Secondary Reconstructive Procedures Research Articles

Three-dimensional secondary reconstruction of mistreated zygomatic fractures using patient specific surgical guides and implants.

The zygomatic bone has a great impact on the anterior and lateral projection of the midface as well as the proper position of the globe. Primary alignment of zygomatic fractures is very important as secondary reconstruction is far more challenging. Treatment of misaligned zygoma requires refracturing of the bone to allow for repositioning. Due to the great impact of the zygoma on the projection of the midface, a precise 3D realignment is of great importance. Technology nowadays develops rapidly and allows for superior results in many surgical fields. The use of patient specific surgical guides and fixation plates is becoming more abundant. Using 3D segmentation and design software, we developed a sequence for using 3D planning and printing both for the refracturing stage, avoiding a coronal approach, and for precise repositioning and fixation of the zygoma in the new position. The method is described as well as a unique advanced 3D analysis, allowing for objectively assessing the results. Two cases are presented, including the design and post operative changes. Pre-op, planned and final positions were compared and showed exceptional accuracy allowing for the elimination of human errors which are common in a 3D sensitive procedure such as refracturing of the zygoma. This method can easily be applied to other secondary reconstruction procedures requiring realignment.

Free functional gracilis transfer for reconstruction of isolated anterior deltoid atrophy following surgical proximal humerus fixation

BackgroundPalsy of the clavicular head of the deltoid is a complication after surgical fixation of proximal humerus fractures. Flexion of the shoulder joint may be impaired as a result. Additionally, patients may complain of joint instability, visible atrophy and pain. Where nerve reconstruction is not possible, muscle transfers remain as secondary reconstructive procedures. MethodsThree patients suffering from anterior deltoid palsy after proximal humerus fixation received a free functional gracilis transfer to the shoulder. Postoperatively, patients underwent biofeedback-based rehabilitation. Before and after the intervention, subjective complaints, pain level and active range of motion (ROM) were recorded. At the final follow-up patients completed a Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. ResultsThe surgery was successful in all patients with first muscle signals registered through sEMG approximately four months postoperatively. At the latest follow-up (> 3 years), the patients showed improved shoulder stability and pain scores. In two patients with preoperative restrictions, active ROM improved. The DASH score showed minimal to no disability in two patients and moderate disability in the third. Two patients voiced satisfaction with the restoration of the ventral bulk of the shoulder. ConclusionsThe free functional gracilis muscle transfer is a novel approach for secondary reconstruction in patients with anterior deltoid atrophy who don’t qualify for nerve intervention. It addresses shoulder instability and pain and may improve active ROM. The addition of fresh muscle tissue to the ventral shoulder can improve its natural contour and prevent protrusion of the humeral head.

Secondary solution for breast reconstruction following total DIEP flap loss: A single-center experience after 3270 DIEP flaps

BackgroundTotal DIEP flap failure is a significant concern in autologous breast reconstruction. Literature on secondary reconstruction options following total flap failure is limited. This study outlines the outcomes of patients who underwent reconstruction post-DIEP flap failure at our institution. MethodsWe conducted a retrospective analysis of patients receiving autologous breast reconstruction between 2004-2021. We aimed to identify causes of total DIEP flap failure, outcomes of revision surgery and outcomes of secondary breast reconstruction procedures. ResultsFrom 2004 to 2021, 3,456 free flaps for breast reconstruction were performed, with 3,270 being DIEP flaps for 2,756 patients. DIEP flap failure was observed in 40 cases (1.22%). Bilateral reconstructions had a higher failure rate (2.31%) than unilateral (0.72%). The primary cause was intraoperative complications during flap harvest (18 cases), followed by insufficient arterial perfusion (seven cases). Other causes included postoperative hematoma (seven cases), venous congestion (six cases), and late-onset fat necrosis (two cases). Post-failure, five patients received a second free flap with three cases of repeated flap failure. Twenty patients received IBR with two cases of reconstruction failure, while seven patients received a pedicled Latissimus Dorsi (LD) flap reconstructions with no cases of reconstruction failure. Eight patients declined further reconstruction. ConclusionA second free flap post-DIEP failure was associated with a high risk of reconstruction failure, suggesting the need for careful patient selection. Implant-based and pedicled LD flap seem to be reliable secondary reconstruction options.

"No-back-scar" Latissimus Dorsi Muscle Flap and Tissue Expander: A Valuable Strategy for Secondary Breast Reconstructions.

An overall complication rates for implant-based breast reconstruction (IBBR) have been reported from 29 to 46%, particularly in the setting of adjuvant radiotherapy. Although the majority of the literature describes autologous conversion in such scenario, a microsurgical flap is not always feasible. The aim of the paper is to assess surgical and patient-reported outcomes of breast reconstruction using a Latissimus Dorsi muscle Flap (LDMF), harvested without a back scar, in combination with a tissue expander for a two-staged reconstruction in the setting of a previously failed IBBR. All consecutive patients undergoing a two-stages LDMF IBBR between January 2016 and June 2020 were retrospectively identified. A minimal length vertical incision along the posterior axillary line was used for LD flap harvest. Demographic, clinical and surgical data were collected. Aesthetic outcome was evaluated with the Aesthetic Item Scale, and BREAST-Q was used to assess patients' reported outcomes. Twenty-one patients met the inclusion criteria. Mean age was 45.6 years, and the average follow-up was 41.2months after tissue expander replacement with definitive implant. All patients completed the secondary reconstructive procedure, without major complications both at reconstructive and donor flap site. All women reported to be very satisfied with the final breast reconstruction. Second-attempt implant-based breast reconstruction for patients with a previously failed IBBR is challenging. A conversion from prosthetic to a mixed breast reconstruction with a "no-back scar" LD flap and tissue expander can be considered as a valuable strategy, especially when an abdominal-based autologous breast reconstruction is not feasible or refused by the patients.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The utilization of a perioperative muscle free flap in total ankle arthroplasty: A case report and brief review of the literature

Ankle arthrodesis and total ankle arthroplasty (TAA) are both approaches to surgical treatment of ankle arthroses, with the latter becoming increasingly popular as it maintains ankle mobility. TAA has been associated with complications, including wound persistence, periprosthetic osteolysis, infection, and implant failure, which can be attributed to the area's poor vascularization and soft-tissue quality. In particular, the anterior compartment - solely supplied by the anterior tibial artery – explains the heightened risk of poor outcomes in ankle surgery. The effect of a secondary reconstructive procedure, such as a skin graft or a muscle flap for prosthesis salvage, has been well described in the literature. Muscle flaps are indicated in soft tissue reconstructive procedures because they provide a reliable blood supply and significant tissue volume where there is dead space. Here we outline a case where a 53-year-old male patient received a gracilis muscle free flap after TAA to improve outcomes and as an alternative orthoplastic procedure for patients who otherwise would undergo limb amputation. After several months of physical therapy, the patient is pain-free and active. With this, it can be concluded that a free muscle flap has the potential to be used perioperatively in higher-risk patients to improve TAA outcomes and as an alternative to other procedures that can reduce a patient's quality of life, such as ankle arthrodesis or amputation.

Distal humeral corrective osteotomy for treatment of supracondylar fracture malunions in children.

This study aimed to determine the functional and radiographic outcomes following corrective distal humeral osteotomies for the treatment of supracondylar fracture malunions in children. We hypothesized that such secondary reconstructive procedures could restore a reasonable and near-normal amount of functionality in a large patient cohort at a tertiary referral center. We retrospectively reviewed the clinical and radiological records of 38 children who underwent corrective osteotomy for posttraumatic supracondylar humeral malunion using K-wire fixation. All clinical data were extracted after chart review, including age, sex, dominant side whenever available, follow-up duration, and elbow range of motion preoperatively and at the final visit. Radiographic parameters, including Baumann's angle, humeroulnar angle, humerocondylar angle, and elbow range of motion were evaluated preoperatively, postoperatively, and at the final visit to identify the surgical correction outcomes. The mean age of the patients at fracture was 5.6 (±2.7) years, and the mean age at surgical intervention was 8.6 (±2.6) years. The mean follow-up period of the current series was 28.2 (±31.1) months. Baumann's angle, humeroulnar angle, and humerocondylar angle were successfully restored to physiological ranges (72.6°, 5.4°, and 36.1°, respectively). Postoperatively, elbow extension improved from -22° (±5.7) to -2.7° (±7.2) versus flexion from 115° (±13.2) to 128.2° (±11.1). Three revision surgeries (8%) were encountered. Corrective osteotomy of the distal humerus with K-wire fixation is a reliable method to efficiently correct malunion of the distal humerus in different planes, thereby improving elbow range of motion and appearance. level IV: Retrospective therapeutic study.

An Update on Tissue Contraction in Immediate Breast Reconstruction Using an Adjustable Implant Partially Filled With Air.

Background With the use of nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) techniques, utilizing a prepectoral underfilled adjustable saline implant allows for tissue contraction and thickening of the flap. This procedure allows for immediate reconstruction using an adjustable implant as a spacer with less risk of skin flap compromise and improves cosmetic outcomes. Methods A retrospective chart review of patients presenting to a single surgeon from September 2013 to September 2021 for breast reconstruction utilizing an underfilled prepectoral adjustable implant following SSM or NSM was performed. Baseline patient demographics, clinical information, postoperative complications, conversion to silicone implant, and contraction distance were recorded and analyzed. Results Fifty-four patients underwent prepectoral breast reconstruction using a Spectrum™ adjustable implant following an NSM or SSM. Tissue contraction and skin flap elevation were observed in all patients. The amount of tissue contraction averaged 4.4 cm (mean). Seven patients (12.96%) developed seromas. Four patients (7.41%) developed hematomas in the early postoperative period. Two patients (3.67%) developed capsular contracture. Two patients (3.67%) had a displaced port. After converting the air to saline, 25 patients (46.29%) opted for a secondary reconstructive procedure to exchange the saline implants for silicone gel implants. Conclusion Tissue contraction reduces the need for skin excision in ptotic breasts undergoing reconstruction procedures following NSM or SSM. The partially filled implant initially functions as a spacer to prevent flap adherence to the pectoral muscleand minimizes tension on the flap to promote flap thickening, elevation around the underfilled implant, and maximizes breast projection and overall aesthetic outcome.

The Treatment of Complex Extremity Wounds Using External Tissue Expansion: A Case Series.

The goal of wound reconstruction is the approximation of soft tissue and re-establishment of an acceptable appearance with minimal risk of complications. For large wound closure in the extremities, skin graft and flap reconstruction are common treatments but are associated with a variety of complications. Comparatively, tissue expansion can provide the opportunity to reconstruct large wounds with native, durable, and sensate tissue without significant donor site morbidity. External tissue expansion is less invasive and avoids complications associated with internal expansion. The authors treated 11 patients with varying extremity wound types and sizes with an external tissue expansion device. Patient age ranged from 18 to 68 years with an average age of 43.7 years (SD, ± 13.1 years). Average wound surface area was approximately 235 cm 2 (SD, ± 135.3 cm 2 ). Devices were affixed and left for 7 to 11 days before closure of the wounds. Outcomes were assessed at 2 to 36 weeks postoperative follow-up. All wounds were fully closed after treatment without need for secondary reconstructive procedures. No patient experienced major complications. All patients demonstrated intact sensation within the area of reconstruction equivalent to surrounding tissues. External tissue expansion, an excellent treatment option in extremity reconstruction, is efficacious and associated with lower complication rates compared with internal tissue expansion, skin grafts, and flap reconstruction. Therapeutic, IV.

Firecracker blast injury to the hand in children: Classification of the thumb injury and the functional outcome assessment

The study aimed to analyze the firecracker blast injury to the hand in children and assess the functional outcome. In addition, the article classified the firecracker blast injury pattern to the thumb in children. A retrospective cohort study was conducted between 2012 and 2020, analyzing 31 children sustaining firecracker blast injuries. The functional outcome was assessed. The author also proposed a classification based on the injury involving the webspace, flexor pollicis longus, thenar, adductor, and flexor muscles, neurovascular injury, and fractures/dislocations. There were 30 males and one female with a mean age of 6 years (range 2–13 years). The mean follow-up was 25 months (Range, 12–36 months). The author classified the injury into grades 1 (n = 9 children), 2 (n = 12), 3A (n = 8) and 3B (n = 2) based on the involved structures. All children had better functional outcomes following the reconstructive procedures based on the classification. The grades of injury did not significantly impact the functional outcome (p = 0.96). Despite the complexity and multitude of firecracker blast injuries, children performed better. The classification based on firecracker blast injury involving vital structures is simple, straightforward, and meaningful. It is helpful for decision-making at the first surgery and subsequent secondary reconstructive procedures. IV. • Firecracker blast injuries to the hand in children are complex and multitude in nature. • The vital structures are badly injured. • A new classification based on firecracker blast injury in children is vital. • It is helpful for decision-making at the first surgery and subsequent reconstructive procedures. • The functional outcomes are better in children's injuries.

Rates of revision and secondary reconstruction procedures 8 years following immediate breast reconstruction: Results from the brighter long-term breast reconstruction outcome study

Introduction: High-quality information on the long-term clinical outcomes of different types of immediate breast reconstruction (IBR) including the need for further surgery is currently lacking. The Brighter study aimed to compare the need for revisional surgery and secondary reconstruction by type of IBR to help women make more informed decisions about surgery.

Purposive bone shortening––a technique which aided soft-tissue coverage in a Grade III Gustillo–Anderson Open Distal Third Leg Fracture: A case report and treatment strategy

Problems faced in open fractures of the distal third tibia are usually associated with soft-tissue coverage, infection control, and union of the bone. Tibia is commonly associated with impaired healing if soft tissues are severely damaged. Not all cases can be treated with flaps due to its unavailability in acute settings, high learning curve, and cost. We present the outcomes of a case of an open Grade III-B Gustillo–Anderson distal tibia fracture treated with debridement and deliberate bony shortening which helped in primary closure of the wound. A 61-year-old gentleman, a known hypothyroid, had an alleged history of accidental cut injury over right lower limb by a machine used for cutting trees. He sustained a 7 cm × 4 cm laceration over the anteromedial aspect of the distal tibia with blown-out soft tissues and bone exposed. Wound debridement and stabilization with ankle spanning external fixation were immediately done. Wound could be primarily closed because the tibia and fibula were deliberately shortened during the external fixation. Many free bone fragments were removed during debridement leaving a bony void. One week later bone graft was used to fill the void after redebridement of the wound and wound could be primarily closed. Negative wound therapy was used as an adjuvant. One month later the external fixator was converted to Ilizarov fixator, which was removed at the end of 5 months, showing a fully healed fracture without soft-tissue complications at the end of 6 months follow-up. Debridement and shortening of the open tibia is a powerful technique to provide bony apposition and allow primary wound closure without tension, averting the need for any secondary reconstructive procedures.

6: ICG-Fluorescence Lymphography After Immediate Lymphatic Reconstruction

Purpose:Immediate lymphatic reconstruction (ILR), performed at the time of axillary lymph node dissection (ALND), has demonstrated promising reductions in the development of breast-cancer associated lymphedema. However, questions remain regarding the effects of adjuvant therapies on the continued patency of the lymphaticovenous anastomosis. The aim of our study is to assess lymphographic outcomes, including ICG pattern and LVB patency, following axillary ILR in patients at high risk for breast cancer associated lymphedema..Methods:Baseline ICG studies of 15 patients who underwent ILR were compared to studies obtained during secondary stage breast reconstructive procedures to assess for any changes in lymphatic morphology and transit in the at-risk arm.Results:All 15 patients in this study demonstrated linear lymphatic flow in intra-operative lymphography studies performed during the initial lymphatic reconstruction. An average of 2.4 (range 1-4) LVBs were performed per patient. Only 1 patient in this study group had preservation of in-continuity lymphatics at time of ALND. Followup lymphographic studies showed clear, linear lymphatic transit in 12/15 patients. Of these 12 patients, an average of 2.5 LVBs were performed, 10 received chemotherapy (7 neoadjuvant, 3 adjuvant), and all 12 received post mastectomy radiation (PMRT). Dermal backflow patterns of varying severity were recorded in 3/15 patients, two of whom showed signs of lymphedema prior to their followup study and the last went on to develop clinically detectable lymphedema. Of these 3 patients, an average of 2 LVBs were performed, all received chemotherapy (2 neoadjuvant, 1 adjuvant) and 2/3 underwent PMRT. Of the 12 patients that remain lymphedema-free, 7 post-operative studies demonstrated clear visualization of linear ICG flow from the lymphatics of the arm into the axilla without evidence of lymphatic collateralization. An average of 3 LVBs were performed in this group and 100% of these patients received adjuvant radiation.Conclusion:We have demonstrated that ICG lymphography can be implemented as a post-operative tool to assess lymphatic function in patients who have undergone ILR in the axilla. Post-operative imaging studies in the majority of patients demonstrated linear ICG flow with evidence of lymphatic contractility and velocity similar to baseline studies obtained at the time of lymphadenectomy and ILR. Additionally, ICG flow patterns through the axilla in post-operative imaging studies provided visual evidence supporting sustained LVB patency despite inflammation and tissue fibrosis associated with axillary irradiation.

Do irradiated osteo-articular recycled tumor autografts still hold promise for biological joint reconstruction? Our experience with acetabular and proximal ulna ECRT

BackgroundJoint reconstruction following resection of malignant bone tumors is challenging in itself in spite of several options in hand. Ability to restore joint anatomy, function and mobility while achieving optimal oncological outcomes are the requirement of reconstructions today. While biological reconstructions (allograft or recycled tumor autografts) following tumor bone surgery are popular for intercalary resections not involving the joint, their use for osteo-articular reconstructions are associated with concerns over cartilage and joint health. We have used extracorporeal radiation therapy (ECRT) and re-implantation of the osteoarticular segment as a size matched recycled tumor autograft reconstruction after complex acetabular and proximal ulnar resections; owing to the lack of significantly superior reconstruction alternatives in these locations and also review the current literature on other biological/non-biological reconstruction options. Questions/purposes(1) What are the oncological, reconstruction and functional outcomes with osteo-articular reconstruction using ECRT and re-implantation of recycled tumor autograft for the acetabulum and olecranon? (2) Is there an evidence of cartilage loss, joint damage or avascular necrosis resulting from irradiation of the articular autograft? Methods19 patients with primary bone tumors underwent limb salvage surgery with en-bloc resection and reconstruction using the resected articular tumor bone after treating it with extra-corporeal irradiation of 50–60Gy. These included 16 acetabular and 3 proximal ulnar. While all patients were included for oncological assessment; minimum follow-up of 24 months was considered for final outcome assessment of function and joint status. ResultsMSTS scores of the 16 acetabular reconstruction patients with minimum 2 years follow-up was 87% (26/30). Neither delayed union, non-union at osteotomy sites nor was any fractures reported in the irradiated graft. There was no local recurrence within the irradiated graft and only 1 patient required graft excision for uncontrolled infection. All 3 patients of proximal ulna reconstruction achieved healing and full range of movement of the elbow. Scores of MSTS: 100% (30/30), MEPS: 100 and DASH: zero was achieved. Two patients developed osteonecrosis of the femoral head; one requiring a joint replacement and one awaiting replacement. One patient of acetabular reconstruction has joint space narrowing on radiographs with mild clinical symptoms. ConclusionsExtracorporeal radiotherapy and re-implantation after osteo-articular resection is an oncologically safe option offering promising outcome in our small series. The availability of size-matched graft, thus avoiding inherent problems of allograft also provides a better economic option over endoprosthesis and its associated complications in select sites. The results can deteriorate over time that may require secondary reconstructive procedures like joint replacement. Level of evidenceLevel IV, Therapeutic Study.

Secondary Surgery and Residual Dysplasia Following Late Closed or Open Reduction of Developmental Dysplasia of the Hip.

Outcomes studies following successful closed reduction of late-detected developmental dysplasia of the hip (DDH) reveal high rates of secondary reconstructive surgery with limited comparative data demonstrating lower rates of residual dysplasia with open reduction. The purpose of this study was to compare long-term outcomes, with regard to radiographic evidence of residual dysplasia and secondary reconstructive procedures, between late closed and late open reduction for DDH in patients 6 to 24 months of age at reduction. We identified all patients between 6 and 24 months of age who underwent closed or open reduction for DDH between 1980 and 2008 and were followed until at least 10 years of age. Outcomes included radiographic measurement of acetabular dysplasia after triradiate cartilage closure, development of osteonecrosis, and the need for secondary procedures for residual dysplasia. One hundred and four hips underwent index closed reduction and 54 hips underwent index open reduction. There was no significant difference in the age at reduction (p = 0.07). Among the 116 hips for which initial anteroposterior pelvic radiographs were available, most closed reductions (55%) were performed in International Hip Dysplasia Institute (IHDI) grade-III hips whereas most open reductions (71%) were performed in IHDI grade-IV hips. Analysis of the hips that did not undergo a secondary procedure showed that those with an index open reduction had a greater lateral center-edge angle (mean and standard deviation, 27.2° ± 10.0° versus 22.4° ± 6.8° in the closed reduction cohort; p = 0.02), lower femoral head extrusion index (22.2% ± 8.9% versus 26.0% ± 6.2%; p = 0.04), and lower Sharp angle (43.3° ± 6.0° versus 46.6° ± 3.1°; p = 0.002) at triradiate closure. There was no difference in the prevalence of osteonecrosis (Bucholz-Ogden grades II, III, and IV) between the closed and open reduction cohorts (22% versus 19%, respectively; p = 0.60). Secondary procedures were performed more frequently after closed reduction than after open reduction (47% versus 30%, respectively; p = 0.03). In patients with late reduction of DDH, closed reduction was associated with increased residual dysplasia and it was associated with a higher rate of secondary surgery in those >12 months old despite a decreased severity of displacement based on the IHDI classification. Additional, prospective studies with assessment of functional outcomes are needed to validate these findings. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Lower Extremity Marjolin's Ulcer Reconstruction With Free Anterolateral Thigh Flap: A Case Series of 11 Patients.

BackgroundMarjolin’s ulcer (MU) of lower extremities usually presents with scar contracture and functional disability. They often follow an aggressive course and poor outcome, and require early radical removal. Split-thickness skin grafts, local flaps, or amputation are commonly practiced surgical options for MU. Though free flaps are gaining popularity for various oncoplastic reconstruction, they are not frequently used for MU. A free anterolateral thigh (ALT) flap may have a beneficial role as it provides simultaneous coverage for a large defect after radical tumor and scar excision.MethodsBetween January 2015 and December 2018, 11 patients with lower limb MU reconstructed with free ALT flap were reviewed retrospectively for the surgical procedure, recurrences, and functional outcomes.ResultsMean dimensions of the defect and flaps were 8 cm × 6 cm and 18.91 cm × 11 cm, respectively, and total flap coverage was obtained in nine cases. Marginal flap loss was noted in one and residual contracture in two cases. Functional improvement of the limb was achieved in all cases. Recurrence or disease-related mortality was not seen in any patient after a mean follow-up of 35.82 months.ConclusionsFree ALT flap reconstruction of MU of extremity facilitates most radical tumor and scar-contracture removal and thus reduces the chances of re-ulceration. It facilitates local radiotherapy protocol with the provision of immediate durable coverage. Thus, it has a beneficial role other than a secondary reconstructive procedure. Moreover, an added benefit may be obtained with a “flow-through’ flap” to avoid amputation and improve functional outcomes.

A Comparative Analysis of Outcomes of Free Nipple Areolar Grafting in Autologous Breast Reconstruction.

Preserving the nipple areolar complex (NAC) increases satisfaction in breast reconstruction. This study aims to describe outcomes using free NAC grafts in microvascular breast reconstruction. A case-control study evaluated prospective outcomes of microvascular breast reconstruction with free NAC grafts compared with matched controls with tattoo or local flap nipple reconstruction. Eligible patients for NAC grafting required correction of ptosis or nipple malposition. Postoperative photographs were rated for complications and aesthetics by the four study authors and two additional unbiased board-certified plastic surgeons. Satisfaction was measured with the BREAST-Q. Twenty patients who underwent 35 autologous breast reconstructions were analyzed. Nipple areolar reconstruction with grafts was completed with 13 NACs in 7 patients. The majority of free NAC grafts (11/13, 85%) were completed in immediate reconstruction, and 15% (2/13) were completed in delayed reconstruction. Partial graft hypopigmentation (mean 18.0%, standard deviation [SD] 7.5) was noted in all grafts. Less than half of grafts had areas of depigmentation (6/13, mean 6.1%, SD 7.5). Minor areas of partial loss occurred in 6/13 grafts (mean 2.9%, SD 4.6). Nipple projection was maintained in 54% of nipples (7/13). Depigmentation, hypopigmentation, graft loss, and projection were not statistically correlated with NAC aesthetic or overall aesthetic rating. However, NAC size (p = 0.003), position (p = 0.022), and symmetry (p = 0.028) were all correlated with aesthetic outcomes. Outcomes and satisfaction were similar to those seen with local flap reconstruction, although partial loss was less common in NAC grafts. Nipple reconstruction can successfully be performed in microvascular breast reconstruction using free grafts. Although partial graft hypopigmentation is common, smaller areas of graft loss or depigmentation are anticipated and do not affect aesthetic outcomes. The use of free NAC grafts may allow additional patients to use their own nipples as part of their microvascular reconstruction and avoid secondary NAC reconstruction procedures.

Long-term results in the patients with traumatic hip fracture-dislocation: Important prognostic factors.

Traumatic hip dislocation with or without acetabular fractures can lead to various outcomes of the hip. Long-term follow-up studies on traumatic hip dislocation are few. We conducted a retrospective study of the treatment and long-term outcomes in patients with hip dislocation to determine prognostic factors. From 2001 to 2016, we enrolled 38 patients in our study. All the patients had been diagnosed through radiography or computed tomography. Emergent closed reduction was performed initially. We hypothesized that poor outcomes, including osteonecrosis and traumatic osteoarthritis, are related to specific factors. All the patients had posterior dislocation initially. Closed reduction or open reduction due to irreducible after closed reduction was performed within 6 hours of dislocation in most patients. In total, nine patients had poor outcomes of the hip, including osteonecrosis and traumatic osteoarthritis and total hip arthroplasty. Specific factors that lead to poor outcomes were patient age and timing of reduction. Although end results in severe traumatic hip dislocation are disappointing, conservatism in applying the secondary reconstructive procedure is desirable. In our series, crucial factors for long-term prognosis were patient age and timing of hip reduction.

Interdisciplinary Treatment of Breast Cancer After Mastectomy With Autologous Breast Reconstruction Using Abdominal Free Flaps in a University Teaching Hospital-A Standardized and Safe Procedure.

Background: Breast cancer is the most common malignancy in women. The interdisciplinary treatment is based on the histological tumor type, the TNM classification, and the patient's wishes. Following tumor resection and (neo-) adjuvant therapy strategies, breast reconstruction represents the final step in the individual interdisciplinary treatment plan. Although manifold flaps have been described, abdominal free flaps, such as the deep inferior epigastric artery perforator (DIEP) or the muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) flap, are the current gold standard for autologous breast reconstruction. This retrospective study focuses on the safety of autologous breast reconstruction upon mastectomy using abdominal free flaps.Methods: From April 2012 until December 2018, 193 women received 217 abdominal free flaps for autologous breast reconstruction at the University Hospital of Erlangen. For perforator mapping, we performed computed tomography angiography (CTA). Venous anastomosis was standardized using a ring pin coupler system, and flap perfusion was assessed with fluorescence angiography. A retrospective analysis was performed based on medical records, the surgery report, and follow-up of outpatient course.Results: In most cases, autologous breast reconstruction was performed as a secondary reconstructive procedure after mastectomy and radiotherapy. In total, 132 ms1-TRAM, 23 ms2-TRAM, and 62 DIEP flaps were performed with 21 major complications (10%) during hospital stay including five free flap losses (2.3%). In all cases of free flap loss, we found an arterial thrombosis as the main cause. In 24 patients a bilateral breast reconstruction was performed without free flap loss. The majority of free flaps (96.7%) did not need additional supercharging or turbocharging to improve venous outflow. Median venous coupler size was 2.5 mm (range, 1.5–3.5 mm).Conclusion: Using CTA, intraoperative fluorescence angiography, titanized hernia meshes for rectus sheath reconstruction, and venous coupler systems, autologous breast reconstruction with DIEP or ms-TRAM free flaps is a safe and standardized procedure in high-volume microsurgery centers.

Long-Term Outcomes of Arm Replantation.

Advances in microsurgery have improved the survival rate of arm replantation. However, the functional outcome of the replanted arms remains unpredictable. The authors performed a systematic review to evaluate the long-term outcome of arm replantation and the secondary reconstructive procedures after replantation. All available English literature in the PubMed, Embase, and CENTRAL databases was searched for articles reporting functional outcome of successful arm replantation with follow-up period more than 1 yr. Clinical data were extracted including study characteristics, patient demographic information, functional outcome, and the numbers, types, and timing of secondary surgery. Among these, factors identified to influence overall outcome were reviewed and analyzed. Twenty-nine studies representing 79 arm replantations met the inclusion criteria. A total of 111 secondary procedures were recorded in 23 studies. The average number of secondary surgical procedures was 2.6 per patient. The most common procedures were nerve repair (23.4%), followed by functioning muscle transfer (19.8%), tendon transfer (17.1%), wound coverage (11.7%), contracture release (10.8%), bone repair (9.9%), arthrodesis (5.4%), and others (1.8%). Procedures involving wound coverage and nerve repair were mainly conducted in the early stage within 4 mos after replantation, whereas functioning muscle transfer, tendon transfer, and arthrodesis were mostly performed after 1 yr postoperatively. The satisfied (Chen I and II) functional outcome was achieved in 49.4% patients. The level of amputation and the type of injury have significant impact on final outcomes, whereas patients' age and timing of nerve repair do not. Patients with amputation at the distal third of the arms had a better outcome than those at the proximal and middle third of the arms (P < 0.05), and patients injured by sharp-cut recovered better than those by crush and avulsion (P < 0.05). Optimal outcomes could be achieved in nearly half of patients with arm replantation, although multiple secondary surgical interventions and long periods of recovery are often required.

Autologous breast reconstruction in older women: A retrospective single-centre analysis of complications and uptake of secondary reconstructive procedures

Women aged ≥65 years have the highest age-specific rates of breast cancer incidence in the UK. However, national audit results demonstrate that the rates of post-mastectomy breast reconstruction offered to and performed on this age group are considerably lower than in younger women (Jeevan, 2009). This discrepancy may arise from unsubstantiated concerns over greater medical and surgical risk in older patients (James, 2015). In the present study, the first of its kind in the UK, we sought to evaluate potential differences in postoperative complications following autologous breast reconstruction between young and older patient populations. We conducted a retrospective review of 59 patients (31 'younger' <65 years; 28 'older' ≥65 years) who underwent autologous breast reconstruction at Oxford University Hospitals, between 2008 and 2017. Clinical, operative, and outcome variables were compared across the two age groups. To examine the complete multi-stage process of breast reconstruction as a whole, we also compared rates of uptake of multiple secondary reconstructive and revisional procedures across age groups. Major surgical, minor surgical, and medical complication rates, as well as length of stay, did not differ significantly by age group. The scar revision rate (at the flap donor site) was higher in the <65 group (19.4% vs. 0.0%; p = 0.025). Otherwise, rates of secondary reconstructive and revisional procedures were comparable across both groups. Patients aged ≥65 years were not at a significantly greater risk of complications following autologous breast reconstruction compared to younger patients. Chronological age, in itself, should not influence treatment decisions surrounding breast reconstruction.