Breast reconstruction with free-tissue transfer.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the rationale for the use of free tissue transfer for breast reconstruction. 2. Understand the indications, advantages, and disadvantages of this method of reconstruction. The authors discuss the indications, advantages, and disadvantages of free-tissue transfer for breast reconstruction. The most common free flaps used today are individually discussed. Details about indications, contraindications, pertinent anatomy, pedicle characteristics, flap pliability, perfusion characteristics, advantages, and disadvantages for each of these flaps are presented. Details pertaining to the more common recipient vessels are presented. Future considerations are also briefly discussed.

Cervicofacial rejuvenation using ultrasound-assisted lipectomy.

This article discusses a technique of cervicofacial rejuvenation that involves ultrasound-assisted lipectomy. This method is indicated for those patients who might be early candidates for a rhytidectomy, and/or those with an adipose volume excess in the lower facial and cervical areas. The application of ultrasonic energy stimulates skin retraction and allows for the superficial fat to be more safely accessed than can be accomplished with conventional liposuction methods. This technique, along with a retrospective analysis of the first 26 cases treated with the technique, will be presented in this article.

Ultrasound-assisted lipectomy using the solid probe: a retrospective review of 100 consecutive cases.

Ultrasound-assisted lipectomy using the solid probe is a predictable and safe method that can yield excellent results. This method is particularly useful and is indicated when the subdermis must be approached to smooth out surface irregularities and/or to stimulate skin retraction. The authors present their method using the solid probe and a retrospective study of their first 100 consecutive cases. The indications for using the solid probe, its advantages and disadvantages, associated complications, and representative cases are presented.

The solid-probe technique in ultrasound-assisted lipoplasty.

The solid-probe ultrasound-assisted lipoplasty technique is a predictable method for obtaining optimal results in body contouring for select patients. Patients with inelastic skin, cellulite, skin laxity, and those undergoing secondary contouring procedures are ideal candidates for the solid-probe technique. The solid probe is thought to be a more efficient fat emulsification device because it imparts more focal ultrasonic energy per amplitude than hollow probes.

Yucatan pig: an optimal hairless model for a true random cutaneous flap.

Porcine models have been used extensively for skin flap research because of the established similarity between the cutaneous blood supply of the swine and humans. The Yucatan minipig provides an excellent model for researching the properties of random cutaneous flaps, offering several advantages over other breeds of swine. In this study, a total of 67 random cutaneous dorsal flank flaps measuring 4 x 14 cm were raised on nine Yucatan minipigs. The mean survival length (10.03 +/- 1.60 cm) of the nondelayed flaps was greater than others reported in the literature. The well-defined plane between the subcutaneous tissue and the panniculus carnosus facilitated flap elevation consistently above the level of the panniculus carnosus thereby ensuring the creation of a true random cutaneous flap. Furthermore, the hairless nature of the skin, particularly beneficial in studying chemical peels, permits easy visualization and monitoring of any external skin changes. These advantages make the Yucatan minipig a more desirable alternative to other breeds of swine for use in skin flap research.

Thermal injury to TRAM flaps: a report of five cases.

Five cases of burns occurring in TRAM flaps utilized for breast reconstruction are presented in this study. These injuries resulted from exposure to thermal and/or solar radiation. We believe that the physiologic changes that result from flap elevation and transposition, mainly denervation, negate the autonomic protective mechanisms for heat dissipation. This renders the flaps more susceptible to injury from these energy forms. Because of these findings, we urge all plastic surgeons who perform TRAM flap reconstructions to carefully instruct their patients to avoid exposing their flaps to heat and solar radiation.

Basal cell carcinoma in the groin of a black patient with femoral vessel invasion and a second primary malignancy.

We have presented an unusual case of basal cell carcinoma that presented in a 76-year-old black woman. This is an atypical case in that it occurred in a black patient, and the incidence of basal cell carcinoma is low in black people. The lesion was located in the groin, which is an uncommon location for basal cell carcinoma. The femoral vessels in this patient also were invaded by the tumor, which is also a very rare occurrence. The patient in this report had a coexisting squamous cell carcinoma of the lung, which may be a common finding in black patients with basal cell carcinoma. It is extremely important for the physician to include skin cancer in the differential diagnosis of any suspicious skin lesion. This will avoid delays in treatment and decrease the overall morbidity. The physician who encounters a black patient with a basal cell carcinoma also should screen the patient for a coexisting noncutaneous malignancy.

The inferiorly based rectus abdominis island flap for the treatment of complex hip wounds.

Complex wounds in the hip region often result from complications of orthopedic procedures performed in this region such as total hip arthroplasty, ORIF procedures, tumor ablation, and/or radiation therapy. Exposure of bone, joint capsule, prostheses, and other hardware often results with these wounds. Salvage of these exposed and/or infected essential elements and providing soft-tissue coverage are difficult and challenging problems for the orthopedic and plastic surgeon. To provide coverage for such situations, we have developed an aggressive strategy of thorough debridement, systemic antibiotics, and well-vascularized soft-tissue coverage utilizing an inferiorly based rectus abdominis island flap. This technique was utilized in five patients with all wounds and joints remaining stable at follow-up periods ranging from 2 to 7 years.

Muscle flap reconstruction aids in urethral regeneration.

Traditional methods of reconstructing full-thickness urethral defects have employed a cutaneous component utilized to replace the lining of the urethra. These methods have failed to take advantage of the regenerative ability of urethral epithelium. This epithelium is capable of regenerating, eliminating the need for urethral lining reconstruction. Muscle flap reconstruction provides an environment that allows for complete regeneration of the urethral epithelium. A 56-year-old male presented with a 12-cm defect of the bulbous and penile urethra involving 180 degrees of the urethral circumference secondary to Fournier's gangrene. A proximally pedicled gracilis muscle was used to reconstruct the urethral defect. This healed without stricture or leak. Urethral biopsies showed satisfactory migration of the uroepithelium across the urethral defect.

A new suction device for microsurgery.

A new suction device for microsurgical procedures is presented. This device is made of soft, compliant PVC, which enables all fluids to be evacuated from the surgical field without damaging the surrounding soft tissue. The device is designed with front and radial ports that allow placement onto the blood vessel or nerve while the anastomosis is being performed. There is a tapered end providing the surgeon with fine control of the suction. Unlike other bulky suction devices, this one readily fits into the operative field without inhibiting operative procedures. It also readily fits varying sizes of conventional Frazier-type tips. The device has been used in over 100 microsurgical procedures and it has served well.

A new vessel occluder for microvascular anastomoses.

A vessel occluder has been developed that is easy to use and provides effective, safe, vascular occlusion. The occluder is small and is easily rotatable in the operative field. It consists of a plastic backing and a compliant foam strap that wraps around the blood vessel. The foam absorbs blood and irrigation which keeps the vessels moist during the anastomosis. This vessel occluder possesses the ability to vary the amount of blood flow through the vessel, enabling the surgeon to identify and readily repair anastomotic leaks. This occluder has been used successfully by the authors in 100 anastomoses.

Anatomical parameters for nipple position and areolar diameter in males.

In this paper we present anatomic parameters for nipple position and areolar diameter in males. Larger forms of gynecomastia with significant ptosis pose a challenge to the plastic surgeon with respect to relocation of the nipples on the chest wall. Selection of the appropriate areolar size is also of concern in gynecomastia correction. There is a paucity of information in the current literature pertaining to this problem. In order to establish guidelines for the placement of the nipple in gynecomastia correction and for the selection of the appropriate areolar size, we set out to determine these anatomic parameters. We believe use of these parameters will enhance the aesthetic results of gynecomastia correction. One hundred males between the ages of 17 to 30 years were chosen for this study. The males selected were of ideal body weight and without evidence of gynecomastia. The distances from the sternal notch to the nipple, the midclavicular line to the nipple, and the nipple-to-nipple distance were recorded. The areolar diameter was also measured in each subject. The average distances were determined for each category. The validity of these values was confirmed with statistical analysis. Equations were then derived, using this analysis, to determine nipple position in males. We have determined the nipple position in males to be approximately 20 cm from the sternal notch and 18 cm from the midclavicular line. The ideal nipple-to-nipple distance is 21 cm. The average areolar diameter is 2.8 cm.

Basal cell carcinoma in black patients: the need to include it in the differential diagnosis.

We present a retrospective study of 276 basal cell carcinomas which we have identified 5 (1.8%) black patients. This finding agrees with the current literature, which states that basal cell carcinoma in the black population is relatively infrequent. Although basal cell carcinoma in black patients is uncommon, it should be included in the differential diagnosis of any suspicious lesion in this population to avoid the morbidity that is associated with a delay in diagnosis. In this study we also present the possible association of basal cell carcinoma occurring concomitantly with a second primary malignancy in this population. In black patients basal cell carcinoma is found more frequently in regions of the body that are protected from ultraviolet radiation when compared to white patients. This leads to the speculation that a different pathogenesis of basal cell carcinoma exists for black patients.