Oncological outcomes of lipofilling breast reconstruction: 195 consecutive cases and literature review.

INTRODUCTION: Lipofilling has become a widely used procedure in breast reconstruction after mastectomy or breast-conserving treatment. The possibility that this technique may increase stimulation of cancer development between the potential tumor bed and the lipoaspirates grafts has been raised regarding its safety. The aim of this study was to identify the oncological risks associated with this procedure in our institution. METHODS: Between years 2007 and 2014 we record 195 consecutive patients with fat grafting technique for reconstructive purpose after breast cancer treatment. The loco-regional recurrence (LRR) as first event of relapse was the primary end point of this study. RESULTS: We performed 319 lipofilling procedures in 132 mastectomy and 63 breast-conserving surgery patients. Invasive carcinoma represents 81.6% of the series. The median follow-up from primary cancer surgery and fat grafting was 74 and 31 months respectively. Median time between oncologic surgery and lipofilling was 36 months. The authors observed a complication rate of 8.2%, most of them liponecrosis and oil cysts (7.2%). Four local, 2 regional and 4 distant recurrences were observed as first event of relapse in 10 patients with invasive ductal carcinoma. The loco-regional recurrence rate was 3.1% (1.08% per year). CONCLUSIONS: Although larger prospective trials are needed, these results support the fact that lipofilling following breast cancer treatment leads to a very low rate of complications and similar to other authors, it does not seem to interfere in patient's oncological prognosis when compared with prior publications.

Multislice computed tomography angiography of the fourth dorsal interosseous space in cadavers.

PURPOSE: To study computed tomography angiography (CTA) findings and compare anatomic correlation of the 4th dorsal metacarpal spaces and to determine the role of this technique for anatomic studies and flap design. METHODS: Hands from 17 cadavers were injected with a radiopaque mixture. The specimens were imaged using 16-detector-row computed tomography. Each image was analyzed by a radiologist, a plastic surgeon, and an anatomist. The following data were recorded: the presence of the 4th dorsal metacarpal artery, proximal and distal communicating branches and distal recurrent branch, and the number of cutaneous perforators. Afterwards, a meticulous dissection was carried out. A correlation between the radiologic findings and the gross anatomy was established. RESULTS: In all specimens, the 4th dorsal metacarpal artery and distal recurrent branch were identified. In 15 cases, at least 1 perforator was identified within the 4th space. In 2 cases, no perforator was identified. In all cases, the radiologic findings correlated with the anatomic findings in the dissection. CONCLUSIONS: Multislice CTA provides good-quality information about the vascular anatomy of the dorsal aspect of the hand, including perforator vessels less than 0.5 mm in diameter. Multislice CTA allows for observation of the axis, trajectory, and branching pattern of the blood vessels and, most importantly, demonstrates the anatomic relationships among blood vessels, bones, and soft tissue.

Cutaneous perforators of the fourth dorsal interosseous space: anatomic study.

PURPOSE: Many investigators have studied the vascular anatomy of the dorsal metacarpal arteries but little attention has been paid to the exact distribution of the cutaneous perforators of the dorsum of the hand. We present an anatomic study of the cutaneous perforators within the fourth dorsal interosseous space, which was supposed to have the most inconsistent vascular anatomy. METHODS: Twenty hands were dissected after black latex injection. A skin paddle was outlined along the fourth dorsal metacarpal space. Suprafascial dissection was performed, preserving any vessel piercing the fascia and reaching the skin. Each perforator was traced back to its origin. The location and origin of each perforator was recorded by digital pictures and measured from a reference point. RESULTS: In 17 of the cases (85%) at least 1 perforator was identified within the fourth space piercing the dorsal interosseous muscle fascia and reaching the skin. In 10 hands, a perforator branching off the proximal communicating branch was identified, located a mean distance of 11 mm from the carpometacarpal joint line. CONCLUSIONS: A dissectable perforator was found consistently (17 of 20; 85%) in the proximal third of the fourth dorsal interosseous space branching off the proximal communicating branch. Few perforators branch off the middle third of the dorsal metacarpal artery. The perforator described herein shows the connection between the superficial and deep vascular systems of the ring and small metacarpal spaces, and establishes the anatomic basis for reconstructive flaps.

Endoscopic breast reconstruction with intraoperative complete tissue expansion and partial detachment of the pectoralis muscle.

We present the surgical technique for mammary reconstruction using tissue expander with endoscopic approach, associated to partial detachment of the pectoralis muscle at the fourth rib and complete or nearly complete intraoperative expansion. Tissue expansion for breast reconstruction is a well-honored technique that provides satisfying esthetic outcomes, with minimal morbidity for the patient. Nevertheless, this technique has some potential problems: (1) wound dehiscence with extrusion of the expander; (2) the patient discomfort during the expansion process (weekly visits for the refill of the expander); (3) the poor definition of the lower pole of the breast and cranial migration of the expander with excessive roundness of the upper pole. By using intraoperative tissue expansion, these drawbacks can be avoided. We report herein our experience with this technique in 53 consecutive patients (56 breasts) undergoing a secondary breast reconstruction since December 2001.

The anatomic basis of the fourth dorsal metacarpal flap: a cadaveric dissection.

PURPOSE: To study the vascularization of the fourth dorsal intermetacarpal space and to determine the contribution of the dorsal metacarpal artery and the interosseous muscle fascia to flap viability. The fourth dorsal intermetacarpal space is considered to be less reliable as a donor site because of previously reported vascular variations. METHODS: We performed 15 cadaver dissections. The vascular tree was injected with black latex through the radial and ulnar arteries at the forearm. The skin paddle was designed within the fourth intermetacarpal space. The proximal border was placed at the wrist joint line. The distal border was located 1 cm proximal to the head of the fourth and fifth metacarpal. The width of the skin paddle was based on whether the donor site could be closed directly. A zigzag incision was performed from the distal end of the skin paddle to the volar edge of the interdigital web. The borders of the skin paddle were outlined down to the fascia of the dorsal interosseous muscle. Once the fourth dorsal metacarpal artery was identified each vascular connection was dissected and recorded. RESULTS: The fourth dorsal metacarpal artery was identified in all specimens under the dorsal interosseous muscle fascia. The distal recurrent branch consistently entered the base of the flap superficial to the extensor digitorum communis tendon of the small finger and the dorsal interosseous muscle fascia. Cutaneous perforators branching off the dorsal metacarpal artery were not found consistently. CONCLUSIONS: Reliable flaps can be raised from the fourth dorsal intermetacarpal space based solely on the distal recurrent branch, excluding the dorsal metacarpal artery and interosseous muscle fascia.

Augmentation mammaplasty with anatomic soft, cohesive silicone implant using the transaxillary approach at a subfascial level with endoscopic assistance.

BACKGROUND: Many augmentation mammaplasty techniques have been developed paying special attention to incision location and pocket plane to achieve more natural-looking breasts. METHODS: The authors' technique of choice in patients with mammary hypoplasia, empty breasts following a diet program, or more than one lactation episode causing skin flaccidity without ptosis is the placement of an anatomical implant using a transaxillary approach in a subfascial plane with endoscopic assistance. Thus, ideal patients are those presenting mammary hypoplasia, empty breasts following two or more lactation episodes, and breast skin flaccidity without ptosis, with the nipple-areola complex placed above the inframammary fold. The technique and its indications are presented thoroughly. RESULTS: Forty-five patients were operated on using this technique from May of 2001 to October of 2003. One-year follow-up results showed highly rated patient satisfaction. One patient underwent an implant exchange because of implant size dissatisfaction. CONCLUSIONS: The authors prefer subfascial plane implants to submuscular ones. Possible rotation of anatomic implants and the subsequent asymmetry when contracting the pectoral muscle are avoided. Pectoral muscle is not detached from its insertions, resulting in less postoperative pain. Likewise, the authors prefer a subfascial to subglandular pocket since the weight of the subglandular pocket and the glandular weight itself are borne by the skin envelope leading to breast ptosis development over time. On the other hand, fascia provides additional support to the subfascial implant, thus eliminating ptosis development and achieving good filling of the upper pole similar to the filling provided by subglandular implants.