Immediate breast reconstruction after skin- or nipple-sparing mastectomy for previously augmented patients: a personal technique.

BACKGROUND: Breast reconstruction for previously augmented patients differs from breast reconstruction for nonaugmented patients. Many surgeons regard conservation therapy as not feasible for these patients because of implant complications, whether radiotherapy-induced or not. Despite this, most authors agree that mastectomy with immediate breast reconstruction is the most suitable choice, ensuring both a good cosmetic result and a low complication rate. Implant retention or removal remains a controversial topic in addition to the best available surgical technique. This study reviewed the authors' experience with immediate breast reconstruction after skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) with anatomically definitive implants. METHODS: The retrospective records of 12 patients were examined (group A). These patients were among 254 patients who underwent SSM or NSM for breast carcinoma. The control group comprised 12 of the 254 patients submitted to SSM or NSM (group B) who best matched the 12 patients in the studied group. All of them underwent immediate breast reconstruction, with an anatomically definitive implant placed in a submuscular-subfascial pocket. The demographic, technical, and oncologic data of the two groups were compared as well as the aesthetic outcomes using the Breast Q score. The proportion of complications, the type of implant, the axillary lymph node procedure, and the histology were compared between the two groups using Fisher's exact test. Student's t test was used to compare the scores for the procedure-specific modules of the breast Q questionnaire in the two groups. RESULTS: A validated patient satisfaction score was obtained using the breast Q questionnaire after breast reconstruction. The demographic, technical, and oncologic characteristics were not significantly different between the two groups. The previously augmented patients reported a significantly higher level of satisfaction with their breast than the control patients. The scores for the other procedure-specific modules were similar in the two groups. CONCLUSION: A valid immediate one-stage implant reconstruction can be obtained for previously augmented patients by placing the implant in a submuscular-subfascial pocket reinforced by the periprosthetic capsule of the previous prosthesis.

DIEP flap donor site versus elective abdominoplasty short-term complication rates: a meta-analysis.

BACKGROUND: Although over the past decade the DIEP flap has emerged as one of the preferred choices for autologous breast reconstruction and the donor-site closure has much in common with the standard abdominoplasty technique, reports on comparisons of the complication rates between DIEP and elective abdominoplasty patients are not currently available. The purpose of this study was to compare DIEP donor-site and elective abdominoplasty short-term complications rates, in support of surgical choices. METHODS: Searches of MEDLINE and CENTRAL for English language articles on DIEP and elective abdominoplasty (EA) published from January 1999 through December 2009 identified 33 studies that met the inclusion criteria and included 3,937 patients. A random-effects model was used to calculate the average complication rate in the literature. RESULTS: The rate of seroma/hematoma in EA (16.1%, 95% confidence interval [CI] = 12.2-20.9%) was approximately four times the rate in DIEP flap patients (3.7%, 95% CI = 1.5-8.8%) was found from analyzing the data under a random-effects model. No substantial differences in the rates of infection, abdominal/umbilical necrosis, or wound dehiscence/delayed healing between the two series of patients were detected. CONCLUSIONS: This meta-analysis reveals that DIEP donor-site complication rates were comparable to those in elective abdominoplasty, and, the rate of seroma in DIEP is an even lower than that of one of the most performed procedures in plastic surgery. We argue that patients presenting for a DIEP flap should be informed about this interesting comparison.

Autologous fat graft in radiated tissue prior to alloplastic reconstruction of the breast: report of two cases.

BACKGROUND: The new indications for radiotherapy in the cure of breast cancer lead to an increasing number of candidates for this adjuvant treatment. However, it raises some concerns with respect to the prosthetic reconstruction of the breast. In fact, the use of implants in the irradiated breast is discouraged by many authors because of the high rate of complications. In these cases autologous tissue reconstruction is being recommended. However, not every patient is a candidate for autologous tissue reconstruction. Furthermore, not all radiotherapies are comparable in dose, timing, and patient tolerance. In this article we present the preliminary results of an alternative surgical management in oncoplastic breast surgery consisting of fat injections before implant placement. METHODS: Six months after the last radiation treatment, a lumpectomy patient and a modified radical mastectomy patient each underwent two sessions of fat injection prior to implant placement, with a 3-month interval in between sessions. The implants were placed 3 months after the last fat injection. RESULTS: There was a 12-month follow-up for the modified radical mastectomy case and a 18-month follow-up for the lumpectomy case. In both cases we report no postoperative complications, Baker grade 1 capsule contracture, good aesthetic outcome, and high patient satisfaction. CONCLUSION: The preliminary results show that fat injection in irradiated tissue prior to breast alloplastic reconstruction may reduce the radiation-related complications on implants. Benefits from fat grafting are in keeping with the theoretical basis of this surgery. Larger studies are needed to confirm our observations.

Otoplasty for prominent ears: a versatile combined technique to master the shape of the ear.

OBJECTIVE: We present our experience with an otoplasty technique that combines "closed" anterior scoring using the Stenström otoabrader with mattress sutures to the posterior cartilage. STUDY DESIGN AND SETTING: In a retrospective study, we report our experience with 135 patients operated on in the last 12 years. Some surgical principles make our procedure different from previous combination techniques: the posterior access incision is linear without skin excision; anterior scoring is performed along the entire antihelix and scapha, with care to score toward the concha at the tail of the antihelix to bring the ear lobe nearer to the mastoid; Mustarde's mattress sutures are used to stabilize the result. RESULTS: There were no major complications and few minor complications. The aesthetic results were graded as very good or good in 95% of the cases; the rest were graded as satisfactory. CONCLUSIONS: Our technique is versatile, gives pleasant, natural-looking results, and has a low complication rate. It is a simple, reliable, reproducible, and easily mastered method.

The effect of liposuction on inferior epigastric perforator vessels: a prospective study with color Doppler sonography.

The authors investigated the effect of abdominal liposuction performed by superficial subdermal liposuction technique on inferior epigastric perforators. We aimed to determine whether previous liposuction is a contraindication to the use of an abdominal flap. The perforators in the abdominal region in 6 patients were marked preoperatively by color and pulsed-wave Doppler sonography (CDS), which gave a morphologic and flowmetric representation. The parameters studied with CDS were the location of the perforators, the diameters of the arteries and veins, and the flow velocity. These parameters were evaluated by the same method preoperatively and 6 months postoperatively. The Student t test was employed to assess differences between pre- and postoperative values of variables. The results of our study led us to conclude that prior abdominal liposuction does no significant injury to most perforating vessels. However, CDS aimed to study the existence and the quality of perforators should be done before planning an abdominal flap.

Immediate breast reconstruction with definitive anatomical implants after skin-sparing mastectomy.

One-stage breast reconstruction with definitive implants was the original method of breast reconstruction. It gave a round breast with a fixed shape. Lack of skin after mastectomy was the main concern who led to the development of techniques to provide 'new' breast skin such as autogenous reconstruction and tissue expanders. This made the use of definitive implants almost obsolete. Since skin-sparing mastectomy (SSM) basically removes the mammary gland and the nipple-areolar complex preserving almost all mammary skin, it makes the use of definitive implants in immediate breast reconstruction possible again. Moreover, the advent of anatomically shaped implants overcomes the drawback of round shape: the anatomical implant with hyperprojected lower pole and short upper pole matches very well the profile of a real breast. The authors report their experience in 36 immediate breast reconstruction after SSM with short upper pole-hyperprojected silicone gel prostheses carried out between October 2001 and October 2003. In most cases SSM is performed through a circumareolar incision. Axillary dissection is preferably performed through the same incision. The anatomical implant is placed in a submuscular position superiorly and in a subfascial pocket inferiorly. Because of skin redundancy and easy distension of subfascial tissue in the inferior pole of the breast, the implant fills the skin of the inferior mammary pole without needing any skin expansion. Whenever possible, the skin incision is closed with a purse-string suture. The skin will look very wrinkled at the end of the surgery, but it will flatten out in a few weeks. The contralateral breast is simultaneously corrected, if needed. Outcome was assessed by evaluation of photographs performed by the authors, by the patients themselves and by a blinded group of surgeons who evaluated breast volume and shape, breast symmetry, and overall outcome. More than 90% of each of these parameters was scored as good or excellent. Complication rates was low with a 8.3% rate. The use of definitive implants in immediate breast reconstruction after SSM is a one-stage breast reconstruction with low morbidity and very good results, and it is associated with high level of patient and surgeon satisfaction.

Flap algorithm in vulvar reconstruction after radical, extensive vulvectomy.

The objective of this study was to assess the reconstructive options after radical, extensive vulvectomy; relate them to tumor characteristics; and select a choice of flaps able to correct every remaining defect. This study is a retrospective review of a 4-year experience with 31 flaps in 20 consecutive vulvar reconstructions. Three of the 31 flaps presented nonsignificant delayed healing at their tips and 3 other flaps developed a major breakdown related to an infection or an error in flap planning. According to the authors, the size of the defect is the main issue that must be taken into consideration during the establishment of reconstructive needs. Closure of vulvar defects is preferably performed using fasciocutaneous flaps, which are very reliable flaps and can be raised with different techniques to meet different needs. A flap is then chosen with the fewest potential complications. An algorithm has been thus established: Small to medium-size defects are closed with island V-Y flaps, island gluteal fold flaps, or pedicled pudendal thigh flaps. Among them, the island V-Y flap is the workhorse flap for vulvar reconstruction because of its versatility, reliability, and technical simplicity compared with its very low complication rate. If the vulvar defect is large and/or reaches the vulva-crural fold, V-Y flaps are also preferred to close these large and posteriorly extended excisions. If the vulvar defect is very large, extending both anteriorly and posteriorly, the use of a distally based, vertically oriented rectus abdominis muscle flap is recommended. Using this algorithm, immediate vulvar reconstruction with pedicled local or regional flaps can be performed easily and reliably.

Neurocutaneous island flap:: an experimental model using the rabbit ear.

The rabbit ear has often been used as an experimental model; however, a neurocutaneous flap has never been described before. The authors examined the reliability of a skin cartilage flap with a pedicle composed only of a sensory nerve with its vascular network in a rabbit model: A 2 x 2-cm cutaneous cartilage flap was harvested on the dorsal side of the ear bilaterally. Vessels were tied and cut on the 4 sides of the flap, including the central auricular artery and vein. The nerve was cut at the distal side of the flap and was "skeletonized" to the extent of 1 cm on the proximal side, meticulously preserving its vascular network. Subsequently, the flap was elevated with the cartilage as a composite flap and was sutured back to its natural site. The authors elevated 28 skin cartilage flaps on the dorsal side of both the ears of 14 New Zealand White rabbits, centered on the central neurovascular axis. All 28 flaps survived. In the control group of 7 rabbits, the artery, vein, and nerve (pedicle) were severed, and the skin cartilage island was sutured back as a composite graft. None of these 14 grafts survived. In 4 additional rabbits, the authors performed a histologic examination 1 day, 3 days, 7 days, and 3 weeks postoperatively of the neurovascular axis after the same skin cartilage flap was harvested. They compared these results with the histologic examination of the nerve of the contralateral nonoperated ear, and noted a marked dilatation and multiplication of blood vessels in the operated ear beginning on day 1 postoperatively. The presence of this neurocutaneous vascularization should be considered when other kinds of flaps (venous flaps or others) are used as experimental models using the rabbit ear.

Our experience with the so-called pull-through technique combined with liposuction for management of gynecomastia.

Gynecomastia is a benign enlargement of male breast, common in adolescents and adults. To treat this deformity, we have been carrying out liposuction through small cutaneous incisions placed in the axilla and on the sternum. If necessary, we performed a surgical excision of glandular tissue through a periareolar incision. From 1995, we started to perform surgical excision of glandular tissue, if necessary, through the small incisions made for liposuction, thus avoiding the periareolar scars. We describe our experience with this technique, which we believe excellent for the correction of glandular and fatty glandular gynecomastia, obtaining excellent esthetic results and minimal local scarring.

Combined treatment of advanced stages of recurrent skin cancer of the head.

OBJECT: The authors investigated whether skull base resection and primary free-flap reconstruction in a single-stage surgery is oncologically effective for treating advanced stages of recurrent skin cancer (RSC) of the head. METHODS: Eighteen consecutive patients were surgically treated. Twelve of them underwent an anterolateral skull base resection, which was performed using a pterional craniotomy combined with an orbitozygomatic osteotomy. Six patients underwent a posterolateral skull base resection, which was performed using an asterional craniotomy combined with a retrolabyrinthine petrosectomy. The wide postoperative defects were covered with muscular or myocutaneous free flaps. The main factor influencing survival was the extent of the resection: patients with no or minimal residual disease showed a statistically significant longer survival time than those with consistent residual disease. Basal cell carcinoma had a better prognosis than squamous cell carcinoma. A trend toward improved survival was observed in patients classified as T4M0 with negative lymph nodes (N0), but this trend was not statistically significant. Adjuvant radiotherapy significantly influenced both survival time and the rate of local recurrence. The surgical morbidity rate was 27.8%; there were two transient cerebrospinal fluid leaks and three seventh cranial nerve injuries. Late complications included radionecrosis in one patient and skin erosion requiring a second surgery in another patient. No deaths occurred during a 30-day postoperative period. CONCLUSIONS: Advances in skull base surgery and free-flap reconstruction allowed the authors to treat patients with advanced-stage RSC of the head in a rather satisfactory manner. Only when it is impossible to achieve no or minimal residual disease should aggressive treatment be considered.

Neovaginal reconstruction with the modified McIndoe technique: a review of 32 cases.

The authors reviewed 32 patients who underwent vaginal reconstruction using a modified McIndoe procedure during the past 15 years. This technique consists of the application of split-thickness skin grafts into a new cavity created between the rectum, bladder, and urethra. The grafts are placed previously on a mold of Optosil, which is a silicon-based condensation curing impression material used by dentists. The mold is kept for 3 months 24 hours each day. During the next 3 to 4 weeks it is applied 12 hours per day. Later, according to sexual activity, the mold can be removed completely. In case of no sexual activity it should be used 1 hour per week. Parameters assessed during the follow-up were mold management, grade of pseudomucinous metaplasia of the skin grafts, sensation of the neovagina, neovagina size changes, sexual satisfaction, and complications. Postoperative complications included partial take of skin grafts (N = 3), postoperative anxiety (N = 2), donor site cheloids (N = 1), and neovaginal stricture in 3 patients who used the mold for 1 month only without having any further sexual activity. Patients who managed the mold correctly or who had constant sexual activity obtained satisfactory dimensions of the neovagina in terms of length, diameter, and elasticity.