Introduction While the originally described transverse profunda artery perforator (tPAP) flap is designed to capture the first profunda perforator, our group hypothesized the dominant perforator may not always be captured in this configuration. This study maps the location of dominant profunda perforators using imaging and cadaveric dissections to determine the probability of capturing dominant perforators with the transverse flap design versus the vertical PAP (vPAP) variant. Methods Fifty preoperative magnetic resonance angiogram or computed tomographic angiogram scans (100 total extremities) were examined from autologous breast reconstruction patients between 2015 and 2019. Profunda perforator characteristics that were examined included the distance from the pubic tubercle to the infragluteal fold (IGF), the distance of the perforators from the IGF, distance posterior to the gracilis, the diameter of the perforator at fascial exit, and total number of perforators present. Profunda perforator dissection was performed in 18 cadaveric extremities. Analysis included mean distance from pubic tubercle, distance posterior to the gracilis, diameter at fascial exit, and total number of perforators. Results In imaging analysis, the mean distance from the IGF to the fascial exit of all dominant perforators was 7.04 cm. The mean diameter of the dominant perforator at the fascial exit was 2.61 mm. Twenty-six thighs (26%) demonstrated dominant perforators that exited the fascia greater than 8 cm below the IGF. In cadaver dissections, the mean distance from the pubic tubercle to the fascial exit of all the dominant perforators was 10.17 cm. Nine cadaver specimens (50%) demonstrated perforators that exited the fascia greater than 8 cm below the estimated IGF. Conclusion The dominant perforator can often be missed in the traditional tPAP design. The vPAP incorporates multiple perforators with a long pedicle, excellent vessel diameter, and favorable donor-site.
Background Patients with long-term complications associated with subglandular breast augmentation are being seen in increasing numbers in the Southern California community. Late deformities include a characteristic “slide-down” deformity, as well as capsular contracture, implant wrinkling, and areolar enlargement. Repositioning the implant to a subpectoral pocket is a recognized revisionary technique to treat this problem; however, technical details of how this is accomplished are lacking in the literature. Objectives To review our technique for treating long-term complications associated with subglandular implants using subpectoral repositioning with partial capsule preservation and mastopexy, without the need for an acellular dermal matrix (ADMs) or mesh. Methods Retrospective review of all patients undergoing subpectoral repositioning over the course of six years was performed. Patient data and long-term outcomes were assessed. A technique is presented utilizing a partial capsulectomy that preserves a portion of the capsule as an ADM/mesh equivalent, ensuring adequate implant coverage and preventing window-shading of the pectoralis major muscle. Results Twenty-four patients with subglandular implants and slide-down deformity as well as other associated complications including capsular contracture, implant wrinkling, and enlarged areolas underwent revision surgery with a subpectoral site change. Often, patients presented many years after their initial augmentation (mean 18 years, range 4-38 years). Average patient follow-up was 3.1 years (range 1.0 – 6.8 years). Two patients required minor revisions with local anesthetic while another two revisions required general anesthesia. Conclusions Long-term deformities associated with subglandular breast augmentation can reliably be corrected by subpectoral repositioning, mastopexy, and utilization of residual breast capsule in place of an ADM or mesh.
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Acquired tracheoesophageal fistulas are rare but associated with significant morbidity and mortality. The majority of cases are due to prolonged or complicated endotracheal intubation, tracheostomy, or esophageal malignancy, or subsequent to radiation or chemotherapy for treatment of the latter. Other etiologies include esophageal stenting and complications secondary to endoscopic procedures. The pathophysiology involves chronic inflammation of the esophagus or posterior wall of the trachea, ultimately promoting fistulization between these two structures. Risk factors primarily depend on the etiology; however, excessive balloon pressures and prolonged intubation are among the strongest predictors of acquired tracheoesophageal fistula. In two reported cases, intubation with persistent air leaks resulted in fistulization. Patients present with refractory pneumonia, aspiration, hypoxemia, acute respiratory distress, enteral feed in endotracheal aspirate, or gastric distention following extubation. It can be difficult to distinguish normal functional deterioration from deterioration secondary to intubation. Up to 51% of patients intubated for at least 48 hours may experience dysphagia following extubation. Ultimately, the diagnostic algorithm includes an esophagogram, followed by imaging with computed tomography (CT) scan, and, more recently, CT scan with three-dimensional reconstructions, a bronchoscopy, and an esophagoscopy. Spontaneous closure rarely occurs, and the primary treatment modalities include interventional therapy with stenting via bronchoscopy, esophagoscopy, or surgical correction. Surgical intervention is associated with higher risks due to surrounding vital anatomy and, often, technical challenges requiring multispecialty care. Our case study presents a novel and effective method of repairing a benign acquired tracheoesophageal fistula utilizing the transverse cervical artery flap.
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