Nipple malformations are common congenital or acquired conditions that can have tremendous cosmetic, psychological, breast-feeding, sexual, and hygienic ramifications. Ideal reconstruction of the nipple-areola complex (NAC) requires symmetry in position, size, shape, texture, pigmentation, and permanent projection, and although many technical descriptions of NAC reconstruction exist in the medical literature, there are insufficient data presented to accurately compare outcomes. The current article comprises a thorough review of the literature, exploring the techniques described for NAC reconstruction, comparing reported outcomes and complications, and providing an evidence-based approach to NAC reconstruction. The findings of the review suggest that evidence regarding surgical correction of nipple deformity and complete NAC reconstruction is lacking, and loss of nipple projection over time is a pervasive problem common to all flap techniques. A combination of a single pedicle local flap with tattooing for complete NAC reconstruction is currently the most supported method; however, data concerning which type of reconstruction is best suited to immediate versus delayed and type of breast mound remain to be examined.
he transverse myocutaneous gracilis flap was described for breast reconstruction in 1992 following cadaveric perfusion studies suggesting that transverse orientation of skin paddles lowered the risk of distal skin necrosis compared to vertical orientation. 1 Despite the local popularity of the transverse upper gracilis flap, previously published high donor-site complication rates and a perception of poor patient satisfaction limit its use. [2][3][4][5][6][7][8] Over the past three decades, techniques have developed with modifications likely to decrease donor-site morbidity and improve patient satisfaction. 2,3,9 Transverse upper gracilis flap breast reconstruction accounts for 8 percent of autologous mastectomy defect reconstruction at the reporting institution, making it the most used donor site after the abdomen. The deep inferior epigastric
Background: The optimal management of mallet fractures is controversial. Currently, published evidence does not clearly define the role of surgery in managing these fractures or identify when splinting alone is suitable.Methods: An observational, prospective cohort study was undertaken between 2012 and 2015 evaluating patient experience, and radiological and functional outcomes following mallet fractures managed with splinting alone or surgery combined with post-operative splinting. This study was registered with our local research facility and ethical approval was granted by the New Zealand Northern B Health and Disability Ethics Committee Health and Disability Ethics Committee (HDEC) #13/NTB/202. All patients provided formal written consent. Results: A total of 109 adult patients with 113 mallet fractures were enrolled in the study and 85 patients with 89 fractures completed follow-up. Mean follow-up was 190 days. Fractures initially associated with subluxation of the distal interphalangeal (DIP) joint treated with splinting alone were five times more likely to fail to meet a minimum standard of success than those fixed with surgery. When the fracture fragment occupies between one and two thirds of the joint surface, even in the absence of initial DIP joint subluxation, 13/35 (37%) joints subluxed during splint treatment. Conclusion: This study aids clinicians by highlighting where splinting is likely to fail and providing a means of identifying injuries in which surgery must be considered
Background:
Perioperative fluid management is an important component of enhanced recovery pathways for microsurgical breast reconstruction. Historically, fluid management has been liberal. Little attention has been paid to the biochemical effects of different protocols.
This study aims to reduce the risk of postoperative hyponatremia by introducing a new fluid management protocol.
Methods:
A single-institution cohort study comparing a prospective series of patients managed using a new ‘modestly restrictive’ fluid post-operative fluid management protocol to a control-group managed with a ‘liberal’ fluid management protocol.
Results:
130-patients undergoing microsurgical breast reconstruction, at a single institution during 2021, are reported.
Hyponatraemia is demonstrated to be a significant risk with the original liberal fluid management protocol. At the end of the first post-operative day, mean fluid balance was +2838 ml (+/- 1630ml). 24/65 (36%) patients had low blood sodium level, 14% classified as moderate to severe hyponatremia.
Introducing a new, ‘modestly-restrictive’ protocol reduced mean fluid balance on day one to +844 ml (+/-700) (p=<0.0001). Incidence of hyponatraemia reduced from 36% to 14% (p=0.0005). No episodes of moderate or severe hyponatraemia were detected.
Fluid intake, predominantly oral water, between 8am and 8pm on the first post operative day is identified as the main risk factor for developing hyponatremia (OR 7; p=0.019). Modest fluid restriction, as guided by the new protocol, protects patients from low sodium level (OR 0.25; CI 95%; 0.11-1.61; p=0.0014)
Conclusion:
The original ‘liberal’ fluid management protocol encouraged unrestricted post-operative oral-intake of water. Patients were often advised to consume in excess of 5-litres in the first 24-hours. This unintentionally, but frequently, was associated with moderate to severe hyponatraemia.
We present a new protocol, characterised by early cessation of intravenous fluid and an oral fluid limit of 2100ml/day associated with a significant reduction in the incidence of hyponatraemia and fluid overload.
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