Long-Term Outcome of Nipple Projection Maintenance After Reconstruction with Clover Flap Technique

BACKGROUND

Nipple reconstruction using local skin flap leaves no morbidity in the healthy nipple. However, one disadvantage of this procedure is that the projection is not often maintained. There are few reports on the rate of long-term maintenance of nipple projection. This study aimed to analyze the 5-year results of clover flap (C-F) nipple reconstruction to determine whether it can be used to maintain nipple projection for long periods and to investigate the factors involved in maintenance of nipple projection.

METHODS

Patients that underwent nipple-areola reconstruction using C-F after undergoing a two-stage implant-based breast reconstruction with skin-sparing mastectomy between January 2012 and December 2019 were included. The projection of the reconstructed nipple was measured annually for 5 years postoperatively, and the nipple projection maintenance rate (%) was calculated. The influence of eight factors, namely smoking, irradiation, scarred skin, flap pedicle relative to the mastectomy scar, location of the mastectomy scar, flap suturing, and flap necrosis, on nipple height were evaluated.

RESULTS

Overall, 275 patients were enrolled. The average maintenance rates (%) at 1-5 years after surgery were 47.1, 39.8, 36.4, 34.6, and 33.5. Creating a well-vascularized skin flap, designing the pedicle farther away from the mastectomy scar, choosing a surgical technique involving an oblique scar on the side of the nipple by wrapping the skin flaps, and including an appropriate amount of fat tissue inside the reconstructed nipple are important for nipple projection maintenance.

CONCLUSION

Nipples reconstructed using the C-F technique on the artificial mound achieve excellent long-term result.

LEVEL OF EVIDENCE IV

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Dermatofibrosarcoma protuberans in a young patient with epidermolysis bullosa: a case report

Background

Epidermolysis bullosa is a group of rare inherited skin diseases characterized by blister formation following mechanical skin trauma. Epidermolysis bullosa is associated with increased skin cancer rates, predominantly squamous cell carcinomas, yet to our best knowledge, there is no reported case of dermatofibrosarcoma protuberans in a patient with Epidermolysis bullosa.

Case presentation

Here, we present a 26-year-old man with junctional epidermolysis bullosa, who developed a DFSP on the neck. Initial, the skin alteration was mistakenly not considered malignant, which resulted in inadequate safety margins. The complete resection required a local flap to close the defect, which is not unproblematic because of the chronic inflammation and impaired healing potential of the skin due to Epidermolysis bullosa.

Conclusions

To our best knowledge, this is the first reported case of a skin-associated sarcoma in a patient with EB; however, further investigation is required to verify a correlation.

[The semi-occlusive dressing in treating Allen III and IV fingertip injuries as an alternative to local skin flaps]

BACKGROUND

Fingertip injuries are very common in emergency departments. According to the literature, Allen III and IV fingertip injuries should be treated with local skin flaps. Instead, we have treated these kinds of injuries in recent years with a semi-occlusive dressing. The main purpose of this study was to evaluate the outcome after semi-occlusive dressing therapy with respect to soft tissue cover, recovery of sensibility and duration of disability.

METHODS

We retrospectively analysed 77 fingertip injuries (39 Allen I, 25 Allen II, 9 Allen III, 4 Allen IV) from 2008-2011 in 23 women and 54 men who were treated with a semi-occlusive dressing. The mean age was 36 ± 14 years and the mean follow-up was seven months. The bone was not shortened even if the bone was exposed up to the wound level. The primarily occlusive dressing was left as long as possible and was sealed when necessary. Furthermore, the treatment time with the semi-occlusive dressing and the period of disability was recorded. Patient sensitivity recovery was also analysed.

RESULTS

The mean treatment duration was 21 ± 10 days and the mean duration of disability was 30 ± 17 days. The mean duration of disability was 19 ± 8 days for Allen I injuries, 36 ± 16 days for Allen II, 45 ± 20 days for Allen III and 58 ± 7 days for Allen IV. All patients developed satisfactory tissue cover and sensibility recovery. For amputation injuries of Allen III and IV, we recorded a normal light-touch 2‑point discrimination in the Semmes-Weinstein Test in 77 % and diminished in 23 %. There were no complications like tissue infections, neuroma or osteitis. Also, no secondary flap supply was necessary.

CONCLUSIONS

The semi-occlusive dressing is a good therapy for all kind of fingertip injuries, regardless of the amputation level. Even if the bone is exposed up to the wound level, satisfactory soft tissue cover can be achieved.

Omega (Ω) Advancement Flap: A Circular Flap Design for the Aesthetic Closure of Circular Skin Defect

BACKGROUND

Most skin defects that require reconstruction with a local skin flap have a circular- or oval-shaped pattern. The majority of the skin flaps are planned in an angled shape. Therefore, it may be necessary to modify the shape of the defect or the distal flap border to minimize tissue distortion. We have designed a circular-shaped advancement flap to be compatible with the circular defect.

METHODS

Eighteen cases of reconstruction of skin defects in the face, chest wall, hand and buttock area were performed using the omega advancement flap between 2010 and 2014. In this technique, a circular-shaped flap that has an equal diameter with the defect is planned adjacent to the defect. To facilitate the advancement of the flap and to avoid standing cones, deepithelialized equilateral triangular flaps are designed on both sides of the main circular flap. The circular flap is easily moved to the defect by pulling of the triangular flaps with minimal tension.

RESULTS

All flaps survived without complication such as infection, hematoma or flap necrosis. No secondary surgery was required to correct contour deformities such as standing cones and trap-door deformities. The results were satisfactory aesthetically and functionally.

CONCLUSIONS

The omega advancement flap is an easy and reliable procedure for reconstruction of circular skin defects located on various anatomical regions.

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 .

Occipital pressure sores in two neonates

The preference for a specific head shape can be influenced by people's culture, religious beliefs and race. Modern Chinese people prefer a "talented" head shape, which is rounded and has a long profile. To obtain their preferred head shape, some parents try to change their neonates' sleeping position. Due to these forced sleeping positions, positional skull deformities, such as plagiocephaly, may be present during the first few months of life. In this article, we report two neonatal cases, of Hui nationality and Dongxiang nationality, with occipital pressure sores that were caused by using hard objects as pillows with the intention of obtaining a flattened occiput. The pressure sores were deep to the occipital bone and needed surgical management. These pressure sores caused wounds that were repaired by local skin flaps, after debridement, and the use of external constraints from a dense sponge-made head frame for approximately two weeks. One case recovered with primary healing after surgical operation. The other case suffered from a disruption of the sutured wound, and a secondary operation was performed to cover the wound. These occipital pressure sores are avoidable by providing guidance to the parents in ethnic minorities' area regarding the prevention, diagnosis and management of positional skull deformity.