Penile reconstruction, phallic construction, and urethral reconstruction

Penile reconstruction, phallic construction, and urethral reconstruction require tissue transfer in the majority of cases. This article discusses the techniques of tissue transfer and presents illustrative cases of penile reconstruction, total phallic construction, and urethral reconstruction. The modified forearm flaps for penile reconstruction, the ulnar forearm flap as used for total phallic construction, and the dartos fascial flap and penile skin islands for urethral reconstruction are illustrated. Graft onlay techniques also are shown.     

不同方法乳房重建术的患者报告结局

乳腺癌术后乳房重建可以提高患者的自尊和健康相关的生活质量,重建方式有自体组织重建与假体重建。自体重建有不同自体组织;假体重建有一步法与二步法,假体植入物有不同类型,按重建时间分为即刻与延期重建;重建后可能需要放疗。不同重建材料、重建时机和术后放疗,都可能会对乳房重建患者的报告结局产生影响。本文就不同方法乳房重建术的患者报告结局的研究进展作一综述。     

Nipple-areola reconstruction

Nipple-areola reconstruction from nonspecialized tissues is presented as a worthwhile component of breast reconstruction. General principles are discussed, as are specific techniques for reconstruction of the areola and the nipple. The author's method is recommended as the most efficient use of local tissue for nipple reconstruction in the prosthetic breast, where skin and fat are both in short supply.     

New trends in breast cancer management: is the era of immediate breast reconstruction changing?

OBJECTIVE: Review of available literature on the topic of breast reconstruction and radiation is presented. Factors influencing the decision-making process in breast reconstruction are analyzed. New trends of immediate breast reconstruction are presented. SUMMARY BACKGROUND DATA: New indications for postmastectomy radiation have caused a dramatic increase in the number of radiated patients presenting for breast reconstruction. The major studies and their impact on breast cancer management practice are analyzed. Unsatisfactory results of conventional immediate reconstruction techniques followed by radiotherapy led to a new treatment algorithm for these patients. If the need for postoperative radiation therapy is known, a delayed reconstruction should be considered. When an immediate reconstruction is still desired despite the certainty of postoperative radiotherapy, reconstructive options should be based on tissue characteristics and blood supply. Autologous tissue reconstruction options should be given a priority in an order reflecting superiority of vascularity and resistance to radiation: latissimus dorsi flap, free TRAM or pedicled TRAM without any contralateral components of tissue, pedicled TRAM/midabdominal TRAM, and perforator flap. CONCLUSIONS: When the indications for postoperative radiotherapy are unknown, premastectomy sentinel node biopsy, delayed-immediate reconstruction, or delayed reconstruction is preferable.     

The impact of breast reconstruction on the oncologic efficacy of radiation therapy: a retrospective analysis

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.     

Rationale for immediate reconstruction of the breast following modified radical mastectomy

In 62 patients in whom modified radical mastectomy was accompanied by immediate breast reconstruction, the operative and pathologic findings are compared to the clinical results. Immediate reconstruction following modified radical mastectomy appears to offer several advantages over delayed reconstruction. The data indicate that immediate reconstruction provides excellent technical results, is associated with less expense and morbidity as compared to delayed reconstruction, and does not adversely affect the natural course of the disease within the follow-up period studied. No adverse effect of adjuvant chemotherapy on the reconstructive effect was noted in this series of 62 patients when the initiation of adjuvant chemotherapy was timed so as to avoid difficulties with hemostasis. The technical aspects of the immediate reconstruction are described.     

Aesthetic aspects of breast reconstruction

Implant exposure, malposition, and capsular contracture, problems often seen with subcutaneous placement of implants in breast reconstruction, have been largely eliminated by submuscular placement of the implant. The pectoralis major, serratus anterior, rectus abdominus, and the latissimus dorsi are available as muscle and musculocutaneous flaps for coverage of implants in breast reconstruction. As symmetry is the goal in breast reconstruction, the shape and form of the opposite breast is taken into account in selecting a suitable flap for breast reconstruction. The roles and indications for each of these flaps in reconstruction of the breast are presented.     

Editorial Commentary: Return to Sport Following Extra-Articular Augmentation of Anterior Cruciate Ligament Reconstruction—Let the LET (Lateral Extra-Articular Tenodesis) Games Commence!

The debate around extra-articular augmentation (EA) of anterior cruciate ligament (ACL) reconstruction continues to provide a rich source of research articles that we ultimately hope will improve patient outcomes. When combined with ACL reconstruction, anterolateral ligament reconstruction or lateral extra-articular tenodesis procedures reduce graft failure and persistent rotatory laxity. An important metric of ACL reconstruction outcome is return to play (RTP). RTP rates are also excellent when EA procedures are used in both primary and revision ACL reconstruction. However, when it comes to RTP, EA augmentation has yet to show significant improvement over isolated ACL reconstruction.     

Mikrochirurgische Brustrekonstruktion

The results of a survey show that less then 10% of affected women are aware of the various options for breast reconstruction. However, in modern medicine the correlation between emotional well-being and physical health has been established as an important factor. The first successful autologous breast reconstruction was performed by Czerny in 1895. After introduction of silicon implants for breast augmentation this method was also increasingly used for breast reconstruction. Worldwide most reconstructions are implant based, however the symptomatic rate of capsular contracture is up to 38% and the reoperation rate for implant-based reconstruction and radiotherapy up to 35%. Autologous reconstruction procedures have a significantly lower complication rate. This article describes the modern microsurgical techniques for breast reconstruction and discusses the indications and achievable results.     

Anterolateral thigh flap for breast reconstruction: review of the literature and case reports

More women than ever before are undergoing mastectomies secondary to increased awareness and screening. This has also caused a corresponding increase in the number of breast reconstructions requested each year. The demand for improved results has fueled recent advances in new techniques. Aside from implant reconstruction, the methods now being employed are related to autogenous donations and reconstruction. Currently, the most commonly used techniques for autogenous breast reconstruction are the DIEP (deep inferior epigastric perforator) and TRAM (transverse rectus abdominis myocutaneous) flaps from the lower abdomen. The anterolateral thigh flap is a type of perforator flap usually described for use in head and neck reconstruction. The authors have discovered this flap's utility as an alternative in autogenous breast reconstruction when the abdomen is not available as a donor site. A review of the literature reveals a dearth of experience in using the anterolateral thigh flap for breast reconstruction. The article reviews the literature with regard to current uses of the anterolateral thigh flap, and then reports three case studies which highlight the thigh flap as an excellent alternative for breast reconstruction in selected patients.     

The deep inferior epigastric perforator free flap for breast reconstruction

Deep inferior epigastric perforator (DIEP) flap breast reconstruction is an improved method of autologous tissue breast reconstruction with minimal insult to the abdominal wall. This study summarizes the data collected on 148 consecutive DIEP flaps used for breast reconstruction in 109 patients. Of the patients, 90.7% had immediate breast reconstruction after mastectomy, 6.5% had secondary reconstruction, and 2.8% had bilateral reconstruction after having had a mastectomy and having a new primary cancer diagnosed in the remaining breast. A total of 78.7% patients underwent unilateral reconstruction, 21.3% underwent bilateral reconstruction, and 15.7% needed two flaps to make a single larger breast. There was one flap failure. Incidence of fat necrosis was 6.8% and incidence of incisional hernia was 1.4%. The advantages of a free transverse rectus abdominis musculocutaneous flap breast reconstruction are inherent in DIEP flap breast reconstruction. The increased technical effort for DIEP flap reconstruction is offset by the lesser insult to the abdominal wall with maintenance of the entire rectus abdominis muscle.     

Editorial Commentary: Pursue the Anatomy of the Knee Anterior Cruciate Ligament Footprint

The paradigm of anterior cruciate ligament reconstruction has shifted from nonanatomic/isometric to anatomic reconstruction so as to mimic the native anterior cruciate ligament anatomy, as well as its function. A triple-bundle reconstruction technique more precisely mimics the native anterior cruciate ligament. On the other hand, functional advantages of triple-bundle reconstruction have not been fully elucidated. Comparative clinical studies between reconstruction techniques are needed.     

Skeletal reconstruction with allograft segments following bone tumor resection

The successful treatment of malignant neoplasms of bone requires surgical removal of the primary tumor. Limb salvage as an alternative to amputation requires surgical resection of the neoplasm with a wide margin and reconstruction of the segmental defect that is created. Transplantation of an allograft bone segment, with or without articular cartilage, is one option for reconstruction. The types of defects created and the types of reconstruction using segmental allografts are classified. Specific technical details involved in allograft reconstruction are discussed.     

Anterior cruciate ligament reconstruction with patellar autograft tendon

There are many techniques, graft choices, and outcome studies evaluating anterior cruciate ligament reconstruction. The current authors specifically look at reconstruction with the patellar tendon from a scientific perspective. Miniopen, endoscopic, and two-incision operative techniques in addition to hamstring versus patellar tendon autograft reconstructions are compared via randomized prospective studies. A review of all studies evaluating arthroscopically-assisted anterior cruciate ligament reconstruction with patellar tendon was conducted. The authors found arthroscopically-assisted anterior cruciate ligament reconstruction to have a high short-term stability rate, extremely high patient satisfaction level, and a low postoperative complication rate. When the endoscopic technique was compared with the two-incision technique, there were no major differences. The difference between patellar tendon and hamstring autograft reconstruction can be described best as subtle, except for the consistent finding of an increased activity level in the patellar tendon group. When the principles of anterior cruciate reconstruction are followed, one can expect consistent results with patellar tendon autograft reconstruction.     

The present status of breast reconstruction following mastectomy in the female

During the last 10 years increased interest has developed in reconstruction of the female breast following mastectomy. A number of methods of reconstruction are now available. These are immediate reconstruction by means of a silicone implant, delayed reconstruction by means of a silicon implant, use of local flaps with the silicone implant, and use of distant tissue and movement of tissue by microvascular anastomosis.The simplest and most efficient procedure is the one-stage reconstruction which consists of insertion of a silicone prosthesis approximately 6 months following the mastectomy. This can be combined, when necessary, with an elevation and reduction of the remaining breast and the reconstruction at the same time of an areolar and nipple complex.Reconstruction of the female breast in no way jeopardizes the survival of the patients. In addition, it may bring the patient to the surgeon sooner since the knowledge of reconstruction helps to reduce the woman's fear of mutilization.     

Is the deltopectoral flap born again? Role in postburn head and neck reconstruction

After extensive use for head and neck reconstruction, the deltopectoral flap has been supplanted by alternative methods of reconstruction and relegated to historical references. However, it remains a very valuable skin flap and should keep its place in the armamentarium of reconstructive surgeons for postburn head and neck reconstruction. We report here five cases of head and neck reconstruction using the deltopectoral flap: one case of perioral reconstruction after ballistic trauma, one case of nasal reconstruction after burn and three cases of neck reconstruction after burn contracture. Technical simplicity and reliability are the main features of this flap. The skin paddle is thin and pliable, and its surface can be extended after a flap delay. Previous tissue expansion can minimize donor site morbidity. The flap division necessitates a second surgical procedure. The major burn contractures of the neck are, in our opinion, an excellent indication of the deltopectoral flap.     

Anatomic endoscopic anterior cruciate ligament reconstruction with patella tendon autograft

Current tibial endoscopic ACL reconstruction techniques provide functional stability, but fall short of the ultimate goal of ACL reconstruction, to restore normal knee kinematics. Vertical graft placement results in restoration of normal anteroposterior stability with a negative Lachman exam, but may not produce a stable knee in rotation, noted by a positive pivot shift. The Clancy anatomic endoscopic ACL reconstruction technique utilizes flexible reamers to achieve anatomic graft placement to more closely reproduce normal knee function. The overall results of arthroscopic anatomic endoscopic ACL reconstruction are essentially the same as we have reported using our previous open and rear-entry, two-incision techniques for anatomic graft placement. The long-term benefits of a more physiologic single incision endoscopic ACL reconstruction are not yet determined; however, short-term results are encouraging.     

Esthetic reconstruction after mastectomy for inflammatory breast cancer: is it worthwhile?

BACKGROUND: Because inflammatory breast cancer (IBC) has been viewed as a malignancy with a poor likelihood of longterm survival, few women have been offered esthetic reconstruction after mastectomy for IBC. Recent advances in multimodality therapy have improved the outcomes for women with this disease. The purpose of this review was to assess the results of esthetic breast reconstruction in the population with IBC. STUDY DESIGN: Review of medical records at the City of Hope National Medical Center for the 10-year period ending in May 1997, revealed 23 women who underwent elective esthetic breast reconstruction after mastectomy for IBC. The records of these patients were reviewed retrospectively. Patients requiring reconstruction for large surgical chest wall defects were not included in the review. RESULTS: Treatment for IBC included mastectomy in all patients, chemotherapy in 22, and chest wall radiation therapy in 14. Immediate reconstruction was performed at the time of mastectomy (n = 14) or was delayed (n = 9). The types of reconstruction included transverse rectus abdominis musculocutaneous flap (n = 18), latissimus dorsi flap (n = 2), or prosthetic mammary implant reconstruction (n = 3). Seven women chose to undergo additional reconstruction procedures (ie, nipple reconstruction) after their initial reconstruction. With a median followup of 44 months for survivors, 16 patients developed recurrence after reconstruction. Of these, 6 were local recurrences and 10 were distant failures. Seven patients are currently alive with no evidence of disease, 4 are currently alive with disease, and 12 have died as a result of breast cancer. The median disease-free survival after reconstruction was 19 months. The median overall survival after reconstruction for all patients was 22 months. The only negative predictor of survival was a positive surgical margin at mastectomy. CONCLUSIONS: The significant emotional and esthetic benefits of breast reconstruction should be available to women with IBC. In light of the improving prognosis of IBC with current aggressive multimodality treatment, reconstructive procedures should be offered as part of comprehensive therapy.     

Practically: differential indications of mandibular reconstruction in maxillofacial cancerology]

This study, based on the authors' experience, intends to determine the specific indications of mandibular reconstruction after oncological maxillofacial resections. Mandibular defects without osseous interruption do not necessarily need an osseous reconstruction: the esthetic and functional problems can be resolved using dental osseointegrated implants. On the contrary, mandibular defects with osseous interruption need imperatively an osseous and/or composite reconstruction: the best esthetic and functional results are obtained with an immediate reconstruction by an osseous or osteocutaneous free flap, either from the fibula or the iliac crest. The advantages and the disadvantages of all these reconstruction technics are detailed and largely illustrated.     

Functional assessment using the step-up-and-over test and forward lunge following ACL reconstruction

This investigation compared lower extremity function of a control group and a group of patients who underwent anterior cruciate ligament (ACL) reconstruction using a repeated measures post-test only control group design. The ACL reconstruction group consisted of 18 patients at least 6 months postoperative (mean 58+/-19 weeks) and the control group consisted of 18 healthy, recreationally active individuals. Both groups performed a step-up-and-over test and a forward lunge on a long force plate. During the step-up-and-over test, the control group produced significantly more force during the initial step than the ACL reconstruction group. Also, when the ACL reconstruction patients led with the involved extremity, they were significantly slower. During the forward lunge test, the impact index and force impulse measurements were significantly greater for the uninvolved leg than the involved leg in the ACL reconstruction group. The implications are that force generation during functional tests may remain compromised for >1 year following reconstruction. The aforementioned tests are promising for evaluation of function following ACL reconstruction.