Nipple viability after nipple-sparing mastectomy in patients with prior circum-areolar incisions.

Nipple-areola-sparing mastectomy (NSM) is becoming more commonplace as it offers a more esthetic breast appearance while still appropriately treating malignancy. However, patients with prior circum-areolar incisions are often considered at risk for nipple viability. The authors present a case series of all patients undergoing NSM at their institution between 2012 and 2016. Eighteen consecutive female nonsmoking patients underwent 32 NSMs. None of the patients had reconstructive failures including those relating to the nipple-areola complex (NAC), such as nipple necrosis. NSM is therefore feasible in cases with prior circum-areolar incisions. These patients can be safely reconstructed with both prosthetic devices and autologous tissue.

One-Step Salvage of Infected Prosthetic Breast Reconstructions Using Antibiotic-Impregnated Polymethylmethacrylate Plates and Concurrent Tissue Expander Exchange.

PURPOSE: Periprosthetic infection represents a major complication in breast reconstruction, frequently leading to expander-implant loss. Recent studies report variable success in the salvage of infected breast prostheses through systemic antibiotic therapy and surgical intervention. There is currently no consensus regarding a management algorithm for attempted salvage. The purpose of this pilot study was to evaluate the early outcomes of a protocol using antibiotic-impregnated polymethylmethacrylate (PMMA) implant placement with expander device exchange. METHODS: A retrospective database was queried to identify all patients with infected implant-based breast reconstruction who were treated by the study authors and who underwent attempted salvage under the study protocol. All patients received intravenous antibiotics followed by surgical debridement of the infected pocket, insertion of antibiotic-impregnated PMMA plates and/or beads, device exchange, and postoperative antibiotics. After clinical resolution of infection, tissue expansion was performed with the PMMA implants remaining in situ until exchanged to permanent implants. RESULTS: All patients with infected prosthetic breast reconstructions achieved implant pocket sterilization using this method. At a mean follow-up of 8.2 months (range, 1-19 months), none of these patients have required reoperation for capsular contracture. One patient, while under treatment with prednisone for a rash, developed recurrent infection, which led to explantation of her implant. Two patients underwent radiation therapy while an antibiotic plate and tissue expander were in place, with no observed exposure or infection recurrence. CONCLUSIONS: Sustained local antibiotic delivery using PMMA implants and expander device exchange can successfully salvage an infected breast implant. Perceived benefits include shorter time to completed reconstruction, preserved skin envelope integrity, and possibly improved long-term aesthetic outcomes.

Posterior cranial vault distraction in the treatment of shunt-induced craniosynostosis.

Cerebrospinal fluid shunt placement is the most common surgical intervention for hydrocephalus. In rare cases, cerebrospinal fluid shunting has been associated with the development of secondary craniosynostosis. Posterior cranial vault distraction osteogenesis is an emerging technique used for the treatment of craniosynostosis. Posterior vault distraction allows greater intracranial volume expansion than do techniques that address the anterior cranium. We present a patient with shunt-induced multisuture craniosynostosis with delayed presentation. She was effectively treated with posterior cranial vault distraction and preservation of her ventriculoperitoneal shunt. This unique case demonstrates the safety and utility of this procedure for complex craniocerebral disproportion.

The ultra-thin, fascia-only anterolateral thigh flap.

BACKGROUND: While many potential donor sites have been described for fascial (fascia-only) flaps, a fascial flap harvested from the anterolateral thigh (ALT) donor site has not gained popularity, likely because of concerns regarding inadequate perfusion of the deep fascia. However, recent clinical experience demonstrates that the ALT fascia-only flap is a suitable option for reconstructions necessitating thin and pliable coverage. METHODS: In this study a retrospective chart review was performed examining the clinical experience of two plastic surgeons with the fascia-only ALT perforator flap from 2008 to 2012. Each flap was initially raised as a standard ALT flap, but all the overlying skin and adipose tissue was excised off the deep fascia before the inset, resulting in the creation of a fascia-only ALT flap. Immediate split- or full-thickness skin grafts were used to cover the flap. The results are reported in this article. RESULTS: Overall seven patients underwent reconstruction of wounds using either free (six) or pedicled (one) fascia-only ALT flaps (length, 10-20 cm, width, 5-10 cm). The following regions were successfully reconstructed using a fascia-only ALT flap: occipital scalp, lower extremity, upper extremity, and groin. All patients were followed for at least 6 months postoperatively. CONCLUSIONS: The fascia-only ALT flap was successfully used to reconstruct a variety of defects in seven patients. The authors experience demonstrates the viability of the fascia-only version of the ALT flap for reconstructions requiring thin coverage with good contour, and further adds to the versatility of the ALT as a donor site for flaps.

Bilateral macrodystrophia lipomatosa with syndactyly: a case report and literature review.

Macrodystrophia lipomatosa is a rare, non-hereditary form of congenital local gigantism characterised by enlargement and hypertrophy of all mesenchymal tissue components with a disproportionate increase in adipose tissue. This form of macrodactyly has been reported in association with other anomalies including polydactyly, brachydactyly, syndactyly, and symphalangism. We describe a previously unreported case of bilateral upper extremity macrodystrophia lipomatosa with syndactyly in a 23-month-old boy. In this report, we emphasise the importance of establishing a diagnosis with imaging and review the described surgical approaches to treating this difficult condition.

Frontonasal and fibrous dysplasia in a patient with unilateral cleft lip and palate.

Frontonasal dysplasia is a rare entity. It has characteristic physical deformities: hypertelorism, broad nasal root, median facial cleft of the upper lip or palate, clefting of the nasal alae, poorly formed nasal tip, cranium bifidum occultum, and a widow's peak hairline. Fibrous dysplasia is a benign bone tumor in which normal bone is replaced by fibrous, poorly formed osseus tissues. We present a patient with frontonasal dysplasia who desired correction of her hypertelorism. Incidentally, fibrous dysplasia was found in her left orbit complicating surgical correction. In addition, the patient has velopharyngeal insufficiency and a class III malocclusion. The interplay of all these craniofacial defects makes the sequencing and timing of surgery important in this unique patient.

Bilateral proximal delta phalanges: an unusual presentation of familial congenital clinodactyly.

We report a unique case of bilateral proximal delta phalanges with secondary distal accessory ossification centers of the long fingers in a 16-month-old boy. The bony anomalies presented as severe ulnar deviation at the proximal interphalangeal joints bilaterally. This is a unique occurrence of congenital clinodactyly which has not been previously reported. Several family members show similar deformity, although to lesser degrees, suggesting an autosomal dominant mode of inheritance with incomplete penetrance and variable expressivity.