Return of lymphatic function after flap transfer for acute lymphedema.

OBJECTIVE: The goals of this work were to develop animal models of lymphedema and tissue flap transfer, and to observe physiologic changes in lymphatic function that occur in these models over time, both systemically with lymphoscintigraphy (LS) and locally using fluorescence microlymphangiography (FM). SUMMARY BACKGROUND DATA: Although lymphedema has been managed by a combination of medical and surgical approaches, no effective long-term cure exists. Surgical attempts aimed at reconnecting impaired lymphatic channels or bypassing obstructed areas have failed. METHODS: The tails of rats (A groups) and mice (B groups) were used because of their different features. Lymphedema was created by ligation of the lymphatics at the tail base and quantified by diameter measurements there. In the experimental group, rectus abdominis myocutaneous flap was transferred across the ligation. In addition to the ligation (A1 and B1) and ligation + flap (A2 and B2) groups, three control groups were included: sham flap with ligation (B4), sham flap alone (B5), and normal (A3 and B3) animals. Observations were made at weekly time points for lymphatic function and continuity. RESULTS: Lymphedema was successfully created in the mouse ligation groups (B1 and B4) and sustained for the entire length of observation (up to 14 weeks). Lymphatic continuity was restored in those animals with transferred flaps across the ligation site (A2 and B2), as seen both by LS and FM. Sham flaps did not visibly affect lymphatic function nor did they cause any visible swelling in the tail. CONCLUSIONS: Acute lymphedema developing after ligation of tail lymphatics in mice can be prevented by myocutaneous flap transfer. Restored lymphatic continuity and function were demonstrable using lymphoscintigraphy and fluorescence microlymphangiography.

Skin-sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early-stage breast cancer.

Skin-sparing mastectomy has been advocated as an oncologically safe approach for the management of patients with early-stage breast cancer that minimizes deformity and improves cosmesis through preservation of the skin envelope of the breast. Because chest wall skin is the most frequent site of local failure after mastectomy, concerns have been raised that inadequate skin excision could result in an increased risk of local recurrence. Precise borders of the skin resection have not been well established, and long-term local recurrence rates after skin-sparing mastectomy are not known. The purpose of this study was to evaluate the oncologic safety and aesthetic results for skin-sparing mastectomy and immediate breast reconstruction with a latissimus dorsi myocutaneous flap and saline breast prosthesis. Fifty-one patients with early-stage breast cancer (26 with ductal carcinoma in situ and 25 with invasive carcinoma) undergoing primary mastectomy and immediate reconstruction with a latissimus flap were studied from 1991 through 1994. For 32 consecutive patients, skin-sparing mastectomy was defined as a 5-mm margin of skin designed around the border of the nipple-areolar complex. After the mastectomy, biopsies were obtained from the remaining native skin flap edges. Patients were followed for 44.8 months. Histologic examination of 114 native skin flap biopsy specimens failed to demonstrate breast ducts in the dermis of any of the 32 consecutive patients studied. One of 26 patients with ductal carcinoma in situ had metastases to the skin of the lateral chest wall and back. Four other patients, one with stage I disease and three with stage II-B disease, had recurrent breast carcinoma. The stage I patient had a local recurrence in the subcutaneous tissues near the mastectomy specimen. Two patients suffered axillary relapse, and one had distant metastases to the spine. The findings of this study support the technique of skin-sparing mastectomy as an oncologically safe one, based on an absence of breast ductal epithelium at the margins of the native skin flaps and a local recurrence rate of 2 percent after 45 months of follow-up. Although these results need to be confirmed with greater numbers of patients and longer follow-up, skin-sparing mastectomy and immediate breast reconstruction may be considered an excellent alternative treatment to breast conservation for patients with ductal carcinoma in situ and early-stage invasive breast cancer.

Reconstruction of scleroderma of the breast.

Although limited to a single case, our study suggests that patients with localized scleroderma of the breast can incur developmental impairment leading to severe breast deformity. The results of any of several methods of breast reconstruction were not available to us for review because of the rarity of this clinical problem. Tissue expansion allowed our patient to avoid the additional scarring and possible functional loss associated with the transfer of autologous tissues. Its successful completion in this one patient indicates that it can be considered for other patients encountered with similar unusual findings.

An investigation of lymphatic function following free-tissue transfer.

Despite microsurgical advances in the repair of severed arteries, veins, and nerves, disrupted lymphatics are not usually identified or reconnected during replantation. Although temporary swelling of a replanted part is attributed to lymphedema, this condition resolves without microsurgical intervention. Spontaneous regeneration or reconnection of lymphatics is thought to occur in such situations. Microsurgical free-flap transfer is clinically analogous to replantation in that it also results in a complete division of all lymphatic channels exiting the flap. The ability of lymphatics to regenerate after flap reconstruction, either pedicled or free, has received little attention because safe and accurate techniques for visualization and evaluation of the status of these structures have not been available. As a result of recent advances in radiocolloid lymphoscintigraphic imaging techniques, it is possible to demonstrate lymphatic flow in a physiologic, anatomic, and noninvasive manner. These methods can be applied to free-flap models to document lymphatic function after surgical treatment and determine when and to what extent such a process of growth occurs. We studied 10 consecutive patients having free-flap reconstruction. These flaps were performed for chronic osteomyelitis (6) and unstable wound coverage (4). Microvascular flaps used were latissimus dorsi, scapular-parascapular fasciocutaneous, lateral arm, rectus abdominis, temporoparietal, and free toe. Radiocolloid lymphoscintigraphy with technetium-99m-antimony trisulfide colloid (Sb2S3) was done on all patients by injection directly into the free-flap dermis. All patients were studied between 8 and 44 days (mean 23.6) after free-flap transfer. Following injection into each flap, rapid egress of the radiotracer along lymphatic pathways with progression to locoregional nodes was observed in all patients. Reestablishment of lymphatic pathways following microvascular free-tissue transfer was demonstrated by radionuclide lymphoscintigraphic techniques in 10 consecutive patients who had reconstruction for extremity wounds.

Silicone gel implant explantation: reasons, results, and admonitions.

Managing the patient who requests removal of her silicone gel implants, either intact or ruptured, can be difficult because the treatment depends on the desires and perceptions of the individual patient, especially in the present absence of data concerning the possible long-term adverse consequences of a silicone gel implant, intact or ruptured. Over 12 months, 46 women underwent removal of 74 silicone gel implants placed for augmentation in 26 and reconstruction in 20. Reason for removal was fear of possible consequences of the silicone gel in 17 patients, aesthetic concerns related to encapsulation in 14, systemic symptoms in 8, rupture determined by mammography in 7, and fear of interference with mammography or clinical examination for breast cancer in 4. Ten of 26 augmented patients rejected replacement because of their concern about saline devices, but only 2 of 20 reconstructed patients declined. Capsulectomy was performed in 34 patients (74 percent). Mammography correctly predicted gel implant rupture in 7 of 8 patients. Eleven of 46 consecutive explantations were broken during removal. Only 1 of 7 patients with severe systemic symptoms was asymptomatic postoperatively, but with no changes in laboratory values. Two patients had 3 implants (6.5 percent) deflate at 10, 13, and 90 days as a result of manufacturing defects. Subcutaneous mastectomy patients (5) had the least aesthetic improvement because of prominent rippling of the anterior skin of their breasts. Two patients developed infection after capsulectomy. We conclude that patients seeking explantation of silicone gel implants because of fear of the possible adverse effects of the silicone will be pleased despite aesthetic limitations.(ABSTRACT TRUNCATED AT 250 WORDS)

Recurrent breast cancer following immediate reconstruction with myocutaneous flaps.

As immediate breast reconstruction with rectus abdominis and latissimus dorsi myocutaneous flaps has become a recognized technique for patients requiring mastectomy, concerns have arisen regarding the detection and treatment of locoregional recurrence of breast cancer. Because most recurrences develop in the residual native skin of the chest wall following a mastectomy, breast reconstruction procedures involving the placement of a subpectoral prosthesis are unlikely to interfere with postoperative cancer surveillance. Myocutaneous flaps, however, transpose blocs of soft tissues into the mastectomy site. This study was done to evaluate the influence of a myocutaneous flap on the subsequent diagnosis and treatment of locoregional recurrence of breast cancer. Data were obtained from 161 patients with breast cancer who had immediate reconstruction with a myocutaneous flap between 1982 and 1990. Of the 161 patients reviewed, 120 had primary mastectomy with immediate reconstruction; 41 patients had salvage mastectomy and immediate reconstruction after failed conservative surgery and radiation therapy. Modified radical mastectomy was performed on all patients. Either a rectus abdominis (n = 65) or latissimus dorsi (n = 97) myocutaneous flap breast reconstruction was performed. Recurrent tumor was observed in 17 of the 161 patients reviewed (10.6 percent). Fourteen of the 17 recurrences occurred in 120 patients having primary mastectomy and immediate reconstruction for a rate of 11.7 percent; 3 of 41 patients (7.3 percent) who had salvage mastectomy and flap reconstruction developed recurrences. Of the 17 recurrences, 6 patients were stage II, 10 were stage III, and 1 was stage IV. All 17 patients who developed a recurrence had invasive breast cancer, with infiltrating and inflammatory tumors predominating. All locoregional recurrences of breast cancer developed within the native skin and subcutaneous tissues adjacent to the mastectomy and flap reconstruction site. Recurrences were seen as rapidly as 2 weeks or as long as 3.8 years (mean 1.4) after the mastectomy and flap reconstruction. Overall mean follow-up for the entire group of 161 patients was 5.4 years. Thirteen of the 17 patients (76.5 percent) developed distant metastases either concomitantly with the locoregional recurrence or within 4.3 years (mean 1.7). From an oncologic viewpoint, the technique of myocutaneous flap breast reconstruction with rectus abdominis or latissimus dorsi flaps appears to be a safe one. An analysis of locoregional recurrence of breast cancer in patients undergoing primary mastectomy or salvage mastectomy with myocutaneous flap breast reconstruction did not show concealment by the flap of any recurrent tumor.(ABSTRACT TRUNCATED AT 400 WORDS)

Improving the latissimus dorsi myocutaneous flap with tissue expansion.

Although the latissimus dorsi myocutaneous flap is a safe and reliable technique for breast reconstruction, its versatility is limited when large cutaneous units are needed to resurface a heavily irradiated or scarred breast and chest wall. The thick back skin, in particular, may be unsuitable for reconstruction opposite either a hyperplastic or moderate sized but ptotic breast. Also, the likely need for a prosthesis can result in encapsulation and firmness. Expanding the latissimus flap has been suggested as a means of improving its aesthetic and reconstructive results. Indications for choosing an expanded flap in 10 patients included: (1) a need for autogenous tissue reconstruction of irradiated breast and chest wall tissues; (2) cutaneous coverage requirements that exceeded the availability of donor site skin; (3) the presence of a hyperplastic or ptotic contralateral breast that the patient preferred to match rather than alter; and (4) unavailability of an alternative flap such as a TRAM and unsuitability of an implant or expander without a flap. Results of this study in 10 patients requiring breast and chest wall reconstruction demonstrate that flap dimensions increased by approximately a factor of 1.5 after expansion. The latissimus flap was pre-expanded on the back before transfer in two patients when skin and soft tissues were inadequate, or was expanded post-transfer in eight patients for both immediate and delayed breast reconstruction. Eight patients underwent a total of two operations, including two who had nipple areolar reconstruction. Earlier in the series, two other patients had nipple areolar reconstruction performed as a third procedure. Mean follow-up was 15.1 months. Complications consisted of partial dehiscence of the donor site wound in one patient after transfer of an expanded flap measuring 16 x 28 cm; three patients developed symptomatic seromas requiring drainage. All patients had soft, nonpalpable implants and no distortion of the flap's shape. The application of tissue expansion techniques yields latissimus flaps that are notable for their capacious dimensions, thinned tissues, and improved pliability. Advantages include an avoidance of reduction or mastopexy procedures in patients with large, ptotic breasts and uncomplicated wound healing in those with a history of prior irradiation. Not all latissimus flaps need to be expanded, but some can be significantly improved when specific indications are present. Most importantly, expanded latissimus flaps appear to resist the early formation of periprosthetic encapsulation.

Mammary ducts in the areola: implications for patients undergoing reconstructive surgery of the breast.

The use of selective excision of the nipple with preservation of the areola ("nipple coring") has been advocated for patients undergoing subcutaneous or total glandular mastectomy. This is based on the assumption that all the mammary ducts in the nipple-areola complex are located in the nipple and that the areola is devoid of mammary ductal tissue. To investigate this issue, we performed nipple coring on eight consecutive mastectomy specimens, excised the areolas, and submitted them in their entirety for histologic examination. Mammary ducts identical in appearance to extralobular ducts in the breast parenchyma were identified in the dermis of the areola in all eight cases. These ducts were present throughout the areola, including the most peripheral aspects. We conclude that mammary ducts are a normal component of the areolar dermis and that nipple coring does not result in the removal of all mammary ductal tissue from the nipple-areola complex. This observation should be taken into consideration by reconstructive surgeons considering preservation of the areola in patients undergoing subcutaneous or total glandular mastectomy.

Reconstruction of the radiated partial mastectomy defect with autogenous tissues.

As conservative surgery and radiation therapy have become accepted treatments for early-stage breast cancer, increasing attention has focused on the cosmetic results of this technique. When partial mastectomy--a term which encompasses a diversity of excisional techniques--is followed by radiation therapy, breast defects characterized by parenchymal loss, nipple-areola complex distortion, and cutaneous abnormalities can occur. From 1981 to 1990, eight patients sought reconstructive correction of a radiated partial mastectomy deformity. Patients were from 42 to 70 years of age (mean 49 years). All had breast cancer, except for one patient with diffuse and chronic breast abscesses. Six patients were reconstructed with latissimus dorsi flaps and two with rectus flaps. No patient underwent reconstruction sooner than 1 year after completion of radiation therapy; for the entire group, a mean of 2.6 years elapsed from completion of radiation therapy to flap reconstruction of the breast. Mammograms were obtained on all the breast cancer patients before and after the myocutaneous flap procedure. Follow-up extended from 1 to 9 years after reconstruction (mean 3.6 years) and included both physical examination and serial mammographic evaluations. Myocutaneous flap reconstruction with either latissimus or rectus flaps achieved an aesthetic improvement of the partial mastectomy deformity in all eight patients. Complications consisted only of seroma formation in two patients following latissimus flap reconstruction. Mammographic evaluation revealed fibrofatty degeneration of the soft tissues of both types of flaps, a change that occurs as early as 6 months after operation and appears as a radiolucent area. The feasibility of mammography as a screening adjunct for recurrent cancer in this group of patients is demonstrated. Advantages of this technique of autogenous tissue reconstruction are improvement of contour deformities associated with conservative surgery and radiation therapy, preservation of normal, sensate breast skin, enhancement of symmetry with the contralateral breast, and avoidance of a prosthesis.

Sixty consecutive breast reconstructions with the inflatable expander: a critical appraisal.

Breast reconstruction using inflatable expanders has become an established and preferred technique. Although our knowledge of the biomechanical changes occurring in expanded skin has increased greatly, little information is available regarding average aesthetic results achieved with this technique. In order to eliminate the bias of best case selection reports, this study of 60 consecutive patients undergoing skin-expansion breast reconstruction was undertaken. Results of the study demonstrated a significant frequency and diversity of complications. In particular, immediate breast reconstruction with skin expanders was identified as a high-risk procedure because of its association with skin necrosis and delayed wound healing. Although two procedures--insertion and replacement--had been anticipated, patients from both the Boston and New York groups required approximately three operations to complete the expansion process. Average aesthetic results, often characterized by problems of symmetry, ptosis, and contour, need to be recognized and improved.

The cocaine user: the potential problem patient for rhinoplasty.

The current popularity of cocaine use poses special hazards for the patient and the plastic surgeon during rhinoplasty. It is incumbent upon the surgeon to inquire preoperatively about possible recreational use of cocaine. As the preferred site of cocaine administration, the nasal septal mucosa is exposed to both the intense vasoconstrictive action of cocaine and the irritative effects of numerous contaminating additives. Pathologic changes in the septal mucosa should be recognized by preoperative rhinoscopy and evaluated by biopsy. In this series of 13 patients, fewer than half were properly identified as cocaine users during the preoperative consultation. Preoperative rhinoscopic findings varied from grossly unremarkable septal mucosa to visible perforation and microscopic evidence of granulomas, inflammation, and necrosis. Surgical complications consisted of localized septal collapse, delayed mucosal healing, and inadequate correction of septal deflection. Submucous resection and septoplasty should be avoided in patients with a known history of intranasal cocaine application. Although rhinoplasty can be safely performed in selected patients with a history of cocaine use, it may be extremely limited, unfeasible, or hazardous in those with significant mucosal and cartilaginous impairment as well as in those patients who refuse or are unable to relinquish the drug.

An experimental model for chronic lymphedema.

Although a multitude of operations exist for the treatment of lymphedema, none is highly successful. An experimental model that reliably and easily produces chronic lymphedema in an extremity would be useful to study treatments in a controlled and comparative manner and would enhance our understanding of the physiology and treatment of lymphedema. Many models that simulate clinical lymphedema have been described, but they suffer from cumbersome protocols, high laboratory costs, and an inconsistent yield of permanent lymphedema. We describe an experimental model for chronic lymphedema in the lower extremity of the rat that creates a lymphatic block in the groin induced by radiation treatment and one operation--surgical division of the superficial and deep lymphatics. All animals develop stable chronic lymphedema of the lower extremity within days of operation, with swelling that persists for at least 9 months. A mortality rate of 8 percent was associated with this technique. Methods for quantification of limb swelling are described, as is analysis of the lymphatic block by lymphoscintigraphic imaging of lymph channels and nodes. This model has the advantages of simplicity of technique, cost-effective use of rodent subjects, reproducibility of lymphedema, and quantification of results.

Pseudocyst formation after rectus flap breast reconstruction: diagnosis and treatment.

Pseudocyst is an unusual complication occurring after rectus flap breast reconstruction. Of four patients in whom a preoperative diagnosis of pseudocyst was made, three had epigastric masses and a fourth presented with a mass of the chest wall. The three patients with epigastric masses were identified by physical examination and evaluated by aspiration of cyst contents. Imaging with computed tomography delineated cyst anatomy and assisted in confirmation of the diagnosis. Most likely, the pathogenesis of these lesions is related to undrained or clinically undetected serous collections which ultimately form firm walls of fibrin. Although all the patients had ipsilateral rectus flap reconstructions, flap transposition does not appear to be causally related to any fluid accumulation. In one patient, a squamous carcinoma, probably arising from the original intraductal breast pathology, created physical and computed tomographic findings suggestive of pseudocyst. Therefore, confirmation of the diagnosis by biopsy, combined with excision, or, at least, biopsy of the anterior cyst wall is recommended in patients with this condition. All three patients with epigastric pseudocysts were explored. There have been no recurrences after an average of 28 months.

Varix of the digit.

Varix of the digit is a rarely described lesion. Over 3 years, eight patients were diagnosed as having this abnormality. Surgical confirmation of the identity of the lesion was accomplished in six of these patients. Repetitive trauma, mechanical compression, and aging phlebectasia have all been associated with the pathogenesis of a digital varix. Thrombophlebitic and thrombotic changes occurring within the varix may lead to an erroneous assessment and clinical confusion. In such instances, a tourniquet test has been useful in demonstrating the presence of a varix. Excision of a symptomatic lesion has proven to be curative for all six patients. Two patients have been observed for 3 years with little change and no resolution of the varix. It is probable that varix of the digit is a more common lesion than indicated by a review of the literature.

The midabdominal rectus abdominis myocutaneous flap: review of 236 flaps.

The midabdominal rectus abdominis myocutaneous flap is described in this review of 236 flaps in 223 patients. This flap is safe, reliable, and extremely well vascularized. It has been our flap of choice for purposes of reconstructing the moderate- or large-sized breast. In particular, the midabdominal flap permits restoration of fascial continuity over the entirety of the abdominal wall without the necessity for synthetic materials. A 2.2 percent incidence of hernias has been observed over a 4-year period. The flap is well suited to immediate reconstruction of the breast, particularly among the growing number of patients with antecedent radiation therapy.

Congenital infiltrating lipomatosis of the face: clinicopathologic evaluation and treatment.

Congenital lipomatosis of the face is characterized by collections of nonencapsulated, mature lipocytes which infiltrate local tissues and tend to recur after surgery. These lesions represent a distinct clinicopathologic entity that has not been previously reported in this location in children. Three children with congenital lipomatosis of the face were treated at the Institute of Reconstructive Plastic Surgery over a 2- to 14-year follow-up period. In each instance, pathologic evaluation by light and electron microscopy revealed similar lesions sharing the following morphologic criteria: (1) nonencapsulated tumors containing mature fat cells, (2) infiltration of adjacent muscle and soft tissue, (3) absence of malignant characteristics, (4) absence of lipoblasts, (5) presence of fibrous elements in conjunction with increased numbers of nerve bundles and vessels, and (6) hypertrophy of subjacent bone. All three lesions recurred after numerous excisions, some of which were extensive. All were benign by histologic examination and remained so for as long as 14 years. Surgical treatment improved the aesthetic appearance of each child despite evidence of tumor persistence. Although these tumors are benign, we recommend an early aggressive surgical approach to control the infiltrative nature of their growth and to improve facial appearance.

An investigation of bacteremia during rhinoplasty.

The rarity of infection after rhinoplasty is not well understood. Despite the apparent low incidence of this complication, many surgeons administered perioperative antibiotics to prevent infection. We studied whether a bacteremia composed of nasal flora can originate during rhinoplasty. Fifty-two health patients admitted for rhinoplasty were studied. Blood and nasal cultures were drawn immediately before operation and blood cultures 5 and 15 minutes after completion of the nasal osteotomies. With the exception of one instance of likely contamination, none of the blood cultures grew microorganisms. Neither local nor systemic infections occurred in any patient. The negative results of this study suggest an exceedingly low incidence of bacteremia during rhinoplasty. For this reason, the value of perioperative antibiotic prophylaxis is questionable.