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Background: With the development and refinement of techniques most mastectomy patients nowadays are candidates for breast reconstruction. No one surgical technique fits all, however. Treatment choices are driven by patient characteristics and preferences, alongside policy and operational factors. These, in turn, might be expected to differ on several levels of aggregation, for example, countries, regions, and hospitals. The aim of this study was to compare choices for breast reconstruction timing and modality in Uppsala (Sweden), Maastricht (the Netherlands), and Rome (Italy). Methods: In this cross-sectional study, patients presenting for first-time post-mastectomy breast reconstruction in three teaching hospitals were included. The primary study outcomes were breast reconstruction timing and modality. Covariables were body habitus (i.e., body mass index, waist circumference, and mastectomy weight), health-related quality of life assessed with the BREAST-Q Reconstruction module, patient preferences assessed with a self-constructed questionnaire, and shared decision making assessed with the CollaboRATE questionnaire. Statistical tests were used to compare data across study sites. Results: Sixty-six participants were included. The most common choices for breast reconstruction timing and modality were delayed DIEP flaps in Uppsala (53%), immediate DIEP flaps in Maastricht (44%), and immediate prepectoral implants in Rome (92%). Participants in Rome were much slenderer than participants in Uppsala and Maastricht (mean body mass index 21.6, 26.2, and 26.3 kg/m2, respectively; p < 0.05). Participants in Uppsala and Maastricht highly valued material used for the reconstruction; participants in Rome were significantly more concerned with complications, scars, and recovery duration associated with the reconstruction. Conclusions: This study shows large differences in choices for breast reconstruction timing and modality in Uppsala, Maastricht, and Rome. Possible reasons for the observed variation include differences in patient characteristics, patient preferences, reconstructive techniques available, and reimbursement. Level of evidence: Level IV, Therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Autologous fat transfer (AFT) seems to be a new minimal invasive method for total breast reconstruction, yet how patients, surgeons, and laymen evaluate cosmesis is lacking. The aim of this study was to evaluate the aesthetic outcome of AFT (intervention group) for total breast reconstruction post-mastectomy, as compared to implant-based reconstruction (IBR) (control group). Methods: A random and blinded 3D photographic aesthetic outcome study was performed on a selection of 50 patients, scored by three panels: plastic surgeons, breast cancer patients, and laymen. Secondary outcomes included agreement within groups and possible patient characteristics influencing scoring. Results: Breast cancer patients and plastic surgeons did not differ in the aesthetic scores between the treatment groups. In contrast, the laymen group scored AFT patients lower than IBR patients (− 1.04, p < 0.001). Remarkably, mean given scores were low for all groups and overall agreement within groups was poor (ICC < 0.50). Higher scores were given when subjects underwent a bilateral reconstruction and if a mamilla was present. Conclusion: Evaluation of aesthetic outcomes varies greatly. Hence, aesthetic outcome remains a very personal measure and this emphasizes the importance of thorough patient counseling including information on achievable aesthetic results before starting a reconstructive procedure. Level of Evidence III: 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. [ABSTRACT FROM AUTHOR]

Background: Since the number of breast cancer genetic gene testing is increasing, more women opt for bilateral prophylactic mastectomy (BPM) followed by breast reconstruction. However, little is known about the differences in Quality of Life (QoL) after various reconstructive surgeries in this population. In this study, the long-term breast-related, body-related, and health-related QoL between immediate implant-based breast reconstruction (IBBR) and autologous breast reconstruction (ABR) were compared, in women who underwent BPM. Methods: In this cross-sectional study, women who underwent postmastectomy breast reconstruction between January 2015 and December 2018 were invited for an online questionnaire, in which the BREAST-Q, the BODY-Q and the SF-36 were included. Women who underwent BPM and immediate breast reconstruction were included for analysis. Multivariable linear regression analysis was performed to adjust mean differences in patient-reported outcomes between IBBR and ABR for potential confounders. Results: Of the included women (n = 47), 33 underwent ABR and 14 women underwent IBBR following BPM. BREAST-Q scores were in favor of the ABR group before and after adjustment, with statistically significance on Satisfaction with breasts (mean difference 15.8, p = 0.019) and Physical well-being (mean difference 13.5, p = 0.033). None of the mean differences in BODY-Q and SF-36 scores between groups, before and after adjustment, were statistically significant. Conclusion: This study suggests that there is a higher satisfaction with breasts and better physical well-being in women who underwent immediate ABR compared to those who underwent immediate IBBR after BPM. However, these data should be interpreted carefully as a result of selection bias and a small sample size. Level of Evidence: Level III, risk study. [ABSTRACT FROM AUTHOR]

Early detection of vascular compromise after autologous breast reconstruction is crucial to enable timely re-exploration for flap salvage. Several studies proposed non-invasive tissue oximetry for early identification of ischemia of deep inferior epigastric perforator (DIEP) flaps. The present study aimed to explore the utility of non-invasive tissue oximetry following DIEP flap surgery using a personalized oxygenation threshold. Methods: Patients undergoing immediate/delayed DIEP flap surgery were included in this prospective observational study. DIEP flap tissue oxygenation (StO2) was monitored continuously using near-infrared spectroscopy. A baseline measurement was performed by positioning one sensor at the marked position of the major inferior epigastric perforator on the abdomen. A new sensor was positioned postoperatively on the transplanted tissue. In unilateral procedures, postoperative StO2 values of the native breast were also obtained. Measurements were continued for 24 h. Results: Thirty patients (42 flaps) were included. Fourteen patients (46.7%) had an uncomplicated postoperative course. A minor complication was observed in thirteen patients; in five patients, at least one major complication occurred, requiring re-exploration. Median StO2 readings were significantly lower in patients with major complications compared to uncomplicated cases. In fourteen unilateral DIEP flap procedures, StO2 values of the native breast were similar to the preoperative baseline measurement (92%; p = 0.452). Conclusions: Non-invasive tissue oximetry following DIEP flap surgery could aid in early detection of vascular compromise. StO2 values of the native breast and abdominal wall preoperatively can be used interchangeably and can serve as personalized reference value. Level of evidence: Level IV, diagnostic / prognostic study. [ABSTRACT FROM AUTHOR]

Patient expectations of the scar after Mohs micrographic surgery (MMS) are often not realistic, leading to subsequent psychosocial sequelae such as anxiety, depression, and avoidance of social situations. When patient expectations are not met, this may also contribute to a decrease in patient satisfaction after surgery. Therefore, altering expectation levels may change patient satisfaction and psychosocial distress levels after surgery. To assess whether patient satisfaction improves in patients after MMS when patients view the surgical defect prior to reconstruction. Patients undergoing facial MMS between December 2017 and September 2019 were included. Patients received or did not receive a mirror after MMS to view the surgical defect before closing the defect. Patients were asked to complete the Dutch FACE-Q Skin Cancer before, one-week, three-months, and one-year after MMS. A total of 113 patients where included. One-hundred-eight (95.6%), 113 (100%), and 93 (82.3%) questionnaires were completed, one-week, three-months, and one-year follow-up, respectively. Satisfaction with facial appearance and appraisal of scars significantly improved over time for all patients, no such improvement was seen for appearance-related distress. Female patients who looked in the mirror had higher satisfaction with facial appearance than female patients who did not look in the mirror. Also, lower appearance-related distress scores were seen in patients who looked in the mirror prior to a flap reconstruction. Showing the defect in the mirror prior to the reconstruction may result in higher patient satisfaction in female patients and patients before undergoing a flap reconstruction. [ABSTRACT FROM AUTHOR]

Intraoperative indocyanine green (ICG) fluorescence angiography has gained popularity and acceptance in many surgical fields for the real-time assessment of tissue perfusion. Although vasopressors have the potential to preclude an accurate assessment of tissue perfusion, there is a lack of literature with regards to its effect on ICG fluorescence angiography. An experimental porcine model was used to expose the small bowel for quantitative tissue perfusion assessment. Three increasing doses of norepinephrine infusion (0.1, 0.5, and 1.0 µg/kg/min) were administered intravenously over a 25-min interval. Time-to-peak fluorescence intensity (TTP) was the primary outcome. Secondary outcomes included absolute fluorescence intensity and local capillary lactate (LCL) levels. Five large pigs (mean weight: 40.3 ± 4.24 kg) were included. There was no significant difference in mean TTP (in seconds) at baseline (4.23) as compared to the second (3.90), third (4.41), fourth (4.60), and fifth ICG assessment (5.99). As a result of ICG accumulation, the mean and the maximum absolute fluorescence intensity were significantly different as compared to the baseline assessment. There was no significant difference in LCL levels (in mmol/L) at baseline (0.74) as compared to the second (0.82), third (0.64), fourth (0.60), and fifth assessment (0.62). Increasing doses of norepinephrine infusion have no significant influence on bowel perfusion using ICG fluorescence angiography. [ABSTRACT FROM AUTHOR]

Purpose: Lymphedema is a debilitating condition that significantly affects patient's quality of life (QoL). The aim of this study was to assess the long-term outcomes after lymphaticovenous anastomosis (LVA) for extremity lymphedema. Methods: A single-center prospective study on upper and lower extremity lymphedema patients was performed. All LVA procedures were preceded by outpatient Indocyanine Green (ICG) lymphography. Quality of life measured by the Lymph-ICF was the primary outcome. Limb circumference, use of compression garments, and frequency of cellulitis episodes and manual lymphatic drainage (MLD) sessions were secondary outcomes. Results: One hundred consecutive patients, predominantly experiencing upper extremity lymphedema following breast cancer (n = 85), underwent a total of 132 LVAs. During a mean follow-up of 25 months, mean Lymph-ICF score significantly decreased from 43.9 preoperative to 30.6 postoperative, representing significant QoL improvement. Decrease in upper and lower limb circumference was observed in 52% of patients with a mean decrease of 6%. Overall mean circumference was not significantly different. Percentage of patients that could reduce compression garments in the upper and lower extremity group was 65% and 40%, respectively. Number of cellulitis episodes per year and MLD sessions per week showed a mean decrease of respectively 0.6 and 0.8 in the upper extremity and 0.4 and 1.0 in the lower extremity group. Conclusions: LVA resulted in significant QoL improvement in upper and lower extremity lymphedema patients. Limb circumference did not significantly improve but good results concerning compression garments, cellulitis episodes, and MLD sessions were obtained. Additionally, a simple and patient-friendly method for outpatient ICG lymphography is presented. [ABSTRACT FROM AUTHOR]

Background: The gluteal region is one of the many alternative donor sites for autologous breast reconstruction. However, the harvest of the gluteal flap is rather difficult, and the major drawback of gluteal flaps has been the need for position changes for flap harvest and inset. A new approach of a gluteal flap is introduced, based on the septocutaneous perforators of the superior gluteal artery: the septocutaneous gluteal artery perforator (Sc-GAP) makeover flap. Methods: A prospective study was performed in Maastricht University Medical Center between January 2018 and December 2019. Patients who underwent a Sc-GAP makeover flap breast reconstruction in the Maastricht University Medical Center and have had preoperative magnetic resonance angiography (MRA) of the abdomen between January 2018 and June 2019 were included. Results: Nine patients underwent breast reconstruction with thirteen Sc-GAP makeover flaps, of which nine flaps were innervated. Indications were the abdomen not being available as a donor site (n = 4) or the flank region was preferred as a donor site by the patient (n = 5). The total operative time was 430 min on average (range 311–683). Mean flap weight was 638 g (range 370–1004) and the mean ischemia time was 53 ± 9.96 min. Coupler size used was 2.0–2.5 mm. All flaps survived. Conclusion: The Sc-GAP makeover flap overcomes the disadvantages of the conventional gluteal flaps, especially by eliminating the need for position changes during the reconstruction procedure. It is a reliable flap that provides sufficient volume and good esthetic outcomes. Level of evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Patient satisfaction after breast reconstruction is dependent on both esthetics and functional outcomes. In an attempt to improve breast sensibility, a sensory nerve coaptation can be performed. The aim of this study was to objectify the sensory recovery in patients who, by chance, underwent bilateral autologous breast reconstruction with one innervated and one non-innervated flap. It must be emphasized that the intention was to coaptate the sensory nerves on both sides. Methods: The cohort study was carried out in the Maastricht University Medical Center between August 2016 and August 2018. Patients were eligible if they underwent bilateral non-complex, autologous breast reconstruction with unilateral sensory nerve coaptation and underwent sensory measurements using Semmes–Weinstein monofilaments at 12 months of follow-up. Sensory outcomes were compared using t tests. Results: A total of 15 patients were included, all contributing one innervated and one non-innervated flap. All patients had a follow-up of at least 12 months, but were measured at different follow-up points with a mean follow-up of 19 months. Sensory nerve coaptation was significantly associated with better sensation in the innervated breasts and showed better sensory recovery over time, compared to non-innervated breasts. Moreover, the protective sensation of the skin can be restored by sensory nerve coaptation. Conclusions: The study demonstrated that sensory nerve coaptation leads to better sensation in the autologous reconstructed breast in patients who underwent bilateral breast reconstruction and, by chance, received unilateral sensory nerve coaptation. [ABSTRACT FROM AUTHOR]

Purpose: With the BODY-Q, one can assess outcomes, such as satisfaction with appearance, in weight loss and body contouring patients using multiple scales. All scales can be used independently in any given combination or order. Currently, the BODY-Q cannot provide overall appearance scores across scales that measure a similar super-ordinate construct (i.e., overall appearance), which could improve the scales' usefulness as a benchmarking tool and improve the comprehensibility of patient feedback. We explored the possibility of establishing overall appearance scores, by applying a bifactor model to the BODY-Q appearance scales.Methods: In a bifactor model, questionnaire items load onto both a primary specific factors and a general factor, such as satisfaction with appearance. The international BODY-Q validation patient sample (n = 734) was used to fit a bifactor model to the appearance domain. Factor loadings, fit indices, and correlation between bifactor appearance domain and satisfaction with body scale were assessed.Results: All items loaded on the general factor of their corresponding domain. In the appearance domain, all items demonstrated adequate item fit to the model. All scales had satisfactory fit to the bifactor model (RMSEA 0.045, CFI 0.969, and TLI 0.964). The correlation between the appearance domain summary scores and satisfaction with body scale scores was found to be 0.77.Discussion: We successfully applied a bifactor model to BODY-Q data with good item and model fit indices. With this method, we were able to produce reliable overall appearance scores which may improve the interpretability of the BODY-Q while increasing flexibility. [ABSTRACT FROM AUTHOR]

Advancements in reconstructive microsurgery have evolved into supermicrosurgery; connecting vessels with diameter between 0.3 and 0.8 mm for reconstruction of lymphatic flow and vascularized tissue transplantation. Supermicrosurgery is limited by the precision and dexterity of the surgeon's hands. Robot assistance can help overcome these human limitations, thereby enabling a breakthrough in supermicrosurgery. We report the first-in-human study of robot-assisted supermicrosurgery using a dedicated microsurgical robotic platform. A prospective randomized pilot study is conducted comparing robot-assisted and manual supermicrosurgical lymphatico-venous anastomosis (LVA) in treating breast cancer-related lymphedema. We evaluate patient outcome at 1 and 3 months post surgery, duration of the surgery, and quality of the anastomosis. At 3 months, patient outcome improves. Furthermore, a steep decline in duration of time required to complete the anastomosis is observed in the robot-assisted group (33–16 min). Here, we report the feasibility of robot-assisted supermicrosurgical anastomosis in LVA, indicating promising results for the future of reconstructive supermicrosurgery. Reconstructive microsurgery is limited by the precision that human hands can achieve. Here, the authors demonstrate in a randomized clinical pilot trial the feasibility of robot-assisted supermicrosurgery using a dedicated microsurgical robot for the completion of lymphatico-venous anastomosis in the treatment of breast cancer-related lymphedema [ABSTRACT FROM AUTHOR]

Incorporation of new technologies advances surgery in general. One example is robot assistance which can potentially overcome limitations in accessibility, dexterity, and ergonomics, thereby improving outcome of surgical procedures. To date, robot assistance has been used successfully in various fields of surgery. Also, in microsurgery robot assistance could offer great advantages as it requires great precision and meticulous technique. Currently available surgical robotic platforms are primarily designed for endoscopic procedures and lack the specific requirements for true microsurgery. Therefore, plastic surgeons of the Maastricht University Medical Center (Maastricht, the Netherlands) teamed up with engineers from the Eindhoven University of Technology (Eindhoven, the Netherlands) and developed the first dedicated robotic platform for (super)microsurgery, the MicroSure Robot (MSR). Level of evidence: Level V, therapeutic study. [ABSTRACT FROM AUTHOR]

Purpose: Breast cancer-related lymphedema (BCRL) is caused by an interruption of the lymphatic system after breast cancer treatment. Lymphaticovenous anastomosis (LVA), by which one or more patent lymphatic collecting vessels are connected to subcutaneous veins, shows promising results. Postoperatively, the patency of these anastomosis can be evaluated; however, little is known concerning the long-term patency after LVA in patients with BCRL. The aim of this study was to analyse the long-term patency, quality of life (QoL) and arm circumference after LVA, and to explore differences between patent and non-patent anastomosis and its correlation with clinical improvement. Methods: Twenty-five patients underwent indocyanine green (ICG) lymphography, lymph ICF-questionnaire, and arm circumference measurement preoperatively and 12 months after the LVA procedure. Results: Seventy-six percent of the patients showed at least one patent anastomosis after 12 months. Quality of life according to the Lymph-ICF increased significantly (p < 0.000); however, arm circumference showed no significant decrease. Sixty-five percent discontinued wearing compression stockings. The patent anastomosis group, compared with the non-patent anastomosis group showed, without significance, more improvement in QoL, arm circumference, and discontinuation of compression stockings, as well as a lower rate of infections both pre- and postoperatively, a shorter duration of lymphedema preoperatively, and a higher rate of early lymphedema and ICG stage. Conclusions: LVA showed an acceptable patency and positive correlation between a patent anastomosis and clinical improvement after 12 months. Further research with a larger study population is required to determine whether outcomes or patient characteristics significantly correlate with a patent anastomosis after LVA operation. [ABSTRACT FROM AUTHOR]

Background: Acellular matrices (AM) might enable a direct single-stage breast reconstruction procedure resulting in an improved efficacy of the reconstruction phase for patients. Safety concerns are an important issue due to a recent study which shows that single-stage breast reconstruction with Strattice™ resulted in more complications versus a two-stage reconstruction. Therefore, the goal of this study is to compare the short- and long-term complications of a single-stage breast reconstruction with the use of two types of AM (Strattice™ and Meso Biomatrix®) versus two-stage breast reconstruction without the use of an AM.Methods: Cohort study with single-stage breast reconstruction with Strattice™ (n = 28) or Meso BioMatrix® (n = 20) or two-stage breast reconstruction without an AM (n = 36) at the Maastricht Academic Hospital, the Netherlands. All complications, in particular major complications with the need for re-admission to the hospital, re-exploration, and implant explantation, were the primary outcome measures. A 1-year follow-up was achieved for all patients.Results: Baseline characteristics of all 52 patients were similar between groups. There was a significantly higher complication rate in the single-stage AM groups with loss of the implant in 40.0% of the breasts from the Meso BioMatrix® group and in 10.7% of the Strattice™ group compared to no implant loss in the control group.Conclusions: This cohort study clearly suggests that the use of a single-stage breast reconstruction is not safe with the use of these AMs. Well-designed prospective studies that guarantee the safety of those matrices should be published before these AMs are used in implant-based surgery.Level of Evidence: Level III, risk / prognostic study. [ABSTRACT FROM AUTHOR]

Background: Near-infrared fluorescence (NIRF) imaging technique, after administration of contrast agents with fluorescent characteristics in the near-infrared (700-900 nm) range, is considered to possess great potential for the future of plastic surgery, given its capacity for perioperative, real-time anatomical guidance and identification. This study aimed to provide a comprehensive literature review concerning current and potential future applications of NIRF imaging in plastic surgery, thereby guiding future research.Methods: A systematic literature search was performed in databases of Cochrane Library CENTRAL, MEDLINE, and EMBASE (last search Oct 2017) regarding NIRF imaging in plastic surgery. Identified articles were screened and checked for eligibility by two authors independently.Results: Forty-eight selected studies included 1166 animal/human subjects in total. NIRF imaging was described for a variety of (pre)clinical applications in plastic surgery. Thirty-two articles used NIRF angiography, i.e., vascular imaging after intravenous dye administration. Ten articles reported on NIRF lymphography after subcutaneous dye administration. Although currently most applied, general protocols for dosage and timing of dye administration for NIRF angiography and lymphography are still lacking. Three articles applied NIRF to detect nerve injury, and another three studies described other novel applications in plastic surgery.Conclusions: Future standard implementation of novel intraoperative optical techniques, such as NIRF imaging, could significantly contribute to perioperative anatomy guidance and facilitate critical decision-making in plastic surgical procedures. Further investigation (i.e., large multicenter randomized controlled trials) is mandatory to establish the true value of this innovative surgical imaging technique in standard clinical practice and to aid in forming consensus on protocols for general use.Level of Evidence: Not ratable [ABSTRACT FROM AUTHOR]

Purpose: The number of breast cancer survivors continues to grow. Due to refinements in operating techniques, autologous breast reconstruction has become part of standard care. Impaired sensation remains a debilitating side effect with a significant impact on the quality of life. Microsurgical nerve coaptation of a sensory nerve has the potential to improve sensation of the reconstructed breast. This study investigates the effect of improved sensation of the reconstructed breast on the quality of life in breast cancer survivors.Methods: A retrospective cohort study was performed in the Maastricht University Medical Center. Patients undergoing a DIEP flap breast reconstruction between January 2015 and January 2016 were included. The primary outcome was quality of life (BREAST-Q domain ‘physical well-being of the chest’). The Semmes–Weinstein monofilaments were used for objective sensation measurement of the reconstructed breast(s).Results: Eighteen patients with and 14 patients without nerve coaptation responded. Nipple reconstruction was the only characteristic that differed statistically significant between both groups (p = 0.04). The BREAST-Q score for the domain physical well-being of the chest was 77.89 ± 18.89 on average in patients with nerve coaptation and 66.21 ± 18.26 in patients without nerve coaptation (p = 0.09). Linear regression showed a statistically significant relation between objectively measured sensation and BREAST-Q score for the domain physical well-being of the chest with a regression coefficient of − 13.17 ± 3.61 (p < 0.01).Conclusions: Improved sensation in the autologous reconstructed breast, with the addition of microsurgical nerve coaptation, has a statistical significant positive impact on the quality of life in breast cancer survivors according to the BREAST-Q. [ABSTRACT FROM AUTHOR]

Objective: To define the role of the lung in the production of glutamine in the critically ill and to determine the effects of the presence of pulmonary infiltrates and the presence and severity of sepsis.Design and Setting: Prospective clinical study in a single center; interdisciplinary intensive care unit at a university hospital.Patients: Eleven critically ill patients were compared to ten patients prior to cardiac bypass surgery.Measurements and Results: Fluxes of glutamine and other amino acids were measured. Chest radiography was performed, and APACHE II and multiple-organ failure scores were calculated. Septic patients showed significantly higher glutamine efflux from the lungs than controls. At least one-half of this glutamine is estimated to result from protein breakdown. Severity of illness had no impact on glutamine fluxes. In the presence of pulmonary infiltrates on chest radiographs glutamine efflux did not differ from zero.Conclusions: The lungs produce significant amounts of glutamine in septic patients. Pulmonary infiltrates decrease the glutamine efflux from the lung in septic patients. We suggest that this is caused by uptake of glutamine by white cells in the lung exerting immunological functions. [ABSTRACT FROM AUTHOR]

In the original publication Table 1 has been removed as the authors did not obtain permission to reproduce the BODY-Q scale. A revised Table 1 is provided in this correction. [ABSTRACT FROM AUTHOR]

We present the case of a 54-year-old woman who underwent a two-stage breast reconstruction with a tissue expander after sustaining a lumpectomy and local radiotherapy for breast cancer. During expansion, the woman developed an abnormal concave deformity of the chest wall. Although respiratory or aesthetic consequences were expected, our patient reported only pain and was satisfied with the end result. Osteoporosis or local recurrence was excluded as predisposing factors, and radiotherapy was considered to be the causal factor in our patient. On the basis of this finding, we advise surgeons to take the risk of chest-wall deformity into consideration when planning a reconstruction with tissue expanders, especially in patients with a history of radiotherapy, and we recommend an alternative reconstructive method in this group of patients. [ABSTRACT FROM AUTHOR]

Isolated synostosis of the frontosphenoidal suture is very rare and difficult to diagnose. Little has been reported on the clinical presentation and fetal development of this suture. To understand the development of the frontosphenoidal suture and the outcome of its synostosis. We studied the normal fetal development of the frontosphenoidal suture in dry human skulls and the clinical features of four patients with isolated synostosis of the frontosphenoidal suture. The frontosphenoidal suture develops relatively late during the second trimester of pregnancy, which explains the mild phenotype when there is synostosis. This rare craniosynostosis results in a deformity that causes recession of the lateral part of the frontal bone and supraorbital rim, with minimal facial asymmetry. Three-dimensional CT is the best examination to confirm the diagnosis. Isolated frontosphenoidal synostosis should be considered in patients with unilateral flattening of the forehead at birth that does not improve within the first few months of life. [ABSTRACT FROM AUTHOR]

In this study, 70 consecutive cases of breast reconstruction with the use of a free Transverse Rectus Abdominal Myocutaneous (TRAM) flap were reviewed with respect to the type of recipient vessels. We describe our evolution of choice of the receptor vessels. The deep inferior epigastric artery was anastomosed to the thoracodorsal artery in 15 cases. In 55 cases the internal mammary artery (IMA) was used as a recipient vessel. The deep inferior epigastric vein was anastomosed to the thoracodorsal vein in 15 cases, to the cephalic vein in eight cases, the external jugular vein in 16 cases and to the internal mammary vein (IMV) in 31 cases. Total flap necrosis occurred in four cases. In an additional four cases there was partial necrosis requiring minor operative correction. In six cases venous outflow problems were the cause of flap necrosis. The external jugular vein ( n = 3) and cephalic vein ( n = 2) were relatively frequently involved in cases of venous outflow problems. One flap was rescued 5 days after surgery following venous thrombosis by inserting a vein graft. The IMA and vein proved to be reliable and easy to access as recipient vessels for anastomosing the vessels of the free TRAM. [ABSTRACT FROM AUTHOR]