Dermatofibrosarcoma protuberans de mama con reconstrucción con colgajo del dorsal ancho. Reporte de caso

El Dermatofibrosarcoma Protuberans es un tumor cutáneo fibrohistiocítico, extremadamente raro y representa menos del 1% de los tumores mamarios. Se caracteriza por un lento crecimiento, pero con comportamiento infiltrante con altas tasas de recidiva local. Se puede sospechar clínicamente, la confirmación es histopatológica y se debe complementar con inmunohistoquímica. El tratamiento de elección es quirúrgico. Se presenta el caso de una mujer de 23 años con Dermatofibrosarcoma Protuberans de mama derecha, sometida a tumorectomía y reconstrucción inmediata de colgajo de dorsal ancho. La paciente tuvo evolución satisfactoria, sin evidencia de enfermedad.

SUMMARY Dermatofibrosarcoma protuberans is a fibro histiocytic cutaneous tumor extremely rare that accounts for less than 1% of all breast cancers, and it is characterized by slow growing but locally invasiveness with high recurrence rates. Confirmation of the diagnosis is with histopathology with immunohistochemistry. Treatment of choice is surgical resection with latissimus dorsalis reconstruction. We present the case of a 23-year-old woman with dermatofibrosarcoma protuberans of the right breast in whom a tumorectomy followed by latissimus dorsalis reconstruction was performed. The patient had a favorable clinical evolution remaining free of disease.

Presence of incomplete superficial axillary arch and pectoralis quartus muscle in one male body / Presencia en un individuo de un arco axilar superficial incompleto y de un músculo pectoral cuarto

SUMMARY: The anatomical variations of the pectoralis major muscle (PMM) and latissimus dorsi muscle (LDM) range from agenesis to the presence of supernumerary fascicles with a variety of insertions and relationships with the muscles, fascia, vessels, nerves and skeletal components of the shoulder girdle and the axilla. Many of these variations are clinically irrelevant, but extremely interesting and revealing from the perspective of comparative anatomy, ontogeny, and phylogeny. In this report, we present two different supernumerary muscles in the chest of one adult male body, identified during dissection practice of undergraduate medical students at Universidad Surcolombiana. These supernumerary fascicles in the axillary region were caudal to the lower edge of the PMM on the right side of the chest, and in contact with the anterior edge of the LDM on the left side of the chest; each fascicle was inserted in the ipsilateral coracoid process. These observations are congruent with the pectoralis quartus muscle and an incomplete and superficial axillary arch, respectively.

RESUMEN: Las variaciones anatómicas del músculo pectoral mayor (MPM) y del músculo latísimo del dorso (MLD) van desde la agenesia hasta la presencia de fascículos supernumerarios con una variedad de inserciones y relaciones con los músculos, fascias, vasos, nervios y componentes esqueléticos de la cintura escapular y la axila. Clínicamente, muchas de las variaciones son irrelevantes, pero extremadamente interesantes y reveladoras desde la perspectiva de la anatomía comparada, la ontogenia y la filogenia. En este estudio, presentamos dos músculos supernumerarios diferentes en la pared torácica de un hombre adulto, identificados durante la práctica de disección de estudiantes de medicina de la Universidad Surcolombiana. Estos fascículos supernumerarios en la región axilar estaban caudales al margen inferior del MPM en el lado derecho del tórax y en contacto con el margen anterior del MLD en el lado izquierdo del tórax; cada fascículo se insertaba en el proceso coracoides ipsilateral. Estas observaciones son congruentes con el músculo pectoral cuarto y un arco axilar incompleto y superficial, respectivamente.

Volumetric change of the latissimus dorsi muscle after immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap

BACKGROUND: In immediate breast reconstruction using an extended latissimus dorsi musculocutaneous (eLDMC) flap, the volume of the flap decreases, which causes a secondary deformity of the breast shape. Since little research has investigated this decrease in muscle volume, the authors conducted an objective study to characterize the decrease in muscle volume after breast reconstruction using an eLDMC flap. METHODS: Research was conducted from October 2011 to November 2016. The subjects included 23 patients who underwent mastectomy due to breast cancer, received immediate reconstruction using an eLDMC flap without any adjuvant chemotherapy or radiotherapy, and received a computed tomography (CT) scan from days 7 to 10 after surgery and 6 to 8 months postoperatively. In 10 patients, an additional CT scan was conducted 18 months postoperatively. Axial CT scans were utilized to measure the volumetric change of the latissimus dorsi muscle during the follow-up period. RESULTS: In the 23 patients, an average decrease of 54.5% was observed in the latissimus dorsi muscle volume between the images obtained immediately postoperatively and the scans obtained 6 to 8 months after surgery. Ten patients showed an average additional decrease of 11.9% from 6–8 months to 18 months after surgery. CONCLUSIONS: We studied changes in the volume of the latissimus dorsi muscle after surgery using an eLDMC flap performed after a mastectomy without adjuvant chemotherapy or radiotherapy. In this study, we found that immediate breast reconstruction using a latissimus dorsi muscle flap led to a decrease in muscle volume of up to 50%.

The efficacy of elongated axillary incision on extended latissimus dorsi flap for immediate breast reconstruction

BACKGROUND: In performing extended latissimus dorsi (ELD) flap procedures, a skin paddle design on the bra line helps reduce visible scarring. This improves the patient’s satisfaction with the outcome. However, such a design leads to a longer operation time and increased fatigue of the surgeon due to the narrow operative field. In this study, the authors propose a method that elongates the axillary incision line posteriorly by 1.5 cm from the lateral border of the latissimus dorsi muscle. We examined whether this method could shorten the operation time and compared the incidence of complications between patients who underwent this novel procedure and patients who underwent the traditional procedure. METHODS: In this study of patients who underwent ELD flap procedures for immediate breast reconstruction, 89 underwent surgery with the elongated axillary incision and 45 underwent surgery without the elongated incision. The total operation time and complications were retrospectively examined based on the patients’ medical records, and we examined whether there was any statistically significant difference in the total operation time. RESULTS: In the experimental group with the elongated axillary incision, the operation time ranged from 125 to 255 minutes (median, 175 minutes). In contrast, in the control group without the elongated axillary incision, the operation time ranged from 142 and 340 minutes (median, 205 minutes). The operation time was statistically significantly different between the two groups, and no significant complications were observed in the experimental group. CONCLUSIONS: Elongation of the axillary incision alone may shorten the operation time of the ELD flap procedure without causing additional complications.

Will a Fibrin Sealant be Effective as a Seroma Reductant and a Hemostatic Agent in Breast Reconstruction Using a Latissimus Dorsi Flap?

BACKGROUND: The latissimus dorsi (LD) flap is widely used in breast cancer reconstruction, but donor-site morbidity is one of the major limitations of this surgery. Donor-site seroma is the most common complication. To prevent seroma formation, we consider the use of a fibrin sealant (FS) because of its hemostatic and sealing effects. In this study, we investigate the effect of a FS on seroma prevention and as a hemostatic agent at the LD donor site. METHODS: A retrospective study was conducted from 2011 to 2015. Herein, we analyzed the preoperative status, changes in the hemoglobin (Hb) level according to the postoperative day, postoperative drain amount, and the drain removal time. RESULTS: The decline in the Hb level was not statistically significantly less in the FS group than in the control group. Further, the difference in the drain amount between the 2 groups was not statistically significant either. The seroma rate and the drain removal time between the 2 groups also did not show any statistically significant difference. CONCLUSIONS: The FS does not have hemostatic effect and the drain amount reduction in the early phase of recovery and does not prevent seroma. Therefore, an empirical use of the FS alone is no longer recommended to prevent seroma. In contrast, the quilting suture has been reported to be effective in seroma prevention. Therefore, it is necessary to study the effects of a combination of quilting sutures and the FS on seroma and the other risk factors of this surgical complication.

Will a Fibrin Sealant be Effective as a Seroma Reductant and a Hemostatic Agent in Breast Reconstruction Using a Latissimus Dorsi Flap?

BACKGROUND: The latissimus dorsi (LD) flap is widely used in breast cancer reconstruction, but donor-site morbidity is one of the major limitations of this surgery. Donor-site seroma is the most common complication. To prevent seroma formation, we consider the use of a fibrin sealant (FS) because of its hemostatic and sealing effects. In this study, we investigate the effect of a FS on seroma prevention and as a hemostatic agent at the LD donor site. METHODS: A retrospective study was conducted from 2011 to 2015. Herein, we analyzed the preoperative status, changes in the hemoglobin (Hb) level according to the postoperative day, postoperative drain amount, and the drain removal time. RESULTS: The decline in the Hb level was not statistically significantly less in the FS group than in the control group. Further, the difference in the drain amount between the 2 groups was not statistically significant either. The seroma rate and the drain removal time between the 2 groups also did not show any statistically significant difference. CONCLUSIONS: The FS does not have hemostatic effect and the drain amount reduction in the early phase of recovery and does not prevent seroma. Therefore, an empirical use of the FS alone is no longer recommended to prevent seroma. In contrast, the quilting suture has been reported to be effective in seroma prevention. Therefore, it is necessary to study the effects of a combination of quilting sutures and the FS on seroma and the other risk factors of this surgical complication.

Comparison of morbidity-related seroma formation following conventional latissimus dorsi flap versus muscle-sparing latissimus dorsi flap breast reconstruction

PURPOSE: The pedicled, descending-branch muscle-sparing latissimus dorsi (MSLD) flap has been widely used for breast reconstruction following total mastectomy. However, the superiority of the MSLD flap compared to the conventional latissimus dorsi (CLD) flap in preventing seroma formation has not been demonstrated. This study compares the morbidities related to seroma formation following pedicled MSLD flap and CLD flap breast reconstruction. METHODS: A total of 15 women who underwent partial mastectomy and immediate partial breast reconstruction with MSLD flaps were compared with 15 women under identical conditions with CLD flap breast reconstruction. The medical records were reviewed for both complications and demographic data. The authors compared morbidity, including donor-site seroma, total volume of drain discharge, indwelling period of drainage, and length of hospital stay following both MSLD flap and CLD flap breast reconstruction. RESULTS: The demographic data of the 2 groups were not significantly different. Donor-site seroma occurred in 2 MSLD patients (13.3%) and in 6 CLD patients (40.0%). The total volume of the drain discharge and the indwelling period of drainage at donor site were significantly lower in the MSLD group. The length of hospital stay was significantly shorter (by approximately a day and a half) for the MSLD group. CONCLUSION: The MSLD flap, with its low complication rate and associated minimal functional and aesthetic deficits at the donor site, may be a useful option for small breast reconstruction if earlier discharge from hospital is demanded.

The Role of Negative-Pressure Wound Therapy in Latissimus Dorsi Flap Donor Site Seroma Prevention: A Cohort Study

BACKGROUND: Donor site seroma is the most common complication after latissimus dorsi (LD) flap harvest. This study aimed to evaluate the efficacy of negative-pressure wound therapy (NPWT) in preventing donor site seroma formation after the harvest of an LD flap for breast reconstruction. METHODS: In this prospective matched-pair study, 40 patients in whom an LD flap was harvested for breast reconstruction were enrolled. NPWT was used in 20 patients, and in a control group composed of another 20 patients, the conventional donor site dressing technique was used. Information was collected regarding postoperative complications, the incidence of seroma, total drainage volume, the number of percutaneous seroma aspirations, and the volume aspirated. RESULTS: In the NPWT group, the incidence of seroma formation after drain removal was significantly lower than in the control group (15% vs. 70%; odds ratio=0.07; relative risk, 0.24). Both the mean percutaneous aspirated volume (P=0.004) and the number of percutaneous aspirations (P=0.001) were also significantly lower in the NPWT group. There were no significant differences in the total drainage volume or the duration of wound drainage between the NPWT dressing group and the control group (P>0.05). CONCLUSIONS: This study showed that NPWT is a promising tool for reducing the incidence of seroma formation after removing the drain at the donor site after LD flap harvesting. It is a simple and safe technique.

Long-term results of oncoplastic breast surgery with latissimus dorsi flap reconstruction: a pilot study of the objective cosmetic results and patient reported outcome

PURPOSE: The goal of oncoplastic breast surgery is to restore the appearance of the breast and improve patient satisfaction. Thus, the assessment of cosmetic results and patient-reported outcomes (PROs) using appropriately constructed and validated instruments is essential. The aim of the present study was to assess the long-term objective cosmetic results and corresponding PROs after oncoplastic breast surgery. METHODS: Cosmetic results were assessed by the patients, a medical panel, and a computer program (BCCT.core). PROs were assessed using BREAST-Q, a questionnaire that measures the perception of patients having breast surgery. The cosmetic results and PROs were analyzed in patients who underwent quadrantectomy and partial breast reconstruction utilizing the latissimus dorsi flap. RESULTS: The mean duration of the follow-up period was 91.6 months (range, 33.3-171.0 months), and mean age of the patients was 51 years old (range, 33-72 years). The mean tumor size was 2.1 cm (range, 0.9-5.5 cm). There was fair agreement between the medical panel and BCCT.core score (K = 0.32, P < 0.001), and a statistically significant correlation between the BCCT.core score and medical panel cosmetic results was identified (r = 0.606, P < 0.001). A better BCCT.core result was related to a higher PRO of each BREAST-Q domain-satisfaction with breasts (R2 = 0.070, P = 0.039), satisfaction with outcome (R2 = 0.087, P = 0.021), psychosocial well-being (R2 = 0.085, P = 0.023), sexual well-being (R2 = 0.082, P = 0.029), and satisfaction with information (R2 = 0.064, P = 0.049). CONCLUSION: Our long-term results of oncoplastic surgery achieved a high level of patient satisfaction with good cosmetic results. The medical panel and BCCT.core results correlated well with the PROs of the patients using valid, reliable, and procedure-specific measures.

A Rare Complication after Latissimus Dorsi Flap Breast Reconstruction: Radial Nerve Palsy

Among autologous breast reconstruction techniques, breast reconstruction using the latissimus dorsi musculocutaneous flap is widely used, offering advantages including the relative simplicity of the procedure and the reliable and consistent vascularity of the flap. Accordingly, more than 500 cases have been performed in the past 8 years at Kyungpook National University Medical Center. This study reports on a rare case involving a radial nerve neuropathy complication which was experienced for the first time at the medical center. The current case demonstrates that in addition to common complications, such as seroma of the donor site and scarring, additional intraoperative complications in areas unrelated to the surgical site can occur, including radial nerve neuropathy in the opposite arm.

The Trapezius Muscle Flap: A Viable Alternative for Posterior Scalp and Neck Reconstruction

BACKGROUND: The trapezius muscle flap is not usually the first reconstructive option for skin and soft tissue defects in the posterior neck and scalp due to surgeons' unfamiliarity with the surgical anatomy and developments in free tissue transfer techniques. The goals of this study were to describe the clinical use of trapezius flaps in posterior neck and scalp reconstruction, and to investigate the vascular anatomy of trapezius flaps in Asians in order to obtain information facilitating the safe design and elevation of flaps in which most of the muscle is preserved. METHODS: A retrospective chart review was performed of 10 patients who underwent trapezius muscle flap for posterior neck and scalp defects. We also performed an anatomical study of 16 flaps harvested from 8 preserved Asian adult cadavers and evaluated the main landmarks relevant for trapezius muscle flap. RESULTS: In the anatomical study, the mean vertical height from the inferior angle of the scapula to the point at which the superficial cervical artery penetrated the trapezius was 4.31±2.14 cm. The mean vertical height of the trapezius muscle flap pivot point was 9.53±2.08 cm from the external occipital protuberance. Among the 10 flaps, partial necrosis on the overlaid skin graft occurred in 1 patient and postoperative seroma occurred in another patient. CONCLUSIONS: Vascular variations in the trapezius muscle flap are uncommon in Asians, but when present, such variations appear to have little impact on harvesting the flap or on its circulation. The trapezius muscle flap is a viable alternative for posterior neck and scalp reconstruction.

The Effect of Intramuscular Stimulation on Otalgia due to Myofascial Pain Syndrome by Contraction of Trapezius Muscle

There are several causes of otalgia, specifically primary otalgia, which originates inside the ear, and referred otalgia, which originates outside the ear. In a rare case, otalgia may result from myofascial pain syndrome (MPS) due to a contraction of cervical muscles. The author of this study reports a case in which otalgia caused by MPS due to contraction of the trapezius muscle was treated with intramuscular stimulation (IMS). A 48-year-old female patient with otalgia for two weeks was otolaryngologically tested and no anomaly was found. A pain clinic consultation was requested and severe contraction of the trapezius muscle was observed by history taking, visual inspections and palpation. She was successfully returned to the normal state with two sessions of IMS.