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Nasal septal defects can be challenging to repair, given their location, size, and the unique, tri-layered structure of the septum, which includes a thin piece of cartilage positioned between mucosal layers. The report herein presents a case of a 47 year-old woman with a large symptomatic nasal septal perforation, despite saline irrigations and ointment. Placement of a septal button or a traditional surgical approach was not considered because of the extremely large nature of the perforation. We describe the use of a tri-layered fascia lata flap prelaminated with buccal mucosa grafts to successfully repair this complicated defect. Subsequent follow-up visits showed complete repair of the defect and patent nasal passages, without the need for any debulking procedures. Based on these results, we conclude that a prelaminated fascia lata flap is a good reconstructive option for large, complex nasal septal defects, bringing thin, healthy mucosalized tissue to the defect and minimizing future surgical procedures.

BACKGROUND:Raynaud phenomenon causes progressively decreasing blood flow to the extremities, resulting from an imbalance between vasoconstriction and vasodilation. Treatment options include biofeedback, phosphodiesterase inhibitors, calcium channel inhibitors, botulinum toxin injection, or surgical sympathectomy. The authors propose fat grafting to the hands as a method to delay progression of the disease. METHODS:Indications included symptomatic Raynaud phenomenon with failure of previous management. Fat is harvested from abdominal depots. Approximately 30 ml of decanted fat is injected by means of blunt cannulae: 10 to 15 ml in the dorsum of the hand, 2 to 3 ml in the snuffbox, 1 to 2 ml in each dorsal webspace, 3 to 4 ml along the superficial palmar arch, 1 to 2 ml in volar webspaces 2 to 4, and 2 to 3 ml in the first webspace. Patients underwent preoperative and postoperative laser speckle imaging study to assess changes in perfusion. RESULTS:A total of 13 patients were treated (21 hands). Twelve patients had undergone prior botulinum toxin injection, and 11 patients had prior sympathectomies. Findings included reduced pain (average reduction, 6.86 of 10 to 2.38 of 10), fewer cold attacks, improved skin and soft-tissue texture, decrease in ulcerations, and patient-reported improved function. Three patients had no changes. Increased blood flow per imaging was noted in five of 11 hands tested. Six patients had decreased readings on laser imaging. None of the laser speckle imaging changes were statistically significant, and they did not correlate clinically. There were no major complications. CONCLUSIONS:Preliminary results of fat grafting to the hands of patients with Raynaud phenomenon revealed improved symptomatology with evidence suggestive of measurably increased perfusion in some cases. Fat grafting may benefit the management of this patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.

BACKGROUND:Use of the thoracodorsal artery perforator (TDAP) flap in combination with alloplastic devices has been proven to be a safe method of breast reconstruction. However, preoperative irradiation increases the complication rate and thus some consider preoperative radiotherapy a relative contraindication to alloplastic alone reconstruction. We evaluated the long-term outcomes of patients with preoperative radiotherapy who had delayed alloplastic reconstruction with a TDAP flap. METHODS:A retrospective analysis of a prospectively maintained database was performed to identify patients who had received a Latissimus Dorsi (LD), a Muscle Sparing Latissimus Dorsi (MSLD), or a TDAP flap plus a tissue expander or implant between 2005 and 2012. Information regarding patients' primary diagnosis, radiation history, prior breast reconstructions, and complications was collected and analyzed. RESULTS:Sixteen patients who had a total of 16 breast reconstructions with an LD (6) or TDAP/MSLD1 flap (10). Demographic data, device type, co-morbidities and complications were analyzed. The rate of capsular contracture and size asymmetry were higher in the LD group, but there was no difference noted for major complications. Minor complications were also similar between the 2 groups. CONCLUSIONS:Patients who underwent irradiation before TDAP flap did not have a higher complication rate when compared with patients who had a full LD flap following radiation. By integrating well-vascularized, nonradiated tissue of a TDAP flap in reconstruction, overall complication rate may be minimized and the results are comparable to the generally accepted method of utilizing the entire latissimus dorsi muscle.

BACKGROUND:Lower T-junction wound dehiscence following breast reduction surgery or mastopexy constitutes a vexing and grievous complication both to the surgeon and the patient. Treatment modalities that can expedite wound healing and reepithelialization rates are highly craved. The objective of this study was to assess wound healing and epithelialization rates of open wounds following breast reduction and mastopexy wound dehiscence treated with charged polystyrene microspheres (CPM). MATERIALS AND METHODS/METHODS:Five female patients with wound dehiscence and subsequent open wounds following breast reduction and mastopexy were treated with daily with CPMsoaked dressings. Wound closure rates were documented. RESULTS:The wounds showed both accelerated granulation tissue formation as well as swift epithelialization rates. No complications or side effects were encountered. CONCLUSIONS:Charged polystyrene microspheres may offer a new and efficacious way to heal open wounds due to wound dehiscence following aesthetic breast surgery. Further research with a larger patient population is still needed to verify these findings. .

BACKGROUND:Use of the acellular dermal matrix (ADM) in two-stage implant-based breast reconstruction has been widely adopted. Despite an increasing focus on health care costs, few reports have addressed the financial implications of ADM use. This study sought to examine the costs of the two-stage technique with and without ADM, concentrating on the direct variable costs of patient care during the expansion process. METHODS:A retrospective review of a prospectively maintained database was conducted. Data were collected on 132 cases resulting in a second-stage exchange for a permanent implant. The findings showed that AlloDerm was used in 61 reconstructions and Strattice in 23 reconstructions. The primary outcome was the number of fills required to achieve the final expander fill volume. The cost of subsequent patient encounters for expansion was estimated using institutional cost data. RESULTS:The number of fills required to achieve the final volume was higher in the non-ADM group (6.5 ± 1.7) than in the ADM group (3.6 ± 1.4) (p < 0.0001). No significant difference was found in the small fill volumes (<350 ml; 5.3 vs. 3.7; p > 0.05). The difference was significant in the larger fill volumes (>500 ml; 8.3 vs. 3.7; p < 0.05). Relative to non-ADM reconstruction, with AlloDerm at current prices, the cost increase ranged from $2,727.75 for large reconstructions to $3,290.25 for small reconstructions ($2,167.75-$2,739.25 with Strattice). CONCLUSION/CONCLUSIONS:The use of ADM in two-stage reconstruction reduces the number of visits required for reconstructions with 350 ml or more. However, at current pricings, the direct cost of ADM use does not offset the cost savings from the reduced number of visits. LEVEL OF EVIDENCE IV/METHODS: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 .

SUMMARY/CONCLUSIONS:The report herein describes the use of a venocutaneous fistula with angiocatheter attachment and near-infrared spectroscopy device to correct venous congestion of a vertical upper gracilis free flap used for breast reconstruction. This method of mechanical leeching was precisely controlled through monitoring trends in the tissue oxygen saturation levels of the flap, allowing venous congestion to be relieved before it became clinically apparent.