Issues related to advances and controversies in breast cancer management: a multicultural experience.

The overview of current diagnostic and therapeutic advances and controversies in the management of breast cancer is presented. Specific topics and their impact on breast reconstruction surgeons practicing in culturally different areas and with variable access to breast education and health care are discussed. The following approaches to the most common types of problems are presented: prophylactic mastectomy for women at high risk of breast cancer, size and location of the primary tumor and feasibility of breast conserving surgery and oncoplastic approach, management of the axilla, post-mastectomy radiation and chemotherapy, emerging breast reconstructive techniques (fat transfer, stem cells) and cancer risk, oncological follow up and imaging of the reconstructed breast, including illustrative cases. This material should help oncological and plastic surgeon specialists to understand each other's considerations for the best possible outcome of the breast cancer treatment.

Extended step-advancement flap for avulsed amputated fingertip--a new technique to preserve finger length: case series.

PURPOSE: The conventional step-advancement flap does not restore fingertip length after avulsion amputation with projecting bone owing to the limited size of the distal triangular flap. To overcome this problem, the extended step advancement flap using the stepladder principle, described in this article, provides an extended distal triangular flap that can be wrapped around the projecting tip of the distal phalanx while avoiding longitudinal volar scarring. The purposes of this study were to present a modification of the original step-advancement technique and to report on results in 6 patients. METHODS: Between 2007 and 2009, 6 men (mean age, 29 y; range, 18-45 y) presented with a large projecting tip of exposed bone of the distal phalanx after avulsion injury. All 6 had reconstruction using the described technique. After surgery, the finger was immobilized with a splint, followed by rehabilitation. During the follow-up of 9 to 12 months, we clinically assessed flap-site skin quality, scar contractures, and finger mobility. We measured the finger's range of motion with a goniometer. Sensibility was evaluated using the static 2-point discrimination test. RESULTS: The postoperative course was uneventful. All flaps survived completely, except one that had mild marginal necrosis. We observed near-total active range of motion in all patients. The average static 2-point discrimination was 4 mm with a range of 3 to 5 mm. All patients resumed normal daily activities after 8 weeks. CONCLUSIONS: The extended step-advancement flap is ideal for closure of challenging fingertip amputation wounds because it maintains length and minimizes scars while providing a well-padded, sensate tip. It is a viable alternative to replantation of the fingertip. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Mons pubis ptosis: classification and strategy for treatment.

BACKGROUND: Obesity and massive weight loss cause bulging and ptosis of the mons pubis. The pubic area can cause an embarrassment to patients. In some cases, the deformity can be seen even under clothing. Ptosis of the mons usually is addressed during abdominoplasty. The author presents a new clinical classification of mons deformity based on the amount of adipose tissue deposit and the degree of ptosis. A strategy of treatment to achieve a proper rejuvenation of mons deformities is provided. METHODS: Between 2004 and 2009, a total of 132 patients with pendulous bellies and mons pubis deformities underwent abdominoplasty and lifting of the mons. A technique using a dermal-fascial suspension with permanent sutures to hang the weight of the mons skin and subcutaneous tissues on the musculoaponeuretic system of the lower abdomen is described. The age of patients undergoing the operation ranged from 20 to 53 years. During the follow-up period (12-38 months), all the patients by the author, who reviewed their medical charts. A Likert scale and an evaluation questionnaire were used to assess the aesthetic outcome of mons lifting. RESULTS: All the patients who underwent lifting of the mons pubis were free of postoperative contour deformities and had a long-lasting outcome. At this writing, patient satisfaction has remained high. CONCLUSION: The clinical classification and treatment guidelines reported are designed to provide simple procedures with minimal complications that have tremendously rejuvenated the mons.

A perforator-based bilobed fasciocutaneous flap: an additional tool for primary reconstruction following wide excision of sacrococcygeal pilonidal disease.

A great variety of procedures have been proposed for the cure of sacrococcygeal pilonidal disease. A bilobed fasciocutaneous flap, based on the parasacral perforators, is described. This retrospective study was conducted to evaluate our experience with bilobed fasciocutanous flaps and to review current publications about flap surgery for the treatment of sacrococcygeal pilonidal sinus. Eight bilobed fasciocutanous flaps have been performed between February 2004 and September 2006. Eight males, aged 19 to 35 years (mean age: 26.2 years), presented with chronic and recurrent pilonidal disease. The duration of the disease was ranged from 2 to 6 years (mean age: 3.8 years). The sinuses were excised in a vertical, elliptical fashion and the defect closed using a bilobed fasciocutanous flap. This flap was designed using the parasacral perforators and tailored to obliterate the midline defect. Primary wound healing was achieved in all patients. Large defects after excision can easily be closed using the bilobed fasciocutaneous flap. The flap provides a tensionless wound closure. Hospitalisation is brief, and the postoperative course is comfortable. No recurrence was seen in any of the eight cases. This procedure is indicated in patients in whom wide skin resection is required, because of the tension-free skin closure in such cases. This technique enabled regional reconstruction, conserved tissues, and provided satisfactory aesthetic results. Therefore, this procedure can be considered an additional, useful tool in the treatment of pilonidal sinus.

Unusual distribution of the lower body fatty tissue: classification, treatment, and differential diagnosis.

Unusual fat distribution of the lower part of the body is clinically characterized by massive symmetric and diffuse fat deposition in the trochanters, groins, buttocks, hips, and lower extremities, which contrasts sharply with the normal upper part of the body. The massive lipomatoses of the lower part of the body can be classified into 3 types: type 1, the familial symmetrical lipomatosis that affects the groins, trochanters, hips, buttocks, and thighs; type 2, the bilateral peritrochanteric familial lipomatoses; and type 3, the unilateral peritrochanteric lipomatosis. This unusual adiposity runs in families and predominantly exists in the Mediterranean region, and seems, however, to be common in North Africa. It is rarely reported in the literature. In this regard, a differential diagnosis is presented regarding the lipomatosis and lipodystrophies-described syndromes to familiarize plastic surgeons with these unique deformities. Between 2000 and 2006, 50 women with abnormal diffuse fat deposits in the lower part of the body were investigated and treated with conventional liposuction; patients' ages ranged between 20 to 46 years. Laboratory examination includes the serum concentrations of lipoprotein, cholesterol, triglycerides, uric acid, fasting glucose, and other routine laboratory tests. Endocrinologic tests include serum estradiol and testosterone levels, and thyroid function tests. Histologic examination of the lipoaspirate was performed. All cases were treated with liposuction. For type 1 cases liposuction was performed in stages; the maximum amount of lipoaspirate per setting was 3,000 to 4,000 mL, and for type 2 and type 3 a single stage liposuction was undertaken. Laboratory examination showed normal values and routine parameters were within normal limits. Endocrinologic investigations revealed no abnormalities and histologic examination of lipoaspirate showed normal subcutaneous fatty tissue. The esthetic outcome of all individuals was satisfactory. Abnormal swelling of the lower half of the female body caused by deposition of subcutaneous fat is determined by heredity and seems to be common in North Africa. It is often accompanied by a psychological reaction due to the disturbed body image. A clinical classification is reported in the current study. The traditional liposuction is the treatment of choice for these esthetic deformities.

The split peroneus muscle flap: a new flap for lower leg defects.

The peroneus brevis tendon mechanism is more effective than the peroneus longus mechanism in rotating the navicular externally and the calcaneus into valgus. A longitudinal vertical split of the peroneus brevis muscle is a new technique that allows coverage of the fibular and pretibial region defects without impairing the muscle function. The essential features of the flap are: transposition of the muscle without disinsertion, splitting the muscle longitudinally along a distinct anatomical plane, and preservation of the anatomical continuity of the muscle. The flap has been tested on seven male patients who had sustained open fractures of the ankle region with metal implant exposure of the fibula. The size of the flap ranged from 13x6cm to 15x7cm (mean 13.8x6.5cm). The soft tissue defects were located between the pretibial region and the lateral malleolus. Their ages ranged from 22 to 39 years (mean 28.7 years). Follow up was from 3 to 24 months (mean 14.5 months). The technique of split peroneus muscle flap was applied successfully in all patients. There was no necrosis of the muscle flap and stable wound healing was achieved. The cosmetic result was good and the function of the muscle was preserved. The advantages offered by this new flap include: technical simplicity, reliability, and the allowance of future use of other local skin and muscle flaps. With the help of this new technique it is possible to cover defects of up to 20x7cm and to preserve the muscle function.

A single stage liposuction and dermopexy for grade 3b and grade 4 pseudogynecomastia after massive weight loss: an observational study.

Nineteen middle-aged males with grade 3b and grade 4 pseudogynecomastia following severe weight loss were treated by liposuction and simultaneous skin reduction. From 1997 through 2005 nine males with grade 3 and ten with grade 4 pseudogynecomastia were included in this study. Ages ranged from 23 to 48 years. Author used two techniques for skin reduction: 1-the dermal mastopexy (keyhole design) for grade 4, and 2-the complete circum-areolar technique (concentric reduction) with de-epithelialization for grade 3b. The current technique offers a proper treatment for the pendulous female-like breast with inelastic and redundant skin. It obviates the need for secondary revision by providing a viable nipple-areola complex at the desired location and eliminating the dish-type deformity that may result from subcutaneous mastectomy. Patients were monitored for the following 18 to 39 months. While reviewing the literature other methods are compared and discussed but it is suggested that the method reported here has a number of advantages and is the treatment of choice in many such cases.

Classification of brachial ptosis: strategy for treatment.

BACKGROUND: The author presents a clinical classification of brachial ptosis based on the amount of adipose tissue deposit and the degree of ptosis. This system offers guidelines for graduated treatment of fat deposit and brachial ptosis. Minor modifications to previous techniques are reported to keep the scar short, as low as possible, and not wide, and to avoid postoperative contour deformities. Five groups of upper arm problems are described, as follows: stage 1, patients with minimal fat deposit and no ptosis; stage 2a, patients with moderate fat deposit and grade 1 ptosis; stage 2b, patients with severe fat deposit and grade 2 ptosis; stage 3, patients with severe fat deposit and grade 3 ptosis; and stage 4, patients with minimal or no fat deposit and with grade 3 ptosis. METHODS: Between 1996 and 2005, four modalities were used to treat 60 patients with brachial deformities: single-stage liposuction, staged liposuction, suction-assisted short scar brachioplasty, and conventional brachioplasty. Age at operation ranged between 24 and 56 years. All patients were seen and the author reviewed their medical charts during the follow-up period (12 to 38 months). RESULTS: All patients who underwent liposuction-assisted arm dermolipectomy (stages 2a and 3) were free of incorrectly placed incisions and postoperative contour deformities. Postoperatively, skin laxity and ptosis in the axillary regions were encountered in two stage 4 patients. One patient experienced widened and hypertrophied scar secondary to wound infection. One stage 3 patient and one stage 4 patient developed postoperative distal edema. CONCLUSION: The clinical classification and treatment guidelines reported are designed to provide simple procedures with minimal complications that tremendously rejuvenate the arm.

Reverse osseofasciocutaneous radial forearm flap for thumb reconstruction: a flap design and case series.

PURPOSE: To report the outcome of the modified design of the osseofasciocutaneous radial forearm flap. The flap was modified because of problems associated with the use in thumb reconstruction. METHODS: We performed retrospective review of all patients who sustained nonreplantable thumb amputations who had this procedure between August 2000 and March 2005. The patients' ages ranged between 24 and 39 years. Demographic data and details of the level of amputation and alternative surgical procedures were reviewed. Eight male patients were identified and constituted the study cohort. The size of flap, length of the radius harvested, time to union, sensibility (moving 2-point discrimination test), grip and pinch strengths, complications, and patient outcome were determined. RESULTS: All patients who had the butterfly design of the reverse-flow osseofasciocutaneous radial forearm flap had an adequate and painless soft-tissue padding on the tip of the reconstructed thumb that provided good protection for the distal stump of the vascularized bone graft. Patients did not experience strictures at the bottom of the reconstructed tubes. CONCLUSIONS: The butterfly design is a useful modification of the skin paddle of the reverse osseofasciocutaneous radial forearm flap for thumb reconstruction. The design offers an easy way to reconstruct a tube shape with adequate padding on the tip and no terminal scar. In addition it prevents the constricting effect of the circumferential scar on the button of the reconstructed tube.

Subtotal reconstruction of the burned auricle.

The goal for external ear reconstruction is to restore the function of the helical rim in order to provide support for eyeglasses and to provide a cosmetically acceptable auricle. Reconstruction necessitates both flap coverage and flexible framework formation. This article reviews 22 patients who underwent subtotal reconstruction of the auricles after burns. The study was conducted from 1996 to 2003. The study group consisted of 14 male and 8 female patients aged 6-43 years (mean 21.9 years). Different modalities have been used: the temporoparietal fascial flap (eight patients), the subcutaneous pocket technique (11 patients), the pre-auricular skin flap (four patients), and the post-auricular skin flap (three patients). The flaps were used for coverage of fabricated autogenous cartilage in all patients. Both aesthetic and functional outcome was satisfactory.

Bilobed fasciocutaneous flap for reconstruction of the posterior neck after necrotizing fasciitis.

Necrotizing fasciitis is an aggressive, deep-seated infection of the fascia and subcutaneous fat with necrosis of overlying skin. Eleven cases of necrotizing fasciitis of the posterior neck are reviewed to demonstrate the advantage of using a bilobed fasciocutaneous flap for repair following surgical debridement. Nine men and two women aged 40 to 65 years (mean age, 54.8 years) presented for reconstruction from April of 1999 to March of 2003. The blood supply of the bilobed fasciocutaneous flap originates from a constant row of musculocutaneous perforators of posterior intercostal arteries. The technique enabled regional reconstruction, conserved tissues, and provided satisfactory aesthetic results.

Abdominal dermolipectomy in an abdomen with pre-existing scars: a different concept.

Although abdominal dermolipectomy is a frequently performed procedure, few publications have reported on the safety of the procedure in the scarred abdomen. The aim of this study was to stress the possibility of performing a natural-looking abdominoplasty with no complication such as skin necrosis or liponecrosis in the presence of abdominal scars and to clarify that the scarred abdomen is not a great limitation for full abdominoplasty as reported in the literature. Seventy-six abdominoplasties were performed on scarred patients from July of 1997 to June of 2003. Twenty-five patients had oblique subcostal scars, six patients had median supraumbilical scars, three patients had median infraumbilical scars, 10 patients had appendectomy scars, nine patients had paramedian supraumbilical scars, eight patients had paramedian infraumbilical scars, seven patients had long transverse scars of repaired ventral hernias, and eight patients had multiple small scars after laparoscopy. In addition, there were concomitant transverse cesarean delivery scars in 40 patients. All patients underwent full abdominoplasties, plication of the musculoaponeurotic system, and liposuction assistance if required (45 patients). Of 76 subjects, three patients had very limited liponecrosis at the watershed area. Eleven patients (14.5 percent) were morbidly obese and heavy smokers. In comparisons of postabdominoplasty complications, such as liponecrosis, wound infection, and dehiscence with and without liposuction in scarred abdomen, no significant differences were found. Secondary revision was more common among abdominoplasties without liposuction [seven of 45 (15.6 percent) versus 12 of 31 (38.7 percent); p = 0.02]. In conclusion, there is no limitation or contraindication for abdominal dermolipectomy with or without liposuction assistance on the previously scarred abdomen as long as the vascular zones of the abdomen are respected. The abdominal wall dissection is limited to allow only the plication of the musculoaponeurotic system, and aggressive liposuction is avoided.

Intraabdominal pressure after full abdominoplasty in obese multiparous patients.

This study measured intraabdominal pressure in morbidly obese and multiparous patients who underwent abdominoplasty with musculoaponeurotic plication. The purpose of this study was to evaluate any potential adverse effect on pulmonary function by virtue of pulmonary function tests and measurement of peak airway pressure. The study included 43 multiparous, morbidly obese women (mean body mass index, 35.8 kg/m2) with a mean age (+/- SD) of 38.6 +/- 7 years. All had full abdominoplasty and repair of the musculoaponeurotic system during the period from June of 1999 to May of 2002. Forty-three morbidly obese multiparous patients were seen over a period of 24 months. Their intraabdominal pressure was estimated by measuring the intravesical pressure before and after repair of severe diastases (divarication) of the rectus abdominis muscles with severely flaccid myofascial component before using a hydrometer connected to a Foley catheter both before and after repair. All patients had pulmonary function checked before and 2 months after the repair. The study confirmed that there are minimal changes on the intraabdominal pressure parameters compared with measurement before and after full abdominoplasty with plication of the rectus muscles, with minimal to negligible changes in the intrathoracic pressure. These changes are clinically and statistically significant (p < 0.0001). The study also recommended the safety of full abdominoplasty and repair of the musculoaponeurotic system in multiparous and morbidly obese patients. Furthermore, no statistically significant difference was found in pulmonary function parameters before and after surgery in patients with a history of bronchial asthma.

Large thoracolumbar meningomyelocele defects: incidence and clinical experiences with different modalities of latissimus dorsi musculocutaneus flap.

In this study, we report a series of large thoracolumbar meningomyelocele (MMS) defects. The total incidence per 1000 live birth is 0.6, the male incidence per 1000 live birth is 0.56, and the female incidence per 1000 live birth is 0.47. The study was conducted on 23 infants, all suffered from large thoracolumbar MMC defects, and our treatment techniques are modifications of procedures previously described. The timing of surgery ranged between 2 and 5 days after birth, and the follow-up was ranged between 3 and 7 years. Different modalities were used for reconstruction: bilateral proximally based skin island, muscle pedicle latissimus dorsi (LD), myocutaneous flap (seven patients), bilateral bipedicled LD, myocutaneous flaps (nine patients), and distally based skin island, muscle pedicle LD, myocutaneous flaps (seven patients). All the patients tolerated procedures smoothly, and because LD muscle may be important for mobility in a potentially paraplegic wheelchair-bound patient, the author presents some modifications in order to preserve the muscle function. Criteria for flap selection will be discussed.

Tendofascial island flap based on distal perforators of the radial artery: anatomical and clinical approach.

The possibility of transferring vascularized tissue to restore function and to resurface large defects, together with the use of composite flaps, has led to recent advances in "one-stage" reconstructive surgical procedures. On the basis of a previous study of the blood supply of the adipofascial flap and a new study of the blood supply of the flexor carpi radialis tendon from the transfascial and direct branches of the radial artery, a fascial island flap complete with tendon was devised and used to treat four male patients who had sustained traumatic soft-tissue losses on the dorsum of the hand and segmental losses of the extensor digitorum communis. The use of a completely vascularized, single-stage, composite flap did not involve sacrifice of the radial artery, the functional and aesthetic results were good, and there was minimal donor-site morbidity.

V-Y fasciocutaneous pudendal thigh flap for repair of perineum and genital region after necrotizing fasciitis: modification and new indication.

Necrotizing fasciitis is an aggressive, deep-seated infection of the fascia and subcutaneous fat with necrosis of the overlying skin, and it is a toxin-mediated disease. The aim of this study was to review 13 cases of necrotizing fasciitis of the perineum and the external genitalia region with regard to the diagnosis, treatment, and methods of reconstruction of secondary defects. The study was performed from June 1997 to May 2001 and involved 11 men and 2 women who ranged in age from 35 to 67 years (mean age, 53 years). All patients presented to the plastic surgery unit with huge secondary defects of the urogenital region, upper thigh, and lower abdomen after being excised initially by general surgeons. Eight patients were treated with bilateral flaps, and the unilateral flap was used in 2 patients. The V-Y island fasciocutaneous flap, used to resurface the urogenital region after necrotizing fasciitis, is considered a new indication. The V-Y axial-pattern design of the flap is also considered a new modification, which enabled the flap to be advanced and tailored nicely in the midline. The idea of using the V-Y-plasty design is raised because the perineum has a pair of symmetrical anatomic structures. In addition, this procedure conserves tissue and the flap donor site is closed primarily without tension. Both aesthetic and functional results were satisfactory.

The use of suction-assisted surgical extraction of moderate and large lipomas: long-term follow-up.

Solitary lipomas and familial multiple lipomatosis are the most common benign tumors and are very well encapsulated. They are very slow growing and have the potential for recurrence if incompletely excised and a very remote chance for malignant changes. These can be freed from surrounding tissue without difficulty, but because of the fibrous nature of the capsule, its violation is more likely with suction technique and may result in an inadequate resection, possibly leading to recurrence. Furthermore, liposuction alone will not allow histopathological study of the swellings. Therefore, we report here the treatment of moderate (>4-10 cm) and large (>10 cm) lipomas with liposuction-assisted surgical extraction of the capsule via the same wound (1 cm in length). This capsule extraction is aimed at avoiding recurrence and evaluating the histopathological nature of these swellings. 16 patients (nine men and seven women) presented with solitary lipomas (in 11 patients) and multiple lipomas (in five patients) have been successfully treated. Methods involved 1-cm incision for both liposuction and surgical removal of the capsule. Another 1-cm counter-incision may be needed in case of large size lipomas. High patient satisfaction was achieved because of the good cosmetic results due to the small postoperative residual scar and the smooth postoperative course. There has been no recorded recurrence in six years postoperative followup.

Use of an adipofascial flap based on the proximal perforators of the ulnar artery to correct contracture of elbow burn scars: an anatomic and clinical approach.

Different techniques can be used to repair contracture of burn scars on the elbow, including local or distant pedicle flaps, muscle or myocutaneous flaps, free flaps, and tissue expanders. Among these, a pedicled adipofascial flap based on the most proximal two to four perforators of the ulnar artery (located 1 to 5 cm from the origin of the artery) can be anastomosed to form a sort of axially patterned blood supply within the fascia and subcutaneous fat. Therefore, no major vessel in the forearm need ever be severed. In addition, use of this type of flap preserves muscle function. The pedicled adipofascial flap described in this article allows for early rehabilitation because the flap is thin and pliable. Additional advantages are the easy and quick dissection and completion of the procedure in one stage. A detailed anatomic dissection of the flap was performed on 16 upper extremities from fresh cadavers; an injection study was also performed to determine the location and dimensions of the pedicle flap and its area of reach around the elbow. In the past 3 years, 14 flaps were used in 13 patients to repair elbow defects after release of burn scar contractures. Flap dimensions ranged from 4 x 7 cm to 6 x 14 cm (mean flap size, 74 cm). The results were very satisfactory.