We present an ethogram of body patterning components that includes large- and small-scale spots, stripes and bars that confer a variety of cryptic patterns amidst a range of complex backgrounds. Field images were analyzed to investigate two aspects of camouflage effectiveness: (i) the degree of color resemblance between animals and their nearby visual stimuli and (ii) the visibility of each fish's actual body outline versus its illusory outline. Most animals more closely matched the color of nearby visual stimuli than that of the surrounding background. Three-dimensional dermal flaps complement the melanophore skin patterns by enhancing the complexity of the fish's physical skin texture to disguise its actual body shape, and the morphology of these structures was studied. The results suggest that the body patterns, skin texture, postures and swimming orientations putatively hinder both the detection and recognition of the fish by potential visual predators. Overall, the rapid speed of change of multiple patterns, color blending with nearby backgrounds, and the physically complicated edge produced by dermal flaps effectively camouflage this animal among soft corals and macroalgae in the Caribbean Sea.

Results from the ASPIRE study for breast reconstruction utilizing the AeroForm™ patient controlled carbon dioxide-inflated tissue expanders

Therapeutic or prophylactic mastectomy is often indicated for women with breast cancer, or for those at a high risk of developing cancer due to familial history or genetic mutations. Favorable aesthetic and psychological results make prosthetic reconstruction of the breast with placement of tissue expanders followed by permanent implant a popular choice for women diagnosed with breast cancer. This study describes the results of the ASPIRE trial, the objective of which was to provide supportive data to demonstrate the performance and safety of the AeroForm™ System in a population with broader selection criteria than previous studies. Results of the earlier PACE clinical studies (PACE 1 and 2) demonstrated that the AeroForm™ System could be used safely and effectively to achieve the desired expansion necessary for successful breast reconstruction. In the current ASPIRE trial described in the paper, performance of the device was evaluated by successful tissue expansion and exchange to breast implant(s) unless precluded by a non-device related event. Safety data was evaluated based on reported adverse events. A prospective, single center, open-label study in which subjects who met the inclusion criteria and agreed to participate were enrolled and implanted with the AeroForm expander either at the time of mastectomy (immediate) or sometime after mastectomy (delayed). In the event of a bilateral procedure, the expander was implanted in each side. Subjects were followed until the explant of the tissue expander(s) and exchange for silicone or saline breast implant(s). Thirty-four expanders were placed in 21 subjects in the clinical trial; the average age of subjects was 49.7 ± 8.6 years with average BMI of 26.1 ± 4.7. Bilateral procedures accounted for 62% of the total and 88% of the reconstructions were completed with a latissimus dorsi flap (anterior approach) per the investigators standard procedure. Four (12%) of the cases (12%) were completed in two subjects using an inferior dermal flap. Overall success rate was 94% (32/34 breasts) with no device related reconstruction failures. Two subjects failed reconstruction, one due to infection and one due to wound healing issues, both requiring unilateral expander removal and revision surgery. However, successful second stage reconstruction was completed in both subjects in a delayed procedure. The ASPIRE trial reports confirmatory data in a more inclusive patient population than the previous PACE 1 and 2 trials, indicating that the AeroForm Expander, provides a time-saving, needle-free, safe and effective method of tissue expansion for breast reconstruction. There were no device related complications that precluded the subjects from achieving the study goal of a permanent implant exchange. Reported complications are similar to those reported in the literature for tissue expansion procedures. Further development may enable a single dose controller to operate both expanders in a bilateral patient and increase the size range offered with this promising technology.

One stage mastopexy augmentation in the ptotic patient. The superiorly based dermal flap for autologous reinforcement of the inferior pole

The use of one stage mastopexy augmentation in the ptotic patient remains controversial. Expansion of breast volume and reduction of the skin envelope contradict each other and increase the risks of potential complications. By carefully selecting and consenting patients appropriately I describe the use of the superiorly based dermal flap for autologous reinforcement of the inferior pole to increase safety and reliability in one stage mastopexy augmentation. To determine whether the superiorly based dermal flap could provide a safe and reliable method of one stage mastopexy augmentation. 40 one staged mastopexy augmentation procedures were performed on 21 patients. Patients were excluded if they smoked, BMI >30, had significant co-morbidities, had unrealistic expectations, required a nipple lift of >8 cm, wanted >400cc volume in primary cases or >25% increase in volume in secondary mastopexy augmentation. Both round and anatomical implants were used in either the sub glandular or dual plane pocket depending on patient's aesthetic wishes. The average implant size was 290cc and average nipple lift was 5 cm. After an average follow up of 27months there have been no implant based complications, no reoperations and no infections/haematomas/seromas. Careful selection and consent of patients make the use of the superiorly based dermal flap for autologous reinforcement of the inferior pole a safe reliable technique in one stage mastopexy augmentation.

27. All-in-one or one at a time – Single stage dermal flap and nipple reconstruction with simultaneous contralateral reduction versus a multi-stage approach

27. All-in-one or one at a time – Single stage dermal flap and nipple reconstruction with simultaneous contralateral reduction versus a multi-stage approach

Reconstruction of Corner of Mouth for Elder Facial Paralysis by Suspension Nasolabial Fold Dermal Tissue Flap: A Modified Method.

A modified method based on existing static facial sling techniques to reconstruct the corner of mouth for elder facial palsy was developed and reported. According to the anatomy and function of the zygomatic minor and zygomatic major, this technique uses nasolabial dermis as a whole to attach to the orbicularis oris to provide attachment to the whole area. Therefore, in our method, the function of the zygomaticus minor and zygomaticus major were reconstructed by attaching to the zygomatic arch periosteum through such slings. This procedure is effective in improving facial symmetry and obtaining inconspicuous scarring. We believe that our technique is a simple, effective and reliable option for elder facial paralysis.