Response of locoregional and systemic symptoms to breast implant replacement with autologous tissues: experience in 37 consecutive patients.

This paper addresses the effectiveness of implant removal as treatment for systemic symptoms perceived to be related to breast implants. We reviewed our experience with 37 consecutive patients who underwent autologous tissue replacement of reconstructive breast implants. All patients were motivated primarily by concern regarding systemic symptoms for which diagnoses could not be provided. The majority of treated patients also had locoregional complaints and physical findings suggestive of either implant failure or symptomatic contracture and/or inflammatory disease. Essentially all patients with locoregional symptoms experienced improvement or resolution of these throughout the period of follow-up (6 to 27 months). However, relief from systemic complaints proved short-lived, with a 90 percent early response rate falling to 32 percent by 6 months postoperatively. We continue to strongly counsel patients to pursue reoperation only when locoregional symptoms are persistent and associated with physical or radiographic findings of significant contracture or implant failure. We conclude that although explantation with or without autogenous reconstruction may be appropriate in certain circumstances, it should not be proposed as a treatment for systemic rheumatologic or neurologic complaints.

Immediate autogenous breast reconstruction in clinically advanced disease.

Breast reconstruction is pursued more aggressively today. We have offered primary autogenous reconstruction to patients with advanced disease and review herein our experience with these patients to define the benefits or problems of this practice. We carried out immediate autologous tissue breast reconstruction in 21 patients with disease in clinical stage IIb or higher, including 12 in stage III and 3 in stage IV. No patient experienced delay in the delivery of adjuvant chemotherapeutic or radiation treatment, and the reconstructed breasts tolerated these treatments well. Although 4 patients required biopsy of postoperative masses deep within the reconstructed breast, none proved to represent recurrence of disease. One patient developed cutaneous recurrence in a scar uniting mastectomy flap with reconstructive flap, and 2 had axillary recurrences. All were quickly detected and treated. Two patients with stage III disease and 2 with stage IV disease died from metastases, but with good local-regional control. Primary autogenous breast reconstruction may be offered to motivated patients regardless of disease stage.

Transverse rectus abdominis musculocutaneous flaps after liposuction of the abdomen.

We describe a patient for whom bilateral transverse rectus abdominis musculocutaneous flap breast reconstruction was successfully accomplished several years after liposuction of the lower abdominal tissues making up the flaps. A history of liposuction within the area of a proposed musculocutaneous flap does not preclude use of that flap. Issues related to flap elevation in sites of previous liposuction are discussed.

Bilateral brachial plexus palsy after immediate breast reconstruction with TRAM flaps.

Although most postoperative upper extremity neuropathies are caused by extremes of position or intraoperative manipulation of the arm, nerve injury is possible without either of these. Pedicled TRAM flap surgery, during which no axillary retraction or hyperabduction of the arm is used, is not free of risk for neural injury. More studies are needed to specifically define risk-related maneuvers for these and other anesthetized patients.

Rupture of abdominal fascial fusion lines: an unusual complication of rectus abdominis flap.

Two cases of rectus abdominis muscle flaps complicated by disruption of the abdominal wall due to avulsion of the anterior rectus sheath from adjacent fascia are reported. Abnormal transmission of intraabdominal pressure is suggested as the cause. A polyglactin mesh patch for the prevention of abdominal disruption is described.

The "circummuscular" free TRAM pedicle: a trap.

A variation of the deep inferior epigastric system is presented in which the vessels or their dominant branches do not enter the rectus muscle at any point on its deep surface. Full submuscular exploration of the deep inferior epigastric pedicle is proposed as a necessity (prior to muscle section) if flap loss is to be avoided during efforts to raise free TRAM flaps with minimal muscle harvest.

Restoring the breast to match the normal side.

Although breast symmetry is for most patients a reconstructive goal of the highest order, the alteration of a normal breast may, for many women, constitute another "branding." Our patients have chosen overwhelmingly to leave their normal breasts "untouched" since having been given the opportunity to do so. Treatment planning and surgical methods are described that have made possible symmetrical results without change in the normal breast. Representative patients are shown to document the usefulness of these plans in women of varied anatomy. Our ongoing experience shows us that it is an uncommon patient, indeed, for whom symmetrical breast restoration cannot be accomplished without resorting to surgery on the normal organ.

Sinus obliteration for chronic oro-antral fistula: a case report.

This report describes a patient with chronic oro-antral fistula resulting from tooth extraction. Several local flap procedures failed to close the fistula, which was complicated by chronic sinusitis. Ultimately, cure was achieved via antral obliteration using vascularised temporoparietal fascia, sparing remaining maxillary alveolar bone. Total, trans-buccal maxillary sinus obliteration with fascia should be considered for the treatment of oro-antral communications refractory to treatment with intraoral tissues.

The teres major muscle flap in breast reconstruction.

We describe the teres major as a muscle flap. The results of anatomical and radiographic studies demonstrate the surgical anatomy. The details of 4 clinical cases illustrate its application in breast reconstruction. The teres major flap offers advantages over previously described muscle flaps in selected cases of breast and chest contour reconstruction.

Adaptive response of rat pancreatic lipase to dietary fat: effects of amount and type of fat.

Pancreatic lipase adapts to changes in dietary fat by parallel changes in synthesis. The adaptation to changes in type of dietary fat (saturation or chain length) is unclear. The effects of changes in amount and type of dietary fat were examined in weanling rats fed for 1 wk diets low in fat (LF) with 10% kcal as corn oil, moderate in fat (MF) with 40% kcal as fat (corn oil, lard, safflower oil, butter, olive oil or coconut oil), or high in fat (HF) with 67% kcal as fat (as for MF). Growth was comparable among rats fed these diets. Pancreatic lipase activity increased in all HF diets (180%) compared to the LF diet. In MF diets, only the highly unsaturated safflower oil increased pancreatic lipase (162%) compared to the LF diet. Food consumption varied, but was not related to the response of pancreatic lipase. When weanling rats were fed diets with 11, 40, 47, 54, 67 and 75% kcal as corn oil, pancreatic lipase activity was not stimulated at or below 47% kcal fat, but was maximally stimulated (twofold) by 54 or 67% fat. These findings suggest that pancreatic lipase activity adapts primarily to the amount of dietary fat and responds to the type of fat only below the threshold level of dietary fat (47% kcal).