Partial Breast Reconstruction with Goldilocks Technique After Excision of Giant Fibroadenoma: A Case Report.
Jan,
2017
Giant juvenile fibroadenomas are relatively rare, accounting for less than 1% fibroadenomas. Large breast tumors create significant asymmetry and provide unique reconstructive challenges after removal. In this case, we describe a 21-year-old female with delayed presentation of a giant fibroadenoma of the right breast. This represents an unusual presentation of benign breast disease requiring reduction of the skin envelope, extensive glandular resection, lower pole reconstruction, and free nipple grafting to achieve symmetry with the opposite breast. A novel modification of the Goldilocks mastectomy technique is described for partial breast reconstruction. Adaptation of the Goldilocks mastectomy technique provides adequate soft tissue for partial breast reconstruction. Using the lower pole deepithelialization breast skin flap provides autologous vascularized tissue to supplement volume loss after tumor and glandular excision. Benign breast disease can create significant breast deformities. Application and combination of the Goldilocks mastectomy technique allow for partial breast reconstruction without the need for an additional donor site or prosthetic devices. Подробнее
Plastic and reconstructive surgery. Global open
Google Glass in the Operating Room: The Plastic Surgeon's Perspective.
Jul,
2016
New technologies and innovations are common in the delivery of modern health care. Google Glass is one such device gaining increased attention in medical specialties. The authors surveyed residents and attending physicians in the Department of Plastic Surgery, MedStar Georgetown University Hospital, on their experience using Google Glass in the operating room. Ease of use, quality of images, gaze disruption, and distraction during surgery were measured. Overall, subjects found the device to be comfortable and satisfying to wear and use during surgery to capture images of good quality. Despite some identified weaknesses, Google Glass is a unique technology with a promising plastic surgical application in the operating room. Подробнее
Plastic and reconstructive surgery
Autologous flap breast reconstruction: Surgical algorithm and patient selection.
Jun,
2016
Whole breast reconstruction using autologous tissue is the gold standard in many regions of the world. Reasons include breast replacement with native skin and fat, ability to shape and mold the tissue into a breast, no foreign materials are necessary, and it lasts forever when successful. There are now many options for autologous breast reconstruction and the decision making process regarding which flap to choose will depend on ones experience and comfort, ability to perform microvascular surgery, and the milieu in which one operates. This chapter will review many of the options for autologous breast reconstruction and provide an algorithmic approach for flap and patient selection. J. Surg. Oncol. 2016;113:865-874. © 2016 Wiley Periodicals, Inc. Подробнее
Journal of surgical oncology
Factors to consider in breast reconstruction.
Jun,
2015
Women considering breast ablative therapy are confronted with a variety of decisions that include the type of mastectomy (partial, total, skin sparing, nipple areolar sparing), the type of reconstruction (prosthetic, autologous, oncoplastic) and the need for adjuvant therapy (chemotherapy, radiation). The parameters for each are multifactorial and require significant thought and counseling. Therapeutic options are essentially individualized and dependent upon a variety of factors such as tumor size and location, lymph node involvement, comorbidities, expectations and body characteristics. The role of reconstructive surgery is now well appreciated and an integral component of the multidisciplinary care of the patient and is influenced by the opinions and recommendations of surgical, medical and radiation oncologists. This manuscript will review the role of reconstructive surgery and the many factors to consider. Подробнее
Women's health (London, England)
Achieving ideal breast aesthetics with autologous reconstruction.
Apr,
2015
Achieving ideal breast aesthetic has become a top priority for women considering breast reconstruction following mastectomy. The use of autologous tissue is generally regarded as providing the most natural results because donor tissues quality and consistency is similar to that of the native breast. There are several donor sites that are particularly useful for autologous reconstruction that include the abdomen, gluteal region, posterior thorax, and the thigh. Traditional and microsurgical techniques can be used. Shaping is a critical component and involves a basic understanding of the footprint, conus, and skin envelope. This manuscript will review many aspects of breast shaping in-order to achieve aesthetically pleasing results in a predictable manner. Подробнее
Gland surgery
Patient-centred decision making in breast reconstruction utilising the delayed-immediate algorithm.
Apr,
2014
Delayed-immediate reconstruction is an increasingly valuable algorithm for patients anticipating post-mastectomy radiation therapy. Despite the cosmetic and long-term advantages of autologous tissue repair, a subset of patients choose implant-based reconstruction after their initial preference for autologous reconstruction. A critical evaluation of patients who initially planned to undergo delayed-immediate reconstruction but later chose to continue with implant-based reconstruction has not been previously reported. A retrospective analysis of the senior author's (M.Y.N.) patients who initially intended to undergo delayed-immediate autologous breast reconstruction following mastectomy and chose to abandon autologous reconstruction in favour of prosthetic reconstruction was completed from 2005 to 2011. Seven patients (10 breasts) met inclusion criteria. The mean patient age and body mass index were 50.2 years and 32.1 kg m(-2), respectively. Expansion required an average of 4.4 office visits to achieve adequate expansion volume, mean 483 ml (240-600 ml). The mean time from expander placement to definitive reconstruction was 14.6 months. Mean follow-up time was 20.4 months. Complications included infection (1/7), incisional dehiscence (1/7) and capsular contracture (2/7), and late revision surgery was performed in two patients. Successful reconstruction was achieved in 100% of patients (7/7) with a patient-reported satisfaction of 100%. Patient motivations for changing the reconstructive algorithm included a faster post-operative recovery in four patients (4/7) and potential donor-site morbidity in three patients (3/7). Depression or cancer-related fatigue symptoms were self-reported in 4/7. Avoiding donor-site morbidity and a simpler recovery are the main factors that influence patients to change their desire for autologous reconstruction to an implant-based reconstruction. Cancer-related fatigue and depression are prevalent in this population and may be implicated in a patient's desire to undergo less extensive reconstructive surgery. Allowing for the choice of definitive implant-based reconstruction in select patients is safe and is likely to result in high patient satisfaction with satisfactory aesthetic outcomes. Подробнее
Journal of plastic, reconstructive & aesthetic surgery : JPRAS
A patient-centered appraisal of outcomes following abdominal wall reconstruction: a systematic review of the current literature.
Feb,
2014
Published assessment tools have attempted to investigate patient-centered outcomes after abdominal wall defect repairs, including quality-of-life measures, functional outcomes, pain assessment, and overall satisfaction scores; however, health-related quality of life following hernia repair remains unclear. Подробнее
Plastic and reconstructive surgery
Use of intraoperative indocyanin-green angiography to minimize wound healing complications in abdominal wall reconstruction.
Dec,
2013
Complication rates following abdominal wall reconstruction (AWR) remain high. Early complications are related to skin necrosis and delayed healing, whereas late complications are related to recurrence. When concomitant body contouring procedures are performed, complication rates can be further increased. It is hypothesised that fluorescent angiography using indocyanin green (ICG) can identify poorly perfused tissues and thus reduce the incidence of delayed healing. A retrospective review was conducted of all patients who underwent AWR with concomitant panniculectomy from 2007-2012. Intraoperative ICG angiography with the SPY system (LifeCell Corp.) was used to determine the amount of resection for body contouring in patients who underwent reconstruction in a cohort of patients. SPY-Q was used to assess relative perfusion of analysed areas. Preoperative, postoperative, and operative details were analyzed. Seventeen patients met inclusion criteria, 12 patients were included in the non-ICG cohort, while five patients were included in the ICG cohorts. Wound-healing complications occurred in 5/12 (42%) patients in the non-ICG cohort vs 1/5 (20%) of the ICG cohorts. A description of the sole patient with complications in the ICG cohort is illustrated. Operative debridement and wound infection development occurred more frequently in the non-ICG cohort compared with the ICG cohort (17%, 17% vs 0%, 0%, respectively). Average time to wound healing was 41.1 days. Intraoperative ICG angiography can accurately detect perfusion abnormalities and can decrease wound healing related complications in complex hernia repair with concomitant panniculectomy. Assessing and ensuring skin viability can decrease the need for operative debridement. Подробнее
Journal of plastic surgery and hand surgery
Breast reconstruction following nipple-sparing mastectomy: a systematic review of the literature with pooled analysis.
Nov,
2013
Nipple-sparing mastectomy is a controversial option for breast cancer treatment due to locoregional recurrence and distant metastasis. In addition to these oncologic factors, technical factors such as ideal incision type or reconstructive options are also debatable. This systematic review examines current trends with nipple-sparing mastectomy, including selection criteria, locoregional and distant metastasis rates, incision choice, and reconstructive options. Подробнее
Plastic and reconstructive surgery
Acellular dermal matrix for secondary procedures following prosthetic breast reconstruction.
Sep,
2011
Acellular dermal matrices (ADM) have generated interest for their possible applications in secondary revisions following prosthetic breast reconstruction. These materials can be effective in a variety of situations, including implant displacement, synmastia, capsular contracture, incisional support, and pocket conversion. ADM can also be placed in the setting of delayed breast reconstruction and to augment nipple projection. These biomaterials have demonstrated feasibility and success for many complex deformities. However, there is an associated learning curve that includes an understanding of proper technique and patient selection. The authors review their cumulative experience between 2004 and 2010 with ADM for the correction of secondary deformities following prosthetic breast reconstruction, focusing on the indications for repair, traditional management, and management with ADM. Подробнее
Aesthetic surgery journal
Breast reconstruction: a review and rationale for patient selection.
Jul,
2009
The importance of good patient selection is becoming increasingly appreciated as a predictor of good outcomes following mastectomy and reconstruction. There are many variables that should be considered when making these decisions. Patient variables include breast characteristics, age, body habitus, comorbidities, and expectations. Oncological variables include tumor size, cancer stage, and perioperative radiation. This article is structured to review the variables that are relevant when deciding upon a particular reconstructive option for a particular patient. Подробнее
Plastic and reconstructive surgery
The impact of breast reconstruction on the oncologic efficacy of radiation therapy: a retrospective analysis.
Mar,
2008
Current indications for radiation therapy in women with breast cancer are controversial and continue to be modified. Current indications for breast reconstruction in the setting of radiation therapy are also controversial and poorly defined. The purpose of this study is to analyze oncologic outcomes following various methods of breast reconstruction in the setting of radiation therapy. A retrospective review of 676 women who had breast reconstruction following mastectomy was completed. A total of 146 women had breast reconstruction either before or after radiation therapy and were analyzed. Response variables included tumor recurrence and patient demise for patients having autologous and prosthetic reconstruction. Explanatory variables included patient age, cancer stage, radiation therapy, diabetes mellitus, and tobacco use. Recurrence of tumor occurred in 29 of 146 women (19.8%), of which 27% was when radiation followed reconstruction and 14.9% was when radiation preceded reconstruction. Patient demise occurred in 8.9%, of which 11.9% was when radiation followed reconstruction and 6.9% was when radiation preceded reconstruction. The difference in tumor recurrence in the setting of radiation therapy before or after breast reconstruction was significant for autologous (P = 0.0146) and prosthetic (P = 0.0424) reconstruction. The difference in patient demise was significant for autologous reconstruction (P = 0.0380) but not for prosthetic reconstruction (P = 0.2827). These results imply that tumor recurrence and patient demise may be increased when radiation therapy is performed following breast reconstruction. The need for a prospective inquiry is validated. Подробнее
Annals of plastic surgery
Managing the opposite breast: contralateral symmetry procedures.
2008
The importance of symmetry after unilateral breast reconstruction is becoming increasingly realized and important. As our reconstructive options have increased and our technical abilities have improved, the expectations of women with breast cancer have been enhanced by virtue of the fact that we are often able to reconstruct a breast with natural volume and contour. When embarking on a unilateral breast reconstruction, the plastic surgeon has several goals and one of which is to obtain breast symmetry. In many circumstances, breast symmetry is achieved without operating on the contralateral breast; however, in some cases, a contralateral operation will be necessary. This is usually based on the volume, contour, and position of the natural and reconstructed breast. Often, the need and/or desire for a contralateral procedure will be evident during the initial consultation. Otherwise, the need for a contralateral procedure will not be evident until after the primary reconstruction has been completed. In either case, it is important for plastic surgeons to be aware of the incidence of these procedures and the options available to them. Подробнее
Cancer journal (Sudbury, Mass.)
Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference?
Feb,
2005
The advantages of breast reconstruction using the deep inferior epigastric perforator (DIEP) flap and the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap (MS-2) are well recognized. Both techniques optimize abdominal function by maintaining the vascularity, innervation, and continuity of the rectus abdominis muscle. The purpose of this study was to compare these two methods of breast reconstruction and determine whether there is a difference in outcome. The study considered 177 women who have had breast reconstruction using muscle-sparing flaps over a 4-year period. This includes 89 women who had an MS-2 free TRAM flap procedure, of which 65 were unilateral and 24 were bilateral, and 88 women who had a DIEP flap procedure, of which 66 were unilateral and 22 were bilateral. The total number of flaps was 223. Mean follow-up was 23 months (range, 3 to 49 months). For all MS-2 free TRAM flaps (n = 113), outcome included fat necrosis in eight (7.1 percent), venous congestion in three (2.7 percent), and total necrosis in two (1.8 percent). For the women who had an MS-2 free TRAM flap, an abdominal bulge occurred in three women (4.6 percent) after unilateral reconstruction and in five women (21 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in 63 women (97 percent) after unilateral reconstruction and 20 women (83 percent) after bilateral reconstruction. For all DIEP flaps (n = 110), outcome included fat necrosis in seven (6.4 percent), venous congestion in five (4.5 percent), and total necrosis in three (2.7 percent) patients. For the women who had DIEP flap reconstruction, an abdominal bulge occurred in one woman (1.5 percent) after unilateral reconstruction and in one woman (4.5 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in all women after unilateral reconstruction and in 21 women (95 percent) after bilateral reconstruction. These results demonstrate that there are no significant differences in fat necrosis, venous congestion, or flap necrosis after DIEP or MS-2 free TRAM flap reconstruction. The percentage of women who are able to perform sit-ups and the percentage of women who did not develop a postoperative abdominal bulge is increased after DIEP flap reconstruction; however, this difference is not statistically significant. Подробнее
Plastic and reconstructive surgery
Lower abdominal bulge after deep inferior epigastric perforator flap (DIEP) breast reconstruction.
Feb,
2005
The etiology of lower abdominal bulge following breast reconstruction with the DIEP flap is uncertain. Most studies report an incidence that ranges from 0.7% to 5%. The purpose of this study was to review a set of factors that may predispose to a lower abdominal bulge. This was a retrospective review of 123 women who had breast reconstruction with the DIEP flap over a 4-year period. The reconstruction was unilateral in 93 women and bilateral in 30 women, totaling 153 flaps. Etiologic factors that were evaluated included patient age, diabetes mellitus, tobacco use, previous abdominal operations, unilateral or bilateral reconstruction, previous childbirth, aponeurotic plication to improve the natural abdominal contour, and use of Marlex mesh. A lower abdominal bulge occurred in 5 of the 123 women (4%), 2 following 30 bilateral reconstructions (6.6%) and 3 following 93 unilateral reconstructions (3.2%). Analysis of the factors for all women demonstrated diabetes mellitus in 1 (0.8%), tobacco use in 9 (7.3%), a prior abdominal operation in 55 (44.7%), previous childbirth in 95 (77%), aponeurotic plication in 49 (40%), and use of Marlex mesh in 4 (3.3%). Statistical analysis did not show any significant association between the explanatory factors and the occurrence of a lower abdominal bulge, except for a weak trend in women who had not been pregnant (P = 0.08). The results of this study demonstrate that the occurrence of a lower abdominal bulge following the DIEP flap is a random event that can occur in anyone. Pregnancy may confer a preventative effect as the collagen fibers strengthen to overcome the stretching forces. Techniques for prevention and treatment include intraoperative assessment of the anterior rectus sheath, use of an adjuvant material for reinforcement if unstable, and vertical plication for bulge repair. Подробнее
Annals of plastic surgery
The internal mammary artery and vein as recipient vessels for microvascular breast reconstruction: are we burning a future bridge?
Oct,
2004
Clinical applications for the internal mammary artery include use as an arterial conduit for coronary revascularization and as a recipient artery for microvascular reconstruction of the breast. This study was completed in an attempt to resolve the controversy over which indication should have priority. Five hundred twenty women with breast cancer who underwent breast reconstruction were reviewed. Of these, 240 were 50 years of age or more and were evaluated for cardiac disease. Three components were studied that included analysis of factors related to cardiac function (prior cardiac surgery, specific cardiac disorders, and cardiac medications), analysis of risk factors related to cardiac disease (hypertension, diabetes mellitus, and tobacco use), and analysis of factors related to the reconstruction (selection of recipient vessels, type of reconstruction). The women were stratified based on age-50 to 59 years, 60 to 69 years, and older than 70 years-to analyze trends based on advancing age. Results demonstrated that the incidence of coronary artery disease was 2 in 240 women (0.8%) and that the incidence of factors related to cardiac function and the incidence of risk factors related to cardiac disease appear to increase with advancing age. The internal mammary vessels were used in 35 of 114 free tissue transfers with no adverse sequelae. No woman in whom the internal mammary artery was used has developed coronary artery disease. The 2 women with coronary artery disease were reconstructed with implants. Based on the results of this study, the author thinks that use of the internal mammary artery as a recipient vessel for microvascular reconstruction of the breast is justified. Options for future coronary revascularization would include the opposite internal mammary artery when available, a saphenous vein graft, or angioplasty. Подробнее
Annals of plastic surgery
Factors associated with anastomotic failure after microvascular reconstruction of the breast.
Jul,
2004
The prevalence of anastomotic failure resulting in return to the operating room and flap necrosis after microvascular breast reconstruction ranges from 1 to 5 percent. The purpose of this study was to review a set of factors that may be associated with this occurrence. Microvascular reconstruction of the breast was performed in 198 women from January of 1998 to July of 2002. The mean age for all women was 47.7 years. There were 158 unilateral and 41 bilateral reconstructions, for a total of 240 flaps. The specific flaps included the free transverse rectus abdominis musculocutaneous flap (n = 176), the deep inferior epigastric perforator flap (n = 58), and the superior gluteal artery perforator flap (n = 6). Upon recognition of anastomotic failure, women were immediately returned to the operating room. Factors that were considered relevant to anastomotic failure included the choice of recipient vessel, timing of reconstruction, previous chest wall radiation therapy, previous axillary lymph node dissection, tobacco use, diabetes mellitus, patient age, and hematoma. Patient follow-up ranged from 5 to 59 months. Descriptive statistics, Fisher's exact test, and exact logistic regression were used for analyses and to summarize data. Of the 240 flaps, return to the operating room was necessary for 20 (8.3 percent), total necrosis occurred in nine (3.8 percent), and the rate of flap salvage was 55 percent (11 of 20 flaps). Venous occlusion was responsible for 16 of the 20 returns and eight of the nine failures. Statistical analysis demonstrated that both return to the operating room and flap necrosis were significantly associated with venous occlusion, delayed reconstruction, and hematoma. Previous lymph node dissection and previous radiation therapy had only a weak association with return to the operating room. The results of this study demonstrate that venous occlusion is responsible for return to the operating room and flap necrosis in the majority of cases. Age, tobacco use, choice of recipient vessel, and diabetes mellitus were not associated with anastomotic failure. The significance of delayed reconstruction may be related to its frequent association with previous lymph node dissection and/or radiation therapy resulting in perivascular fibrosis. Подробнее
Plastic and reconstructive surgery
Recipient vessel analysis for microvascular reconstruction of the head and neck.
Feb,
2004
The selection of recipient vessels that are suitable for microvascular anastomosis in the head and neck region is one of many components that is essential for successful free tissue transfer. The purpose of this study was to evaluate a set of factors that are related to the recipient artery and vein and to determine how these factors influence flap survival. A retrospective review of 102 patients over a 5-year consecutive period was completed. Indications for microvascular reconstruction included tumor ablation (n = 76), trauma (n = 13), and chronic wounds or facial paralysis (n = 13). The most frequently used recipient artery and vein included the facial, superficial temporal, superior thyroid, carotid, and jugular. Various factors that were related to the recipient vessels were analyzed and included patient age, recipient artery and vein, diabetes mellitus, tobacco use, the timing of reconstruction, the method of anastomosis, previous radiation therapy, creation of an arteriovenous loop, and use of an interposition vein graft. Successful free tissue transfer was obtained in 97 of 102 flaps (95%). Flap failure was the result of venous thrombosis in 4 and arterial thrombosis in 1. Statistical analysis demonstrated that anastomotic failure was associated with an arteriovenous loop (2 of 5, P = 0.03) and tobacco use (3 of 5, P = 0.03). Flap failure was not related to patient age, choice of recipient vessel, diabetes mellitus, previous irradiation, the method of arterial or venous anastomosis, use of an interposition vein graft, or the timing of reconstruction. Подробнее
Annals of plastic surgery
Symmetrical breast reconstruction: is there a role for three-dimensional digital photography?
Nov,
2003
Clinical applications of three-dimensional digital photography include assessments of breast volume and contour. It was hypothesized that knowledge of preoperative and postoperative breast volumes might facilitate obtaining symmetry after reconstructions with autologous tissue or implants. Breast reconstruction was performed for 382 women during a 4-year period. Of those women, 334 completed all phases of the reconstruction and underwent symmetry analysis. Reconstructive procedures included the use of pedicle transverse rectus abdominis musculocutaneous flaps, free transverse rectus abdominis musculocutaneous flaps, deep inferior epigastric perforator flaps, superior gluteal artery perforator flaps, or latissimus dorsi flaps or expanders/implants. Three-dimensional digital photographic images were obtained for 33 women, whereas the remaining 301 women were not digitally photographed. The differences in symmetry after the initial reconstruction and after the secondary procedures were compared for all women and for the groups with and without three-dimensional photographic images. For the group with three-dimensional imaging, initial volume symmetry was obtained for 73 percent, initial contour symmetry was obtained for 27 percent, secondary procedures were necessary for 70 percent, final volume symmetry was obtained for 88 percent, and final contour symmetry was obtained for 79 percent. For the group without three-dimensional photographic images, initial volume symmetry was obtained for 57 percent, initial contour symmetry was obtained for 34 percent, secondary procedures were necessary for 50 percent, final volume symmetry was obtained for 80 percent, and final contour symmetry was obtained for 71 percent. The results demonstrated that there was no significant difference in final contour and volume symmetry between women who had or did not have three-dimensional digital photographic images taken. However, the results demonstrated that autologous tissue reconstructions resulted in improved contour and volume symmetry, compared with implant reconstructions. Подробнее
Plastic and reconstructive surgery
Infectious complications following breast reconstruction with expanders and implants.
Aug,
2003
The incidence of infection following breast reconstruction with expanders and implants ranges from 1 to 24 percent. Numerous factors associated with infection have been described; however, a one-variable at time setting and multifactorial analysis have not been performed. The purpose of this study was to analyze a set of factors that may predispose women to infection of the expander or implant. Between 1997 and 2000, a total of 168 implant reconstructions were performed in 130 women at a single institution. The mean age for all women was 48.2 years (range, 25 to 77 years). The factors that were analyzed included axillary lymph node dissection, chemotherapy, radiation therapy, tumor stage, timing of implant insertion, number of sides (unilateral versus bilateral), tobacco use, and presence or absence of diabetes mellitus. Statistical analysis was performed with stepwise logistic regression. Mean time to follow-up for all patients was 29 months (range, 12 to 47 months). Infectious complications occurred in 10 women (7.7 percent) and in 10 expanders or implants (5.9 percent). Infected implants were removed an average of 116 days following insertion (range, 14 to 333 days). Cultured bacteria included Staphylococcus aureus and Serratia marcescens. A significant association (p < 0.04) was detected between implant infection and radiation therapy. The chance for implant infection was 4.88 times greater for implants that were exposed to radiation therapy compared with those that were not. In addition, there was suggestive (p < 0.09) evidence that the chance of implant infection following lymph node dissection was 6.29 times higher than when no lymph nodes were removed. No significant association between implant infection and age, diabetes, tobacco use, tumor stage, timing of implant insertion, or chemotherapy was found. Подробнее
Plastic and reconstructive surgery
Recalcitrant abdominal wall hernias: long-term superiority of autologous tissue repair.
Jul,
2003
Secondary repair of recurrent ventral hernia is difficult, and success depends on re-establishing the functional integrity of the abdominal wall. Current techniques used for closure of these defects have documented recurrence rates as high as 54 percent. The authors' 8-year experience utilizing variations of the components separation technique for autologous tissue repair of recalcitrant hernias emphasizes that recurrent or recalcitrant hernias benefit from the creation of a dynamic abdominal wall. A total of 389 patients were retrospectively identified as having abdominal wall defects, and 284 of these patients met the selection criteria. Study patients were grouped according to the type of surgical repair used. The recurrence rate was 20.7 percent over all study groups and was directly related to the extent of repair required. Group 1 patients (wide tissue undermining) had a recurrence rate of only 15 percent, while in group 2 (complete components separation), the recurrence rate was 22 percent. Group 3 patients (interpositional fascia lata graft) had a 29 percent recurrence rate. Time to recurrence was also significantly different across treatment groups, with study group 3 experiencing earlier hernia recurrence. The most frequent postoperative complication was wound infection, which was directly related to the repair performed. The relative odds of recurrence versus the risk factors of age, sex, perioperative steroid use, wound infection, defect size, and the presence of enterocutaneous fistula were studied with a logistic regression analysis. These factors did not possess statistical significance for predicting hernia recurrence. The preoperative presence of mesh was independently significant for hernia recurrence, increasing the relative odds 2.2 times (p = 0.01). Similarly, when other risk factors were controlled for, increasing the complexity of the treatment group, from study group 1 (wide tissue undermining) to study group 3 (interpositional fascia lata graft), also increased the odds of hernia recurrence 1.5-fold per group (p = 0.04). Average inpatient cost was $24,488. The length of inpatient stay ranged from 2 to 172 days (average, 12.8 days). The length of inpatient stay and costs were directly related to the extent of repair required. Using the analysis of variance test for multiple factors, the presence of an enterocutaneous fistula (p = 0.0014) or a postoperative wound infection (p = 0.008) independently increased the length of inpatient stay and hospital costs. A total of 108 successfully repaired patients were contacted by telephone and agreed to participate in a self-reported satisfaction survey. The patients noticed improvements in the appearance of their abdomen, in their postoperative emotional state, and in their ability to lift objects, arise from a chair or a bed, and exercise. These results suggest that recalcitrant hernia defects should be solved, when possible, by reconstructing a dynamic abdominal wall. Подробнее
Plastic and reconstructive surgery
Sentinel lymph node biopsy for the T1 (thin) melanoma: is it necessary?
Jun,
2003
The use of sentinel lymph node biopsy for the T1 melanoma is controversial. Recent reports have demonstrated that certain T1 melanomas are at increased risk for early regional metastases and late recurrence when compared with all thin melanomas. The purpose of this study was to review the authors' experience with wide excision and sentinel lymph node biopsy for certain patients with T1 melanoma. A retrospective analysis of 34 patients with T1 melanoma was completed over a 3-year period. Indications for sentinel lymph node biopsy included a Breslow thickness of less than or equal to 1 mm a Clark level of III or IV tumor ulceration, or tumor regression. Twenty-four patients met these criteria (13 men and 11 women). Mean age was 47.6 years (range, 23-88 years). Mean tumor thickness for all patients was 0.69 mm (range, 0.3-1.0 mm), 0.61 mm for the Clark level III patients (N = 15), and 0.72 mm for the Clark level IV patients (N = 9). Tumor ulceration was present in 1 patient and histological regression was present in 2 patients. Regional lymph node metastases were confirmed histologically in 2 of 24 patients (8.3%) in whom the thickness of the melanoma was 0.9 mm and 1 mm. Both patients have died of metastatic melanoma. No recurrence has been demonstrated in the remaining 22 patients at the 2 to 5-year follow-up. Current indications for sentinel lymph node biopsy for patients with T1 melanoma include tumors associated with Clark level IV or V invasion, ulceration, regression, a positive deep margin on initial biopsy, or previous melanoma. Acral lentiginous melanoma associated with at least a Clark level III invasion warrant sentinel lymph node biopsy. Superficial spreading or nodular melanoma larger than 0.9 mm should include sentinel lymph node biopsy regardless of other associated histological factors. Подробнее
Annals of plastic surgery
Breast reconstruction in the elderly: preserving excellent quality of life.
Jun,
2003
There is a paucity of information in the literature that focuses on quality-of-life issues after mastectomy with breast reconstruction in elderly women. The purpose of this study was to review the authors' experience with breast reconstruction after mastectomy in women older than 65 years of age. Emphasis was placed on the types of reconstructions, outcomes, and evaluation of issues related to quality of life. Between July 1997 and July 2001, 316 consecutive women (400 reconstructions) with breast cancer underwent mastectomy with reconstruction at the authors' institution. Of these women, 24 (28 reconstructions) were at least 65 years old. Mean patient age was 69.3 years (range, 65-77 years). Methods of breast reconstruction included two-stage implant reconstruction (50%), free tissue transfer (transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flap, 25%), pedicle transverse rectus abdominis musculocutaneous flap (14%), or a latissimus dorsi musculocutaneous flap (11%). Outcomes were assessed with the use of a self-reported questionnaire (SF-36) addressing health-related quality of life, body image, and physical functioning. With respect to overall quality-of-life issues after reconstruction, older patients with breast reconstruction scored higher (better outcomes) than age-matched general population patients and previously reported mastectomy-only patients (>55 years) in all surveyed areas. Specifically, study patients reported dramatic increases (better outcomes) in the subscales that are strongly influenced by one's mental health. However, when compared with prior data for younger patients undergoing mastectomy and reconstruction, the older patients scored lower (worse outcomes) in the areas related to physical function. The older patients maintained superior scores (better outcomes) over the younger patients in the subscales influenced by one's mental health. Подробнее
Annals of plastic surgery
Clinical applications of three-dimensional photography in breast surgery.
Jul,
2002
Three-dimensional imaging in breast surgery has several uses clinically. The most practical applications are for the evaluation of breast asymmetries, both congenital and acquired, and for the evaluation of factors affecting breast shape in augmentation mammaplasty. Other uses of three-dimensional imaging that we have found clinically helpful are for evaluation of patients desiring reduction mammaplasty and for evaluation of patients undergoing unilateral breast reconstruction to determine the expander and permanent implant size that gives the best symmetry with the contralateral breast. We present five cases in which we investigate the use of three-dimensional imaging clinically by using the images to determine quantitative information about the breast, such as volume or projection. Overall, three-dimensional imaging is very helpful in providing objective information about the breast for use in preoperative planning. In addition, by analyzing clinical cases, it can provide objective data about the breast and surgical mammaplasty (especially augmentation mammaplasty) that may help surgeons better understand those factors that contribute to breast shape and influence surgical outcomes. There are currently some limitations of this system, influenced by patients with significant ptosis or obesity, which may introduce errors into the three-dimensional data, making them unreliable. However, we believe three-dimensional imaging has great clinical potential in surgical mammaplasty. Подробнее
Plastic and reconstructive surgery