Anatomical Variations of the Medial Plantar Artery Flap: A Cadaveric Study With Clinical Applications.

The medial plantar artery flap (MPAF) presents both unique value as well as significant challenges. As the plantar foot has specific anatomy, the use of the MPAF to recreate this highly specialized area may provide improvements in durability and rates of limb salvage. The purpose of this study is to establish the anatomic course of the branching patterns of the medial plantar artery (MPA) and provide a foundation for MPA flap nomenclature as it is related to design and elevation. Thirty-seven fresh frozen cadaver feet were used for dissection: 20 right and 17 left sided limbs. Anatomic measurements recorded included: branching pattern of the MPA, bifurcation distance of the superficial branch (SB) and deep branch (DB) from the origin of the MPA, distance from the MPA origin to the anterior colliculus of the medial malleolus, and the distance from the SB and the DB to the navicular tuberosity. The MPA was found to bifurcate into SB and DB in 30 (81%) specimens; 6 (16%) specimens had only a SB, whereas 1 (3%) specimen had only a DB, which had not been previously described. The distance from the anterior colliculus to the MPA was 3.0 cm, MPA to the distal bifurcation was 2.9 cm, and navicular tuberosity to the SB and DB was 2.2 cm and 1.3 cm, respectively. Minimizing the complexity of the dissection with the use of more reliable landmarks and a deeper understanding of the anatomy may reduce complications and allow for more reproducible outcomes when utilizing the MPAF.

Single-Stage Immediate Breast Reconstruction Using Anatomical Silicone-Based Implant and The Hammock Technique of Dermal-Muscle Flap in Large and Ptotic breasts: A Multicenter Study.

BACKGROUND: This study revisits the previously described technique of inverted-T skin-reducing mastectomy and dermal-muscle pocket as a single-stage breast reconstruction using anatomical implants in large and ptotic breasts. Refinements have been added to enhance the quality of implant coverage, improve aesthetic outcome, and augment the implant volume than previously described in the literature. SUBJECTS AND METHODS: The study was performed in three centers in the UK, Egypt, and Libya. It included patients with large ptotic breasts with a breast cup size of D or larger. The areola-to-inframammary fold distance is of 8 cm or more, and a nipple-sternal notch distance is 25 cm or more. Modification of the dermal-muscle flap was made through dividing the medial and lateral ends of the de-epithelialized flap at a distance of one inch to create wings that could be sutured to the free edge of pectoralis major muscle to act as a hammock. RESULTS: It included 42 patients, and the mean age of the patients was 44.4 years (range 28-62). The mean body mass index was 34.2 (range 24-42). The reconstruction was unilateral in 32 (76.2%) patients and bilateral in ten (23.8%) patients. The average implant volume was 498.5 CC (range 375-650). Seventeen (40.5%) patients had a symmetrizing breast reduction. The average follow-up time was 52 weeks. Major complications were noticed in four (7.7%) breasts: Three breasts had major skin necrosis and one breast had hematoma that necessitated surgical evacuation. There were no reported cases of implant extrusion. Minor complications were recorded in six (11.5%) breasts; two had wound infection, and three had minor skin necrosis. CONCLUSION: The hammock technique of dermal-muscle flap is safe and versatile in large and ptotic breasts. It also creates a natural-looking breast with bigger implants.

The surgical management of male breast cancer: Time for an easy access national reporting database?

INTRODUCTION: Male breast cancer is extremely rare with an incidence of less than 1% of all breast cancers. Literature reports a peak of incidence at roughly 71 years of age. Management currently follows the same clinical pathways as female breast cancer as a general rule. METHODS: A retrospective search for all patients who were referred and diagnosed with male breast cancer at our centre was undertaken. Patients notes were then explored for demographics, histological staging, multidisciplinary team meeting outcome and treatment. A literature search including the search terms 'Male Breast Cancer AND Surgery' or 'Male Breast Cancer AND Experience' were used. Non English language articles, or those without abstracts were excluded. RESULTS: Seven patients were reviewed over 3 years (2006-2009). Mean agea was 69 years and mean lesion size was 15 mm. Histology was invasive ductal carcinoma for all patients. All patients were ER receptor positive. Two patients were HER2 positive. Five patients were offered mastectomy. One patient refused treatment. In follow up at 36 months there were 3 recurrences. 1 patient was lost to follow up. There were 3 mortalities. The literature search identified 72 articles. Articles were subdivided into those that discussed the surgical management of male breast cancer (n = 8), articles that discussed male breast cancer as podium presentations or posters with no full text article publication (n = 13) and finally full text publications of case experience of male breast cancer (n = 21). DISCUSSION: We report a series of seven cases of male breast cancer encountered over three years, evaluating patient demographics as well as treatment and outcomes. In our series patients were managed with mastectomy. New evidence is questioning the role of mastectomy against breast conserving surgery in male patients. Furthermore there is a lack of reporting infrastructure for national data capture of the benefits of surgical modalities. Literature review highlights the varied clinical experience between units that remains reported as podium presentation but not published. The establishment of an online international reporting registry would allow for efficient analysis of surgical outcomes to improve patient care from smaller single centres. This would facilitate large scale meta analysis by larger academic surgical centres.

The pulsatile head mass, 'uncommon things are sometimes common'. A case series.

INTRODUCTION: Superficial temporal artery aneurysms account for less than 1% of all reported aneurysms. It is often the result of mild blunt trauma to the side of the head and patients present several weeks later with a pulsatile head mass. PRESENTATION OF CASE: We report two cases referred to surgery in a 3 month period, from the same GP, of patients which this condition. The first case is a 21 year old carpenter who sustained blunt trauma during a rugby match to the side of the head. He presented several weeks later with headache and an otherwise painless pulsatile mass. The second case refers to a 20 year old male who received blunt trauma to the side of head from an assault. He was referred to his GP due family observing a painless pulsatile mass to the scalp. DISCUSSION: These cases highlight the relatively little force required to cause this pathological process. Management of this condition is by surgical excision. Simple examination techniques to obliterate the pulse locally can reveal the diagnosis. Subsequent literature search allowed discussion of the management of this rare but important differential diagnosis of a pulsatile head mass. CONCLUSION: Although rare, STA represents a complication of low energy trauma that requires elective surgical management.

Superficial temporal vessels as a reserve recipient site for microvascular head and neck reconstruction in vessel-depleted neck.

Reconstructions for local recurrence and second primary oromucosal cancer remain a challenge because the recipient vessels are depleted in the neck. The objective of this study was to investigate the outcome of superficial temporal vessels, as reserve recipient vessels for microvascular surgery in vessel-depleted neck patients. Between March 2003 and August 2005, the superficial temporal vessels were used as a recipient site for microsurgical head and neck reconstruction in 15 patients with vessel-depleted necks. There was no flap loss in any of the reconstructions. One venous anastomosis was revised for thrombosis and flap salvaged. The superficial temporal vessels provide a good alternative for head and neck reconstruction in vessel-depleted neck patients with the advantages of radiation spared, constant anastomy, and suitable size. It obviates the need for long pedicle flaps or the use of vein grafts. Care must be taken not to damage or kink the vein.

The pedicled 'policeman' flap salvage of exposed vascular prosthesis - a case report.

A case report of a patient with exposed, infected, subcutaneous, extra-anatomical, vascular prosthesis is presented, which was successfully salvaged using pedicled omental flap after other reconstructive procedures had failed.