Pre-expansion before risk reducing mastectomy combined with lipomodelling to enhance results from implant based reconstruction.

Implant based breast reconstruction after risk reducing mastectomy (RRM) is challenging as implants are inadequately covered in their lower pole. Also complication rates with one stage procedures are significant. We describe a novel method of pre-expansion by inserting subpectoral anatomical expandable implants to prepare the breast mound before RRM is carried out. Lipomodelling is later used to enhance the overall result of the reconstruction. Six patients who were BRCA 1 mutation carriers requested bilateral RRM. Median age was 31. All were non-smokers. Anatomical expandable implants were inserted via an inframammary incision and were expanded in the next two months. RRM was carried out 6-13 months later and was followed by lipomodelling seven months afterwards. Four patients had a nipple sparing mastectomy. In three cases access was via the previous inframammary scar. In all cases complete implant cover had been achieved. There were no early postoperative complications but one patient has developed grade III capsular contracture on the side of previous wide local tumour excision and radiotherapy. Five patients have so far undergone post-mastectomy lipomodelling to improve breast contour. In conclusion, we believe that our technique provides better aesthetic results with reduced complication rates for these patients.

The C-V flap for nipple reconstruction after previous skin-sparing mastectomy and immediate breast reconstruction: refinements of donor-site closure.

BACKGROUND: The C-V flap including its modifications is very popular flap used for nipple reconstruction. METHODS: This report describes a refinement of the C-V flap used in nipple reconstruction for patients who previously have undergone skin-sparing mastectomy and immediate breast reconstruction. Closure of the V flap donor sites is facilitated by means of designing two opposing advancement "areolar" skin flaps. RESULTS: Our modification ensures that no "dog ears" remain after the donor sites of the two V flaps are closed and that all scarring remains within the skin paddle of the neo-areola without any extensions on the mastectomy skin flaps. CONCLUSION: Our refinement of the closure for the donor site of the C-V flap used in nipple reconstruction produces an aesthetically pleasing result without unnecessary donor-site scar extensions on the mastectomy skin flaps.

Distally based dorsal metacarpal flaps: a review of a series of patients treated in a 6-month period.

The management of dorsal digital and hand injuries can pose a difficult problem to the trainee surgeon. Often repair involves using tissue from neighbouring digits. Our experience using local perforator flaps based on the direct cutaneous branch of the dorsal metacarpal arteries shows that these can be dissected and used successfully in the management of complex injuries of the dorsum of the hand and proximal phalanges. The flap has been used in a series of seven patients treated over a 6-month period by plastic surgery trainees with 100% success. This one-stage procedure resulted in good functional and aesthetic outcome and left an acceptable donor scar.

TNF-alpha increases human melanoma cell invasion and migration in vitro: the role of proteolytic enzymes.

Inflammatory mediators have been reported to promote malignant cell growth, invasion and metastatic potential. More specifically, we have recently reported that tumour necrosis factor alpha (TNF-alpha) increases melanoma cell attachment to extracellular matrix (ECM) substrates and invasion through fibronectin. In this study, we extend these investigations asking specifically whether the TNF-alpha effect on cell invasion and migration involves activation of proteolytic enzymes. We examined the effect of TNF-alpha on melanoma expression/activation of type IV gelatinases matrix metalloproteinases 2 and 9 (MMPs -2 and -9) and general proteolytic enzymes. Stimulation with TNF-alpha significantly increased both melanoma cell migration at 24 h (+21%) and invasion through fibronectin (+35%) but did not upregulate/activate the expression of latent MMP-2 constitutively produced by these cells and did not upregulate their general protease activity. However, the increased cell migration and invasion through fibronectin observed following stimulation with TNF-alpha were inhibited by the general protease inhibitor alpha(2) macroglobulin. These findings suggest that the promigratory and proinvasive effect of TNF-alpha on this melanoma cell line may be mediated to some extent by induction of localised cell membrane-bound degradative enzyme activity, which is not readily detected in biochemical assays.