Closure of the donor defect for breast reconstruction with rectus abdominis myocutaneous flaps.

The abdominal muscles not only constitute a multidirectional cinch that holds the abdominal contents in place, but they also determine the flexion and rotational movements of the trunk. The rectus is mainly responsible for flexion and the obliques are responsible for rotating the trunk. It is therefore important to maintain the tone and direction of pull of the oblique muscles. The key to closure of the fascial defect is to replace the same area of anterior rectus fascia (tendon of both obliques and transversus muscles) as has been removed with the rectus abdominis flap pedicle. This replacement, done with a double Merselene mesh, should extend up to the costal margin and should be of the same width as the fascia taken with the muscle pedicle. This technique was drawn from experience with 186 patients. Of these, 31 were simply approximated, and 43 percent developed weakness, bulging, or hernias, of which 5 required secondary repair. A total of 155 patients were closed with Merselene mesh, and only 4 percent developed bulging that was later repaired and attributed to technical mistakes. There were two cases of infection and three cases of exposed mesh due to necrosis (mesh did not need removal). Seromas were common (14 percent), but the incidence was reduced to 5 percent after tacking stitches were done from the mesh to the subcutaneous fascia.

Immediate breast reconstruction after mastectomy using a rectus abdominis myodermal flap without an implant.

In the authors' opinion there is no physical reason for a waiting period after total mastectomy before the breast is reconstructed. If the duration of the patient's survival is limited, the sooner the breast is reconstructed the better. The authors do not use silicone implants that may be blamed for the appearance of recurrent tumour but reconstruct the breast with a vertical rectus abdominis myodermal flap immediately after the mastectomy. The flap is an island of skin, fat and muscle extending from the xiphoid to the pubis; it receives its blood supply from the perforators of the superior-inferior epigastric vascular axis on the same side as the mastectomy. The rectus abdominis muscle is the pedicle and carrier of the vessels that feed the ellipse of skin. The flap is doubled on itself and thus forms a cone. It is then passed into the breast area by undermining the intervening bridge of skin. Nipple and areola are grafted onto the flap. This operation enables a wide resection, so that the principles of cancer management are not compromised.

The value of safety belts: a review.

The literature is reviewed to ascertain the values and dangers of safety belts. They are said to reduce the risk of major or fatal injury in impacts by nearly 60%. An incidence of abdominal trauma of the order of 0.5% is ascribed to the safety belt, and in addition there is a low incidence of a specific type of spinal fracture. The safety belt has not been shown to make injuries worse, and in causing injuries of its own has prevented more serious ones. The design of the safety belt is discussed; the three-point (lap-and-diagonal) belt is probably the best type for automobiles currently available. Recent research suggests that more sophisticated restraint systems may make survival possible in very severe impacts.