Nipple-areolar reconstruction: a different approach to skin graft fixation and dressing

Skin grafting treatment of adolescent lower limb avulsion injury

Background

Under the influence of various factors, the number of lower extremity avulsion injuries in adolescents is increasing year by year. The main modality of treatment is skin grafting. There are many types of skin grafting. Although many studies on skin grafting after avulsion injuries have been published in the past few decades, there are differences in the treatment options for adolescents with post avulsion injuries.

Main body

Thorough debridement and appropriate skin grafts are essential for the surgical management of avulsion injuries for optimal prognosis. In the acquisition of grafts, progress has been made in equipment for how to obtain different depths of skin. The severity of the avulsion injury varies among patients on admission, and therefore the manner and type of skin grafting will vary. Especially in adolescents, graft survival and functional recovery are of great concern to both patients and physicians. Therefore, many efforts have been made to improve survival rate and activity.

Conclusion

This review summarizes the principles of treatment of avulsion injuries, the historical development of skin grafts, and the selection of skin grafts, hoping to be helpful for future research.

Guiding Nipple-Areola Complex Reconstruction: Literature Review and Proposal of a New Decision-Making Algorithm

BACKGROUND

Nipple-areola complex reconstruction (NAR) most commonly represents the finishing touch to breast reconstruction (BR). Nipple presence is particularly relevant to the patient's psyche, beyond any shadow of doubt. Many reconstructive options have been described in time. Surgery is easy, but final result is often disappointing on the long run.

METHODS

The goal of this manuscript is to analyze and classify knowledge concerning NAR techniques and the factors that influence success, and then to elaborate a practical evidence-based algorithm. Out of the 3136 available articles as of August 8th, 2020, we selected 172 manuscripts that met inclusion criteria, which we subdivided into 5 main topics of discussion, being the various NAR techniques; patient factors (including patient selection, timing and ideal position); dressings; potential complications and finally, outcomes/patient satisfaction.

RESULTS

We found 92 articles describing NAR techniques, 41 addressing patient factors (out of which 17 discussed patient selection, 14 described ideal NAC location, 10 described appropriate timing), 10 comparing dressings, 7 studying NAR complications, and 22 addressing outcomes and patient satisfaction. We elaborated a comprehensive decision-making algorithm to help narrow down the choice among NAR techniques, and choose the correct strategy according to the various scenarios, and particularly the BR technique and skin envelope.

CONCLUSIONS

No single NAR technique provides definitive results, which is why we believe there is no "end-all be-all solution". NAR must be approached as a case-by-case situation. Furthermore, despite NAR being such a widely discussed topic in scientific literature, we still found a lack of clinical trials to allow for more thorough recommendations to be elaborated.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

Polyurethane Foam Wound Dressing Technique for Areola Skin Graft Stabilization and Nipple Protection After Nipple-Areola Reconstruction

We describe a new wound management technique using a soft dressing material to stabilize the areola skin graft and protect the nipple after nipple-areola reconstruction at the final stage of breast reconstruction. We introduced a center-fenestrated multilayered hydrocellular polyurethane foam dressing material that provides adequate pressure and retains a moist environment for a smooth skin graft "take." Moreover, the reconstructed nipple can be monitored at any time through the fenestrated window for adequate blood circulation. Altogether, this simple and inexpensive wound dressing technique improves the clinical outcome. 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Rapid, Simple, Effective, and Inexpensive Reconstructed Nipple Flap Guard

Nipple reconstruction is a commonly performed component of breast reconstruction. A nipple reconstructed using local skin flaps requires protection from trauma. Here we describe a novel, effective, simple, rapid, inexpensive, and convenient method to protect a reconstructed nipple in the early postoperative period.

The acellular dermal matrix onlay graft for areolar reconstruction

BACKGROUND

Acellular dermal matrix (ADM) has been well described for use in breast reconstruction. The purpose of this study was to describe a novel use for ADM in areolar reconstruction.

METHODS

A total of 19 patients and 24 nipple-areolar complexes of breast cancer or BRCA-positive patients status postmastectomy were treated. After nipple flap reconstruction was completed, the areolar complex was marked at 40-45 mm and de-epithelialized. ADM was reconstituted and cut to size. This was sewn into place as an areolar onlay graft using 5-0 chromic running sutures and a vaseline gauze bolster.

RESULTS

All 24 areola re-epithelialized in an average of 8.1 weeks. Graft take was 100% in 23 areolas, while 1 areola had only 75% graft take. Two patients underwent subsequent nipple projection procedures. Sixteen areolas were tattooed for color, with plans to tattoo the others. All patients had satisfactory transition from native skin to nipple-areolar complex. All surveyed patients stated they would undergo the procedure again. Average follow-up was 15.7 months.

CONCLUSION

The ADM onlay graft for areolar reconstruction is a feasible addition to the plastic surgeon's armamentarium. The primary benefits of this technique are grafting the donor bed of nipple reconstruction, avoidance of a skin graft donor site wound, and prevention of flattening of the breast dome, as seen with primary closure after nipple flap reconstruction. The cost of ADM must be taken into account ($31 per square centimeter), which could be offset by banking excess ADM at the time of breast reconstruction.

Silicone nipple shields: an innovative postoperative dressing technique after nipple reconstruction

BACKGROUND

The newly reconstructed nipple is extremely sensitive to mechanical pressure and shearing forces, which can cause flap necrosis and sloughing of the skin, eventually promoting infection. Current available dressing solutions are cumbersome, inefficient, displeasing, or otherwise not readily obtainable.

METHODS

In this study, 10 patients with newly reconstructed nipples were instructed to use breastfeeding nipple shields as the sole means of nipple dressing after the reconstruction procedure.

RESULTS

No complications were observed overall. Patients reported full adherence to the postoperative dressing regimen as well as ease of use, availability, low costs, and pleasing aesthetic appearance under garments.

DISCUSSION

Silicone breastfeeding nipple shields offer an efficient, affable, cheap, widely available, and aesthetically pleasing form of postoperative dressing for reconstructed nipples. Their use may enhance patient compliance with the dressing regimen and lower the postoperative complication rate.

Surgical outcomes and nipple projection using the modified skate flap for nipple-areolar reconstruction in a series of 422 implant reconstructions

Numerous techniques have been used in an attempt to achieve long-term nipple projection following nipple-areolar reconstruction (NAR). A common setback, however, is the diminution of projection over time; this phenomenon is particularly evident following implant based breast reconstruction. The purpose of this report was thus to evaluate surgical outcomes and long-term nipple projection with the use of "modified skate flap" technique in exclusively implant based postmastectomy reconstructions. A retrospective review was performed for the period between 1993 and 2007. All consecutive patients with 2-staged tissue expander/implant reconstructions followed by NAR using the modified skate flap technique performed by the senior author (P.C.) were identified in a prospectively maintained breast reconstruction database. Only patients with a minimum of 1-year follow-up were included in the study. Patients with a history of irradiation to the breast were excluded from nipple projection assessment. Clinical outcome measurements included long-term nipple projection as well as incidence of complications from the NAR procedure using the modified skate flap technique. Over the 15-year study period, 475 patients underwent 2-staged tissue expander/implant reconstruction followed by NAR using the modified skate flap technique. Of these, there was a total of 292 patients with the minimum requirement of 1-year follow-up post NAR (61% follow-up rate). The total number of reconstructed nipple areolar complexes evaluated in this series was 422 (130 bilateral and 162 unilateral NAR). Forty patients (28 unilateral and 12 bilateral NAR) who received radiation to their breasts were excluded from nipple projection assessment. At a median follow-up of 44 months (range: 12-84 months), mean nipple projection was 2.5 mm (range: 1-4 mm). Minor complications occurred in 7.2% of the patients (n = 292). Skin graft donor site dehiscence was the most common complication (3.1%) followed by partial skin graft nontake of the areola (2.1%). This report documents the largest series of NAR using a single technique in the setting of postmastectomy reconstructions. This technique can be safely performed over breast implants with acceptably low rates of complications and predictable results. Long-term nipple projection over implant reconstructions using this technique is modest and this must be forewarned to patients completing the final stage of their implant reconstruction.

Evaluation of Tielle hydropolymer dressings in the management of chronic exuding wounds in primary care

The concept of moist wound healing is not fully implemented in daily practice in Germany. Thus, the objective of this investigation was to evaluate the use of Tielle hydropolymer dressings in chronic exuding wounds in primary care. A total of 6,993 patients with pressure sores (26.6%), venous leg ulcers (59.8%), diabetic foot disease (9.5%) and other wounds (5.1%) were enrolled into three multicentre, open-label, single-arm, prospective phase-IV studies for an observational period of either 4 or 12 weeks. Within the 4 (12)-week study using Tielle, 43.3% (59.1%) of the wounds healed and 51.6% (36.9%) improved. Wound area was reduced by 78.2% (85.1%). Medium or strong levels of exudates were reduced from 57.4% to 6.7% (4.0%). Cosmetic results were excellent or good in 96.3%. Compared with patients' previous treatment, efficacy and tolerability were assessed as better or much better in 92.5% and 70.4%, respectively. 97.1% of the patients remained free of adverse events. The frequency of dressing changes was reduced from 5 to 3 per week (-43%). Tielle provides an effective and safe dressing in the management of chronic exuding wounds in primary care improving patient's comfort. Due to longer wearing times, Tielle may also be cost saving.

Hydropolymer dressings in the management of wound exudate

In the UK the so-called 'foam' dressings are currently the most widely used absorbent dressings. They can, in certain cases, be particularly useful for the management of exuding wounds. One type of foam dressing--the Tielle hydropolymer adhesive dressing family (by Johnson & Johnson Wound Management)--is a range of five types of hydropolymer dressings: Tielle Original dressing, Tielle Lite dressing. Tielle Plus dressing, Tielle Borderless dressing and Tielle Packing dressing. The Tielle range shares a common basic composition that gives each dressing bacterial barrier properties and the capability of managing exudate by the combined process of absorption and moisture vapour transmission. Each type except Packing can be used as either a primary or as a secondary dressing. The choice should be based on the characteristics of the primary dressing, if any, on the degree of exudate that the wound is producing and on the condition of the surrounding skin. This article aims to give an overview of the Tielle range and a review of research-based clinical and scientific evidence to support the management of differing levels of exuding wounds in everyday clinical practice.

Clinical evaluation of TIELLE* Plus dressing in the management of exuding chronic wounds

This clinical evaluation, which was carried out between May 2000 and January 2001, measured the efficacy and safety of TIELLE* Plus dressing, a novel hydropolymer dressing with super-absorbent properties. In total 2121 patients with leg ulcers (59.1%), pressure ulcers (20.7%), diabetic foot ulcers (10.9%) or other chronic wounds (9.4%) were included in the study. These were recruited by 624 physicians in a German post-marketing study. All wounds had been present for at least 4 weeks prior to treatment with TIELLE* Plus dressings and many had been treated with other dressings previously. Within the observation period of 12 weeks, 43% of the wounds healed and 50.4% were considered as 'improved'. With this combined total of about 95% the subjects clearly benefited from a change in therapy from conventional regimes (in Germany) such as ointments and gauze, but also from modern, moist wound healing dressings such as hydrocolloids. The frequency of side-effects was low at 4.8%. Over 90% of the patients rated the TIELLE* Plus dressing therapy as 'much better' or 'better' tolerated than the previous treatment regime. For the large majority of the patients the quality of life also improved. On the basis of the positive experiences with respect to effectiveness, safety and handling, 96.8% (604) of the participating doctors wanted to adopt TIELLE* Plus dressings in their therapy plan. TIELLE* Plus dressings can be considered as an effective, safe and simple-to-handle wound dressing for therapy of chronic wounds in daily practice. The shortening of healing time and the less frequent change of dressing also make this therapy regime attractive on cost grounds.