Reconstructive Interventions Research Articles

A European comparison of reimbursement in breast reconstruction

AimsCase payment mechanisms have become the principal means of remunerating hospitals in most developed countries. The purpose of this study was to make an international comparison of reimbursement for breast reconstructive surgery. MethodsWe analysed remuneration for unilateral and bilateral female breast reconstruction (pedicled flaps, free flaps, alloplastic procedures) across five different European countries. National grouper software was used to identify Diagnosis Related Groups from which the proceeds were derived. ResultsThe mean reimbursement was € 5593 for pedicled flaps, € 9149 for free flaps and € 4037 for implant-based reconstructions. The highest payments were in Sweden and the lowest in Italy. When adjusting payments by purchasing power parities, the relation among the countries did not change. The Austrian system makes a clear distinction between one-stage and two-stage delayed reconstructive interventions whereas reimbursement in other countries favoured a two-stage approach. Only one of five national reimbursement systems distinguishes between unilateral and bilateral reconstructions. ConclusionsAcross a spectrum of European countries, reimbursement for breast reconstruction was based on similar procedure-specific systems, although there was a wide variation in tariffs and consideration of other factors such as underlying diagnosis. As delivery of healthcare becomes more rationalised, there is a need for individualised reimbursement which correlates directly with activity. Drawing on the experience of different healthcare systems may lead to development of a more robust and fair system of reimbursement.

Reconstructive Restorative Surgical Interventions in Complex Treatment of Children with Legg-Calve-Perthes Disease

For optimization of anatomic and functional treatment results pre- and postoperative roentgenologic data were analyzed for 120 patients aged from 6 to 14 years with Legg-Calve-Perthes disease accompanied by severe affection of epiphysis. Mean follow up period after reconstructive (remodeling) surgical interventions, i.e. corrective osteotomy of the femur, pelvic osteotomy by Salter, combinations of those 2 techniques, triple pelvic osteotomy made up 10 years. It was shown that remodeling of femoral head was possible only when the degree of bone coverage was equal or exceeded 1. If that parameter was below 1 the conditions for deformity progression developed. Roentgenologic variants of the affected joint anatomic structure that enabled to define concretely the indications to a certain type of femoral head surgical remodeling were determined.

Primary and secondary prophylactic nipple-sparing subcutaneous mastectomy (NSSM): A retrospective single-center analysis.

162 Background: Given a strict indication the NSSM is a oncologically safe surgical procedure and allows breast reconstructive interventions with a good cosmetic result. With regard to prophylactic mastectomy (PM) the (radical) ablatio mammae is so far regarded as the therapy of choice, since a maximal removement of the breast glandular tissue seems ensured. So far, it is unclear if NSSM is a oncologically safe treatment option also in the context of prophylactic surgery. The introduction of new materials for tissue extension in plastic-reconstructive interventions such as porcine acellular dermis (Strattice) or titanized polypropylene meshes (TiLoopBra) permits the reconstruction of the natural breast shape and size and thus the preservation of the body integrity also in prophylactic operations. Methods: This is a retrospective analysis of the PM performed at the Department of OB/GYN of the TU München (Munich, Germany) between 01/2005 and 12/2011 (76 cases). Primary PM were done in 13 cases due to positive family history (n=3), BRCA mutations (n=9) or at the request of the patient (n=1). 63 breast cancer patients were operated (secondary contralateral mastectomies) because of a positive familiy history (n=21), BRCA mutations (n=17) or high need for security (n=25). 19 mastectomies and 57 NSSMs were performed. With all NSSMs an instant reconstruction was done (17x expander, 25x implants, 1x TRAM, 14x DIEP), in 42 patients using a tissue extension (titanized poylpropylene meshes or acellular dermis). 9 patients with ablatio mammae received a breast reconstruction. Results: There was a continuous increase in prophylactic operations and NSSMs over the past five years. In four patients there was a coincidental pathological finding diagnosed in the healthy breast (2x DCIS, 1x Ca, 1x CLIS). In the group of primary prophylactic operated patients there were no (pre-)cancerous lesions found. In the secondary PM patients there were no recurrences, secondary cancers or metastases. Conclusions: In conclusion there was no difference between both surgical techniques with regard to oncologic safety. As far as breast reconstructive possibilities are concerned there are clear advantages in NSSM.

Nierenbeckenplastik – pro laparoskopisch

With increasing experience and availability of the da Vinci® robotic surgery system there has been an extension of the indications from initially exclusively ablative interventions, such as nephrectomy and radical prostatectomy to reconstructive interventions, such as pyeloplasty, bladder augmentation and urinary diversion. Laparocopic pyeloplasty has been established for both adults and children, with results comparable to the open procedure. In comparison the conventional laparoscopic procedure is little cost-intensive and therefore widely used. The available literature has to be analysed to find advantages for the cost-intensive, robot-assisted laparoscopic pyeloplasty from which patients can profit.

RECONSTRUCTIVE PLASTIC SURGERY FOR BREAST CANCER

Breast cancer is the most common malignant neoplasm in women. Radical mastectomy is an integral component of its treatment, but this increases survival rates and the number of disabled persons. Emphasis has been recently made on the improvement of quality of life in patients with breast cancer. Today breast reconstructive surgery is an important component in the general treatment regimen. Breast reconstruction ameliorates psychological trauma associated with mastectomy; the women lose a feeling of mutilation, depression, and apprehension of their femininity. A variety of modifications and options for reconstructive interventions creates the choice problem to be solved together with the patient.

Asymmetric Bilateral Variations in the Musculocutaneous and Median Nerves with High Branching of Brachial Artery

Brachial Plexus is formed by the union of the anterior rami of cervical 5, 6, 7, 8 and thoracic 1 nerves. These nerves unite and divide to form the key nerves innervating the upper limb. Variations in the course of these nerves are clinically important to anesthetists, neurologists and orthopedicians. We report bilateral variations in the arterial and neural structures in the upper limb of a 65 year old cadaver. The muscles of the arm on one side were innervated by the median nerve with absence ofmusculocutaneous. While on the other side the musculocutaneous nerve contributed to the formation of the median nerve. There was a presence of high bifurcation of brachial artery on both sides. Knowledge of such variations in the innervations of muscles and the arterial supply of the limbs are important to remember before performing any reconstructive procedures or interventions on the limb.

Fusion of Musculocutaneous Nerve with Median Nerve in the Proximal One - Third of the Arm- A Case Report

During the routine undergraduate dissection of the anterior compartment of the right arm of a 48 years old male cadaver, a communication between musculocutaneous nerve and median nerve was encountered. The musculocutaneous nerve which normally arose from the lateral cord of the brachial plexus (C5, 6, 7) gave a branch to coracobrachialis in the proximal one-third of the arm without piercing it. After that, it was completely fused with the median nerve. The latter was formed normally by the union of the medial and lateral roots from the respective cords of brachial plexus anterior to the brachial artery. The other two muscles of the front of the arm viz. biceps brachii and brachialis were found to be supplied by median nerve. Knowledge of such variations in origin, course, and pattern of branching and distribution of nerves are useful not only for an anatomist but also for surgeons to avoid unnecessary damages during dissection. These types of variations of the nerves of the arm should be considered prior to traumatic evaluations and reconstructive interventions.

The exposed breast prosthesis at the infra-mammary region: treatment by local flaps

Exposure of a breast implant is a matter of grave concern for every plastic surgeon. Basic surgical principles mandate removal of exposed foreign material. Nevertheless, removal of a breast prosthesis involves a huge psychological distress for the patient. In addition, it often requires subsequent reconstructive interventions, and the final cosmetic result may be compromised. In the literature, only a few strategies, concerning management of an exposed prosthesis, have been reported. We present two cases where a successful salvage procedure was achieved by providing tissue support in the critical area by using local flaps. Between July and August 2009, two patients presented with implant exposure at the infra-mammary scar. There were no signs of systemic or local infection. One patient had previously undergone cosmetic breast augmentation; the other patient suffered implant exposure after breast reconstruction following mastectomy. Both patients refused to have their implants removed. After the patients were thoroughly informed about the options and possible risks, they were prepared for an implant salvage procedure. After rinsing both the pocket and implant, an infra-mammary tissue support was provided by means of a local flap. Three procedures were performed in these two patients. Three different flaps were used: an external oblique muscle flap, an adipofascial flap and a posterior capsular flap. In both patients, we were able to salvage the original implant. During a follow-up period of more than 18 months, both patients remained without recurrence, and no capsular contracture occurred. In case of implant exposure in the infra-mammary region and the absence of severe infection, salvage surgery procedures should be considered and form part of the plastic surgeon's armamentarium.

Cost of surgical intervention for reconstructive therapy of HIV-associated facial lipoatrophy

This study aims to assess direct cost of reconstructive interventions with facial fillers for treatment of HIV (human immunodeficiency virus)-associated facial lipoatrophy (FLA). Evaluation was performed on data from patients enrolled in one arm of a comparative study of immediate versus delayed reconstructive treatment of facial lipoatrophy. Median costs were standardized for efficacy, estimated using data reported by physicians and patient reported outcomes. The variations of the results were evaluated with a sensitivity analysis. Evaluation was performed on 66 patients characterized by significant differences in terms of severity of FLA. Total cost resulted of €140,416.15, with a median cost per patient of €2126.04 (interquartile range [IQR]: 1599–2822). Taking into consideration severity of disease, median costs were €1641.67 (IQR: 1326.67–2126.04) and 2557.12 (IQR: 1939.34–2872.04) (P = 0.0) respectively for patients with low and high severity scores at baseline. Significant differences in term of cost-effectiveness ratios were also found between patients with different severity of FLA, and sensitivity analysis showed that these ratios increase with higher severity scores at baseline and vary widely depending on the costs of filler. Although these results cannot be considered representative because of important limitations, the present study suggests the severity of disease as an important determinant of costs.

NEW CONSTRUCTION IN CONDITIONS OF HISTORICALLY DEVELOPED BUILDING OF SAMARA IN VIEW OF BORDERS OF DOMESTIC SPACES

In article the specific character of new construction in conditions of historically developed environment of Samara which basis is the account of the borders which have developed during long-term town-planning evolution domestic spaces is viewed. On this basis strategy of reconstructive intervention in a city fabric of a historical part of Samara is defined.

ANATOMIC VARIATIONS AND asymmetry in Anterior chest wall in women

Kind of mammary glands in women as in an aesthetic sense and in terms of symmetry depends not only on the condition of breast tissue, but also from the anterior contour of the chest. If reconstructive or Augmentation interventions on the type of mammary glands are strongly influenced by the size, shape and location of implants. Understanding the diversity of forms and degree of asymmetry may help in the planning of surgical treatment to achieve an aesthetically acceptable result. According to X-ray computed tomography was obtained to assess the prevalence of anatomic changes and the asymmetry of the anterior chest wall in women. These results underscore the importance of evaluating the contour anterior chest wall at the planning stage of rapid increase in breast cancer in order to achieve predictable aesthetic results.

Preoperative Stimulation of Erythropoiesis in Patients with Anemia

Objective: to comparatively study different postoperative analgesia modes in patients undergoing reconstructive interventions into the abdominal aorta. Subjects and methods. The impact of analgesia on the course of the early postoperative period was comparatively studied in 98 patients. According to the mode of postoperative analgesia, the patients were divided into 3 groups: 1) 35 patients received traditional analgesia with narcotic analgesics (promedol, morphine i.m.); 2) 32 patients had prolonged epidural infusion of 0.2% ropivocaine solution with fractional epidural administration of fentanyl 0.1 mg twice daily; 3) 31 patients were given a combination of epidural naropine and fentanyl with parenteral ketorolac 90 mg/day and paracetamol 3 g/day. The magnitude of pain syndrome was analyzed using the visual analogue scale. The parameters of central hemodynamics (CHD) were estimated applying thoracic tetrapolar rheocardiography. Autonomic homeostatic changes were studied from the cardiac rhythm variability by computer rhythmocardiography. Results. The least magnitude of pain syndrome, the eutonic type of autonomic regulation of the cardiovascular system, and the highest cardiac index values were recorded in Group 3. Conclusion. The use of mul-timodal postoperative analgesia ensures valid analgesia with the stable parameters of CHD and autonomic homeostasis. Key words: analgesia, epidural infusion, visual analogue scale, central hemodynamics, cardiac rhythm variability.

Prostanoids for critical limb ischaemia

Peripheral arterial occlusive disease (PAOD) is a common cause of morbidity and mortality due to cardiovascular diseases in the general population. While numerous treatments have been adopted for different disease stages, there is no option other than amputation for patients presenting with critical limb ischaemia (CLI), unsuitable for rescue or reconstructive intervention. To determine the effectiveness and safety of prostanoids in patients presenting with CLI. The Cochrane Peripheral Vascular Diseases Group searched their trials register (last searched October 2009) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (last searched 2009, Issue 4) for publications describing randomised controlled trials (RCTs) of prostanoids for CLI. We ran additional searches in MEDLINE, EMBASE, LILACS, and SciSearch, and we also contacted pharmaceutical companies and experts, in order to identify unpublished data and trials still underway. Randomised controlled trials describing efficacy and safety of prostanoids compared with placebo or other pharmacological control treatments, in patients presenting with CLI, without chance of rescue or reconstructive intervention. Two authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data. Disagreements were resolved by consensus or by the third author. We retrieved 532 citations which after the first screening resulted in 111 potential studies. Finally, after exclusion of studies of poor quality and a lack of sufficient information, 20 trials were included in the review.Prostanoids seem to have efficacy regarding rest-pain relief (risk ratio (RR) 1.32, 95% confidence interval (CI) 1.10 to 1.57; P = 0.003), and ulcer healing (RR 1.54, 95% CI 1.22 to 1.96). Iloprost also shows favourable results regarding major amputations (RR 0.69, 95% CI 0.52 to 0.93). The more frequently reported adverse events when using prostanoids were headache, facial flushing, nausea, vomiting and diarrhoea. Despite some positive results regarding rest-pain relief, ulcer healing and amputations, there is no conclusive evidence based on this meta-analysis of the long-term effectiveness and safety of different prostanoids in patients with CLI. Further well-conducted, high quality randomised double-blinded trials should be performed.

Emerging patterns in the reconstruction of conflict‐affected countries

This paper introduces the five other contributions that make up this special edition of Disasters. It presents some background on the general issues that surround the reconstruction of conflict-affected countries, before going on to comment on some of the more prominent concerns that have emerged within the sphere of humanitarianism over the past decade or so. To contextualise the overall theme of this special edition, it then points to three areas of commonality among the five substantive papers-namely, issues of 'marketisation', 'politicisation', and 'securitisation'. These, this paper proposes, represent emerging patterns in the reconstruction of conflict-affected countries generally. The focus of this special edition thus has a broader resonance and, as such, it might be considered to be representative of wider geopolitical trends. It is, in sum, argued that these three patterns have combined to narrow the space in which humanitarian and reconstructive interventions into conflict-affected countries are organised and undertaken.

A public health framework to translate risk factors related to political violence and war into multi-level preventive interventions

Political violence, armed conflicts and human rights violations are produced by a variety of political, economic and socio-cultural factors. Conflicts can be analyzed with an interdisciplinary approach to obtain a global understanding of the relative contribution of risk and protective factors. A public health framework was designed to address these risk factors and protective factors. The framework resulted in a matrix that combined primary, secondary and tertiary interventions with their implementation on the levels of the society-at-large, the community, and the family and individual. Subsequently, the risk and protective factors were translated into multi-sectoral, multi-modal and multi-level preventive interventions involving the economy, governance, diplomacy, the military, human rights, agriculture, health, and education. Then the interventions were slotted in their appropriate place in the matrix. The interventions can be applied in an integrative form by international agencies, governments and non-governmental organizations, and molded to meet the requirements of the historic, political-economic and socio-cultural context. The framework maps the complementary fit among the different actors while engaging themselves in preventive, rehabilitative and reconstructive interventions. The framework shows how the economic, diplomatic, political, criminal justice, human rights, military, health and rural development sectors can collaborate to promote peace or prevent the aggravation or continuation of violence. A deeper understanding of the association between risk and protective factors and the developmental pathways of generic, country-specific and culture-specific factors leading to political violence is needed.

Structural Modifications of Colonic Transplant in Plastic Repair of the Esophagus

Structural changes in the colonic transplant were studied after esophagoplasty, carried out for post-burn cicatricial strictures of the esophagus. It was shown that artificial esophagus was liable to hypotony and deformation in delayed periods after reconstructive interventions. Regeneratory and adaptive reactions in the mucosa underlie its restructuring, while under pathological conditions proliferative catarrhal changes predominated in the artificial esophagus. The leading pathomorphological characteristics of the colonic transplant are epithelial degeneration, active, sometimes unbalanced proliferation, hyperplasia and hypersecretion of goblet cells, lymphoplasmacytic infiltration of the stroma paralleled by slight sclerosis. Modifications of the ultrastructural organization of cell populations in the Lieberkuhn crypts are determined by the intensity of pathological processes and are aimed at realization of the cytoprotective potential of the transplant mucosa.

Tissue Engineering in Cleft Palate and Other Congenital Malformations

Contributions from multidisciplinary investigations have focused attention on the potential of tissue engineering to yield novel therapeutics. Congenital malformations, including cleft palate, craniosynostosis, and craniofacial skeletal hypoplasias represent excellent targets for the implementation of tissue engineering applications secondary to the technically challenging nature and inherent inadequacies of current reconstructive interventions. Apropos to the search for answers to these clinical conundrums, studies have focused on elucidating the molecular signals driving the biologic activity of the aforementioned maladies. These investigations have highlighted multiple signaling pathways, including Wnt, fibroblast growth factor, transforming growth factor-beta, and bone morphogenetic proteins, that have been found to play critical roles in guided tissue development. Furthermore, a comprehensive knowledge of these pathways will be of utmost importance to the optimization of future cell-based tissue engineering strategies. The scope of this review encompasses a discussion of the molecular biology involved in the development of cleft palate and craniosynostosis. In addition, we include a discussion of craniofacial distraction osteogenesis and how its applied forces influence cell signaling to guide endogenous bone regeneration. Finally, this review discusses the future role of cell-based tissue engineering in the treatment of congenital malformations.

The Effect of an Augmentation Patella Prosthesis Versus Patelloplasty on Revision Patellar Kinematics and Quadriceps Tendon Force: An Ex Vivo Study

The purpose of this study was to assess the effect of 2 revision reconstructive interventions on patellofemoral joint mechanics in comparison to control. We flexed 8 cadaver knee specimens from 0° to 60° of flexion in a test rig designed to simulate weight-bearing flexion and extension (Oxford rig). Quadriceps tendon extensor force and patellar kinematics were recorded for control total knee arthroplasty (TKA) (normal primary TKA with patella resurfaced) and then for each of the 2 revision patellar interventions (after patelloplasty of typical revision knee patellar bone defect to leave a simple bony shell, and after TKA with augmentation patella resurfacing). Our results demonstrate that patellar kinematics and quadriceps extensor force are optimized when the patella is reconstructed to normal anteroposterior thickness.

Maxillofacial Prosthetic Rehabilitation Using Extraoral Implants

The prosthetic rehabilitation is a surgical alternative in functional-aesthetic facial reconstruction when the conventional reconstructive surgery cannot be applied either because of the psychophysical conditions of the patient or because of an excessive substance loss. From May 2002, 35 facial prosthesis (111 implants) have been positioned. Defects were congenital (N = 12), consequent to trauma (N = 8) and to demolitive surgery for malignant tumors (N= 8), and infection (N = 7). In 4 patients, implants were placed in previously irradiated areas. A total of 111 titanium implants were placed to support 21 auricular prostheses (bilateral in 2 cases), 4 orbital prostheses, 8 nasal prostheses, and 2 complex midfacial prostheses. Implant failure was observed for 2 of the 3 implants placed to support a nasal epithesis in a patient with hepatitis C virus, with an important parodontal disease, who experienced a postinfective necrosis of the nose after a liver transplantation; it was necessary to place an adhesive prosthesis. An implant failure was also observed in a diabetic patient with an extensive midfacial defects due to a mycotic infection, but it did not compromise the retention of the prosthesis. According to our experience, the indication to epithesis is when the conventional reconstructive interventions is inapplicable.

Ischémie bilatérale des plexus lombosacrés avec atteinte de la marche suite à une réparation de fistule aortodigestive secondaire : à propos d’un cas: Revue de la littérature

Objective Aortoenteric fistula is a rare and serious pathology with a high mortality rate (around 50%). The surgery's neurological complications are also rare (around 0.25% of reconstructive interventions); two-thirds are spinal cord infarcts, with the remaining one-third corresponding to cases of ischemic polyradiculopathy. The latter condition is rarely described and appears to have a better functional prognosis. Methodology We report a patient case with aortoduodenal fistula complicated, first by acute haemorrhage and then, by polyradicular damage and a sensorimotor impairment in both legs. Results EMG revealed bilateral damage to the lumbosacral plexus but NMR did not detect any abnormalities. The motor impairment in the legs was linked to sensory damage. We monitored the patient for two years. The initial functional disability score was 68 but it worsened steadily to a maximum value of 126 two years later. Conclusion The paraclinical data (EMG, NMR) and the functional worsening strengthened our diagnosis of bilateral lumbosacral plexus ischemia, which is rarely described. However, the prognosis appears to be better than for infarction of the conus medullaris, the principal differential diagnosis.