Simultaneous mastopexy in patients undergoing prophylactic nipple-sparing mastectomies and immediate reconstruction.

BACKGROUND: In some patients, a satisfactory aesthetic result of reconstruction following a nipple-sparing mastectomy (NSM) is limited by breast ptosis that goes uncorrected in the early phase of reconstruction. Most plastic surgeons remain hesitant to perform a mastopexy at the time of NSM due to concerns with nipple and/or skin flap loss. METHODS: From 1990 to 1995, 33 female patients underwent NSM with simultaneous mastopexy and immediate implant-based reconstruction by a single surgeon at our institution. On chart review, the following data were extracted: age, co-morbidity, indication, breast size, initial/final implant volumes, type of implant, mastopexy technique, mastectomy flap/nipple necrosis, other complications, revision surgery and follow-up. An unpaired, two-tailed t-test was performed where indicated. P-value<0.05 was considered significant. RESULTS: Wound complications occurred in 18.2% patients (10.9% breasts) without delaying tissue expansion. As many as 3% patients developed unilateral, isolated partial ischaemia of the mastectomy flap and 8% patients developed unilateral, superficial areolar loss. All resolved with conservative treatment. Only one patient developed bilateral total nipple loss. There was no correlation between preoperative breast size and postoperative complications. None of the patients developed breast cancer. Average follow-up was 11.6 years. CONCLUSION: With proper technique, simultaneous mastopexy is a safe procedure in highly selected patients undergoing NSM with reconstruction.

Efficacy of bilateral prophylactic mastectomy in BRCA1 and BRCA2 gene mutation carriers.

BACKGROUND: In women with a family history of breast cancer, bilateral prophylactic mastectomy is associated with a decreased risk of subsequent breast cancer of approximately 90%. We examined the association between bilateral prophylactic mastectomy and breast cancer risk in women at high risk for breast cancer who also had mutations in BRCA1 and BRCA2 genes. METHODS: We obtained blood samples from 176 of the 214 high-risk women who participated in our previous retrospective cohort study of bilateral prophylactic mastectomy. We used conformation-sensitive gel electrophoresis and direct sequence analysis of the blood specimens to identify women with mutations in BRCA1 and BRCA2. The carriers' probabilities of developing breast cancer were estimated from two different penetrance models. RESULTS: We identified 26 women with an alteration in BRCA1 or BRCA2. Eighteen of the mutations were considered to be deleterious and eight to be of uncertain clinical significance. None of the 26 women has developed breast cancer after a median of 13.4 years of follow-up (range, 5.8-28.5 years). Three of the 214 women are known to have developed a breast cancer after prophylactic mastectomy. For two of these women, BRCA1 and BRCA2 screening was negative, and no blood specimen was available for the third. Estimations of the effectiveness of prophylactic mastectomy were performed, considering this woman as both a mutation carrier and a noncarrier. These calculations predicted that six to nine breast cancers should have developed among the mutation carriers, which translates into a risk reduction, after bilateral prophylactic mastectomy, of 89.5%-100% (95% confidence interval = 41.4% to 100%). CONCLUSIONS: Prophylactic mastectomy is associated with a substantial reduction in the incidence of subsequent breast cancer not only in women identified as being at high risk on the basis of a family history of breast cancer but also in known BRCA1 or BRCA2 mutation carriers.

Efficacy of contralateral prophylactic mastectomy in women with a personal and family history of breast cancer.

PURPOSE: To estimate the efficacy of contralateral prophylactic mastectomy in women with a personal and family history of breast cancer. PATIENTS AND METHODS: We followed the course of 745 women with a first breast cancer and a family history of breast and/or ovarian cancer who underwent contralateral prophylactic mastectomy at the Mayo Clinic between 1960 and 1993. Family history information and cancer follow-up information were obtained from the medical record, a study-specific questionnaire, and telephone follow-up. Life-tables for contralateral breast cancers, which consider age at first breast cancer, current age, and type of family history, were used to calculate the number of breast cancers expected in our cohort had they not had a prophylactic mastectomy. RESULTS: Of the 745 women in our cohort, 388 were premenopausal (age < 50 years) and 357 were post- menopausal. Eight women developed a contralateral breast cancer. Six events were observed among the premenopausal women, compared with 106.2 predicted, resulting in a risk reduction of 94.4% (95% confidence interval [CI], 87.7% to 97.9%). For the 357 postmenopausal women, 50.3 contralateral breast cancers were predicted, whereas only two were observed, representing a 96.0% risk reduction (95% CI, 85.6% to 99.5%). CONCLUSION: The incidence of contralateral breast cancer seems to be reduced significantly after contralateral prophylactic mastectomy in women with a personal and family history of breast cancer.

Long-term satisfaction and psychological and social function following bilateral prophylactic mastectomy.

CONTEXT: Prophylactic mastectomy is a preventive option for women who wish to reduce their risk of breast cancer. There has been concern about possible negative psychological sequelae following this procedure. However, few data are available regarding long-term satisfaction and psychological and social function following this procedure. OBJECTIVE: To evaluate patients' long-term satisfaction and psychological and social function following prophylactic mastectomy. DESIGN, SETTING, AND PARTICIPANTS: Descriptive study of all women known to be alive (n = 609) who had a family history of breast cancer and elected to undergo bilateral prophylactic mastectomy at a large, tertiary US health care clinic between 1960 and 1993, 94% (n = 572) of whom completed a study questionnaire. MAIN OUTCOME MEASURES: Satisfaction with procedure and effects on psychological and social function, based on responses to the study-specific questionnaire. RESULTS: Mean time from prophylactic mastectomy to last follow-up was 14.5 years. Most women (70%) were satisfied with the procedure; 11% were neutral; and 19% were dissatisfied. Among the psychological and social variables, the most striking finding was that 74% reported a diminished level of emotional concern about developing breast cancer. The majority of women reported no change/favorable effects in levels of emotional stability (68%/23%), level of stress (58%/28%), self-esteem (69%/13%), sexual relationships (73%/4%), and feelings of femininity (67%/8%). Forty-eight percent reported no change in their level of satisfaction with body appearance; 16% reported favorable effects. However, 9%, 14%, 18%, 23%, 25%, and 36% reported negative effects in these 6 variables, respectively. CONCLUSIONS: This study suggests that positive outcomes following prophylactic mastectomy include decreased emotional concern about developing breast cancer and generally favorable psychological and social outcomes. These must be weighed against the irreversibility of the decision, potential problems with implants and reconstructive surgery, and occurrence of adverse psychological and social outcomes in some women. JAMA. 2000;284:319-324

Plasma 17beta-estradiol levels and ovarian interstitial cell structure in embryonic Japanese quail.

Plasma concentrations of 17beta-estradiol (E2) and left ovarian histology were investigated by light and electron microscopy in female Japanese quail from Day 10 of embryonic development through Day 7, posthatch. Plasma E2 levels remained relatively constant (102 to 140 pg/mL) in the embryo followed by a sharp decrease posthatch (47 to 70 pg/mL). Beginning on Day 10 of incubation, cells in the medullary portion (medullary cell; MC) of the left ovaries exhibited ultrastructural evidence of steroidogenic capability. The MC had numerous lipid droplets in close proximity to the smooth endoplasmic reticulum (SER). Mitochondria were also observed in the vicinity of the lipid droplets and SER. On Days 10 and 12, the cristae of the inner mitochondrial membranes were of a lamellar configuration; the cristae of some mitochondria in MC had a tubular appearance by Day 14. These data document relative ontogenic changes in ovarian morphology and plasma E2 levels during the early developmental period in female Japanese quail. These data further support the role of this steroid in sexual differentiation.

Short-term international medical service.

There are many opportunities for short-term medical service internationally. Prerequisite preparation must include consideration of motivation, flexibility, culturally sensitive health care, and problems in communication and patient approach. Practical considerations require recognizing the importance of choice of locale, lack of materials and equipment, health concerns, travel, and expenses. A reference for opportunities available and a list of articles suggested as supplementary reading are provided.

A safe and rapid technique for modified neck dissection.

The technique of modified neck dissection presented here, by the very limited anatomic area it addresses of necessity shares aspects of techniques described by other authors. Developed over many years of teaching residents, it provides, if carefully followed, a simple, safe, and relatively rapid method of carrying out the procedure, having been used by the senior author and his residents in scores of patients both at our institution and in many overseas operations under rather primitive conditions without modification. It is not a new way of doing the procedure, but rather a combination of some of the simplest approaches and aspects which may be especially helpful to those without wide experience.

Efficacy of bilateral prophylactic mastectomy in women with a family history of breast cancer.

BACKGROUND: Options for women at high risk for breast cancer include surveillance, chemoprevention, and prophylactic mastectomy. The data on the outcomes for surveillance and prophylactic mastectomy are incomplete. METHODS: We conducted a retrospective study of all women with a family history of breast cancer who underwent bilateral prophylactic mastectomy at the Mayo Clinic between 1960 and 1993. The women were divided into two groups - high risk and moderate risk - on the basis of family history. A control study of the sisters of the high-risk probands and the Gail model were used to predict the number of breast cancers expected in these two groups in the absence of prophylactic mastectomy. RESULTS: We identified 639 women with a family history of breast cancer who had undergone bilateral prophylactic mastectomy: 214 at high risk and 425 at moderate risk. The median length of follow-up was 14 years. The median age at prophylactic mastectomy was 42 years. According to the Gall model, 37.4 breast cancers were expected in the moderate-risk group; 4 breast cancers occurred (reduction in risk, 89.5 percent; P<0.001). We compared the numbers of breast cancers among the 214 high-risk probands with the numbers among their 403 sisters who had not undergone prophylactic mastectomy. Of these sisters, 38.7 percent (156) had been given a diagnosis of breast cancer (115 cases were diagnosed before the respective proband's prophylactic mastectomy, 38 were diagnosed afterward, and the time of the diagnosis was unknown in 3 cases). By contrast, breast cancer was diagnosed in 1.4 percent (3 of 214) of the probands. Thus, prophylactic mastectomy was associated with a reduction in the incidence of breast cancer of at least 90 percent. CONCLUSIONS: In women with a high risk of breast cancer on the basis of family history, prophylactic mastectomy can significantly reduce the incidence of breast cancer.

Reconstructing the human face by using the tissue-integrated prosthesis.

Reconstructing the human face with autogenous tissue is extremely difficult. A prosthetic device is often used, but retention is a problem. The tissue-integrated prosthesis has resolved this issue, however, and the technique is currently available worldwide. The tissue-integrated prosthesis--that is, a prosthesis supported (retained) by osseointegrated implants in the underlying bone--originated during the 1950s, when Brånemark began his laboratory studies of tissue healing in Sweden. The term "osseointegration" was introduced in 1977 and later was defined as "direct anchorage of an implant by the formation of bony tissue around the implant without the growth of fibrous tissue at the bone-implant interface." Early studies during the 1980s and 1990s documented the success of reconstruction of the human face with use of the tissue-integrated prosthesis. Herein we describe three cases in which this reconstructive procedure was successful.

Treating recurrence of parotid benign pleomorphic adenomas.

Treatment for recurrence after surgical removal of parotid benign pleomorphic adenoma (PBPA) has not been well defined and is often followed by further recurrence. Surgery is overwhelmingly the most common approach. The risk of facial nerve injury is greater at reoperation since the nerve is less well defined. The value of radiation therapy (RT) has not been determined and incurs with it the risk of possible late occurrence of malignancy or nerve damage. The charts of patients with recurrent PBPA treated consecutively by a single surgeon from 1965 to 1993 were reviewed. All patients had a histopathologically verified diagnosis of PBPA both at the time of primary and subsequent surgeries. Follow-up was obtained from clinical charts and correspondence communication. Recurrence curves were generated using the Kaplan-Meier method. Thirty-nine patients with recurrent PBPA (36 referred and 3 treated primarily at Mayo) were evaluated. The patients were classified according to the type of surgery: 14 patients had previously undergone some form of parotidectomy or had only resection of the tumor for recurrence, and 25 patients underwent parotidectomy since this had not been performed primarily. The mean age in the two groups was 49 and 50 years respectively. The mean follow-up was 10 years after the recurrence treatment. The mean time between initial resection and recurrence in the two groups was 14 and 15 years. The mean time between the recurrence treatment and a second recurrence was 7.5 years. Nine patients had RT in addition to the local resection. Of this group 3 patients (33%) developed another recurrence. Five patients had local resection only, and of this group 1 patient (20%) developed another recurrence. Of the group that had superficial parotidectomy, 3 patients had additional RT and one of these patients (33%) developed another recurrence. Twenty-two patients had superficial parotidectomy only, and of this group 3 patients (14%) developed another recurrence. Only 2 of the 39 patients had complications. One patient developed Frey's syndrome after superficial parotidectomy and 1 patient developed facial paralysis after RT. As in other series, the number of patients is inadequate to allow for firm conclusions. However, it appears that when previous parotidectomy has been performed, simple excision with a margin of surrounding tissue would seem appropriate. Parotidectomy should be carried out if not performed previously. In simple excision after previous parotidectomy, there is a greater risk to the facial nerve because of difficulty in distinguishing the facial nerve from surrounding scar tissue. Our preference is to use general anesthesia so that branches of the nerve are not paralyzed and stimulation of the nerve aids in safe dissection. The value of RT is still indeterminate.

Distribution and significance of microcalcifications in the neoplastic and nonneoplastic prostate.

OBJECTIVE: To determine the distribution and significance of microcalcifications in histologic sections of the prostate. DESIGN: Retrospective review of all histologic slides of completely embedded prostates from surgical specimens. MATERIALS: Randomly selected material included 266 radical prostatectomy and 10 cystoprostatectomy prostates without prostate cancer. Nonrandomly selected specimens included 26 radical prostatectomy specimens with a Gleason pattern 5 component, 24 cases with collagenous micronodules, and 8 cases previously noted to have microcalcifications within foci of prostate cancer. RESULTS: Four patterns of microcalcifications were noted in association with prostate cancer: (1) dystrophic calcification in the comedo-type necrosis of Gleason pattern 5, (2) intraluminal calcification in cribriform-type Gleason pattern 3 prostate cancer, (3) intraluminal calcification in small acinar adenocarcinoma, and (4) stromal calcification within collagenous micronodules associated with prostate cancer. Microcalcifications were noted in 32% of prostates without cancer; 1.9% of randomly selected prostates demonstrated microcalcifications associated with prostate cancer. CONCLUSIONS: Microcalcifications are less common in association with prostate cancer than with benign prostatic ducts and acini. However, intraluminal microcalcifications associated with an atypical small glandular proliferation should not be taken as unequivocal evidence of a benign process.

Treatment outcome for 424 primary cases of clinical I cutaneous malignant melanoma of the head and neck.

BACKGROUND: Cutaneous malignant melanoma (CMM) is increasing in frequency. Surgery remains the primary and only curative treatment method. Our aim was to define prognostic factors and outcome predictors for patients with clinical stage I CMM of the head and neck. METHODS: Surgical treatment and outcome was analyzed for 424 patients with clinical stage I melanoma of the head and neck, completing initial treatment at the Mayo Clinic (1970-1990). The data were analyzed using the Kaplan-Meier product-limit method and Cox multiple-regression models. RESULTS: Overall, 180 (42%) patients underwent elective lymph node dissection (ELND) as part of the initial treatment; occult disease was demonstrated in 15 (8.3%). Among patients with tumor > 1.5 mm thick, occult regional disease was found in 15%. Failure of final treatment occurred in 152 (36%). Overall, 82% and 75% of the patients survived 5 and 10 years, respectively. CONCLUSIONS: Tumor thickness, extent of invasion, and the presence of occult region metastatic disease were the only independently predictive value (p < .005) of recurrence. The detection of disease by ELND did not appear to protect the patient from disease progression but identified those with regionally advanced disease and highest risk for recurrence. The development of recurrence significantly reduced but did not eliminate the potential for extended disease-free survival with subsequent treatment.

Ontogenic changes in the circulating concentrations of insulin-like growth factor (IGF)-I, IGF-II, and IGF-binding proteins in the chicken embryo.

The ontogeny of circulating concentrations of insulin-like growth factor (IGF-)-I, IGF-II, and IGF-binding proteins (IGF-BPs) was examined in the chick embryo. Distinct ontogenic changes in the circulating concentrations of IGF-I and IGF-II were observed. The present study confirms the overall profile for circulating concentrations of IGF-I. During middevelopment, plasma concentrations of IGF-I increased to a maximum which was attained on Day 14.5 of incubation. Thereafter, plasma concentrations of IGF-I declined with decreases (P < 0.05) between Days 14.5 and 15.5 and between Days 16.5 and 17.5 of incubation. In contrast to the monophasic profile for IGF-I, plasma concentrations of IGF-II were maximal on Day 10.5 of incubation and declined to a nadir on Day 17.5 of incubation. In late developmental stages (17.5 or 18.5 days of incubation), three IGF-BPs, having molecular weights of 22, 28, and 36 kDa, were detected in the plasma of chick embryos. No significant ontogenic changes in the circulating levels of the 28- and 36-kDa IGF-BPs were observed. However, it should be noted that prior to Day 17.5 of incubation, the 22-kDa IGF-BP was nondetectable in the circulation. The role of these changes in the functioning of IGF in embryonic development is discussed.

Complications leading to surgery after breast implantation.

BACKGROUND: Local complications that require additional surgical procedures are an important problem for women with breast implants. METHODS: We studied 749 women who lived in Olmsted County, Minnesota, and received a first breast implant at the Mayo Clinic between 1964 and 1991. We identified complications that occurred after the initial procedure and after any subsequent implantation. A complication was defined as a surgical procedure performed for any of the following reasons: capsular contracture; rupture of the implant; hematoma or bleeding; infection or seroma of the wound; chronic pain; extrusion, leakage, or sweating of the implant; necrosis of the nipple, areola, or flap; malfunction of the filler port of a tissue expander; and wound dehiscence. RESULTS: During follow-up (mean, 7.8 years; range, 0 to 25.8), 208 (27.8 percent) of the women underwent 450 additional implant-related surgical procedures. Ninety-one (20.2 percent) were anticipated, staged procedures or were done because the patient requested a size change or aesthetic improvement, and 359 procedures (79.8 percent) had at least one clinical indication (thus constituting a complication). Complications occurred in 178 (23.8 percent) of the 749 women and involved 274 (18.8 percent) of the 1454 breasts with implants and 321 (18.8 percent) of the 1703 implants. The most frequent problem was capsular contraction (272 cases), followed by rupture of the implant (60), hematoma (55), and wound infection (23). The rate of complications was significantly lower (P<0.001) among women with cosmetic implants (6.5 percent at one year, 12 percent at five years) than among women who underwent implantation after mastectomy for breast cancer (21.8 percent at one year, 34 percent at five years) or prophylactic mastectomy (17.3 percent at one year, 30.4 percent at five years). CONCLUSIONS: Women who have had breast implantation frequently experience local complications during the subsequent five years. Complications were significantly less frequent among patients who received implants for cosmetic reasons than among those who received implants after mastectomy for cancer or for cancer prophylaxis.

Noma: a review.

Cancrum oris or noma is a condition not well known in western Europe and North America. It is, however, a relatively common cause of mortality and disability in children of undeveloped areas of Africa, Asia, and South America. This paper describes the experience at Galmi Hospital, in the sub-Saharan region of South Africa in the Niger Republic, with 50 operative patients out of a group of 300 who were referred. An extensive review of the literature is presented describing the epidemiological impact of the disease, the characteristics of the lesions, the pathogenesis, symptoms, sequelae, differential diagnosis, and preoperative preparation. Additionally, we review approaches to anesthesia, methods of reconstruction, and the most common causes of complications and mortality. Numerous photographs illustrating the devastating consequences of this problem are presented.

The sternocleidomastoid myocutaneous flap: a reappraisal.

The sternocleidomastoid myocutaneous flap was described 40 years ago. However, its reliability has been a matter of discussion, mainly because of its random blood supply and subsequent tendency to necrosis. This paper describes the use of the sternocleidomastoid island myocutaneous flap, superiorly based, in 10 patients with good results. In these patients, the superior thyroid artery was sacrificed and the skin paddle was incised directly over the muscle, as described by Ariyan. We believe this approach assures the usefulness of the flap and justifies its expanded utilization.

Significant hemangiomas and vascular malformations of the head and neck: clinical management and treatment outcomes.

The treatment dilemmas and our institutional experience with head and neck hemangiomas and vascular malformations are reviewed. Fifty-eight patients (38 with hemangiomas, 20 with vascular malformations) aged from newborn to 78 years were treated from 1975 to 1993. Eighty-seven percent of patients provided up-to-date follow-up, yielding a median follow-up interval of 7.18 years from intervention. Only significantly sized tumors (minimum diameter > 4 cm) were studied. Sodium tetradecyl sulfate sclerotherapy (SDS) was a sole therapy in 12 patients (all with hemangiomas) and was used in combination with surgical ablation in 22 patients (16 with hemangiomas, 6 with vascular malformations). The minority of tumors from both categories were completely removed with ablative surgery (six hemangiomas [23%], eight vascular malformations [44%]). Significantly debilitating tumor postsurgical recurrence, which led to mortality in some patients, was unique to vascular malformations with high flow on the basis of increased arterial to venous shunting. Less alarming but significant functional and cosmetic challenges are created in primarily postadolescent patients with incompletely involuted hemangiomas and low-flow vascular malformations of the head and neck. We have had a favorable experience with the combined application of sclerotherapy and conservative ablative surgery in this group. Patient survey implied satisfaction with treatment in the majority: Nine indicated they benefited significantly (17%); 37 indicated they were generally improved (71%); and 6 stated they did not benefit (12%). Tumor-specific philosophy on ablative therapy, recurrence patterns, and associated complications are presented.