Oncoplastic Technique for the Elimination of the Lateral “Dog Ear” During Mastectomy

Abstract: Following a mastectomy, both the cosmetic and functional results can be impaired by the presence of a lateral “dog ear.” This is a particular problem in women with a large body habitus giving an increased amount of adipose tissue lateral to the breast. The standard approaches to this operation of horizontal or oblique incisions often results in an uncomfortable, unsightly lateral “dog ear”. We describe a modification to the standard mastectomy incision that allows extensive excision of the lateral adipose tissue, re‐draping the skin over the chest wall, thus eliminating the “dog ear.” The mastectomy is performed through two oblique incisions originating in the axillary skin crease encompassing the nipple areolar complex, followed by extensive lateral fat excision. A distance of 2–3 cm is kept between the superior limit of the two incisions. At closure the lateral skin flap is advanced superiomedially on the chest wall without tension. This simple and reproducible technique improves cosmesis and patient satisfaction following modified radical mastectomy by eliminating the lateral “dog ear.”     

The fine connective tissue architecture of the human ligamentum nuchae

STUDY DESIGN: An anatomic study of the posterior midline structures of the cervical spine was performed using a new sheet-plastination (E12) technique in conjunction with gross anatomic dissection. OBJECTIVES: To clarify the structural status of the human ligamentum nuchae. SUMMARY OF BACKGROUND DATA: Little is known about the arrangement of connective tissue attachments of the neighboring neck muscles to the ligamentum nuchae. In addition, it is not clear whether the cervical supraspinous ligaments form part of the ligamentum nuchae. METHODS: This study used a combined approach of a detailed gross anatomic study on eight cadavers and a macroscopic and microscopic study of the connective tissue organization of the posterior midline structures on serial horizontal thin (2.5 mm) plastinated slices of the cervical spine (occiput-T1) from an adult female cadaver. RESULTS: The dorsal and ventral portions of the ligamentum nuchae are a single entity formed by the aponeurotic fibers of the trapezius, splenius capitis, rhomboideus minor, and serratus posterior superior muscles. CONCLUSIONS: The regional differences in the connective tissue organization of the ligamentum nuchae and its well-defined attachments to the C6 and C7 vertebrae suggest that it is designed to function in the lower cervical spine.     

Treating the Banana Fold with the Dermotuberal Anchorage Technique: Case Report

The banana fold, or the infragluteal fold, is a fat deposit on the posterior thigh close to the gluteal crease and parallel to it. A banana fold may form for different reasons, among which an iatrogenic cause is recurrent. Although banana fold is a common problem, unrelished by most women, few procedures are targeted specifically to fight it. This report presents a severe case of iatrogenic banana fold corrected by a modification of the dermotuberal anchorage buttock-lifting technique, as reported by the author for gluteal ptosis. The operation is performed by tucking in part of the banana fold tissue caudal to the gluteal crease, sliding that tissue, after depithelization, under the buttock, and pulling it up toward the ischial tuberosity until the redundant skin on the posterior thigh is tight and the banana fold is reduced. Assessment of the results 1 year after surgery showed that the technique provided a good scar kept within the subgluteal crease, and that it satisfactorily corrected the patient’s major complaint: the banana-shaped fold.     

151Engineering a Human ‘Skin” with Adult Primary Cells.

The inability to experiment in humans creates a great need to develop culture systems that mimic human tissues/organs. Skin is arguably the simplest human tissue and therefore provides an excellent prototype for tissue engineering. Moreover, skin is the body’s first line of defense. Currently available skin replacements have been classified into four categories: (i) those that are composed completely of epidermal cells; (ii) those consisting of dermal components derived from processing of cadaver skin or from collagen and other matrix molecules; (iii) those containing both dermal and epidermal components and (iv) those that contain dermal, epidermal and vascular components. All of these substitutes have drawbacks. Therefore, there is a need for skin replacements that: (a) are prepared with pertinent primary human cells but yet can be ready “off” the shelf; (b) can be prepared rapidly; (c) contain stable structures in particular microvessels that can rapidly connect with the patient’s vasculature in this manner establish circulation in the “graft” increasing the chances of survival; (d) can be tailored for specific wound impairments (e) are long lasting. We have developed a new generation human “skin” that can fulfil these requirements and can potentially be used as a “living bandage”. We start with three primary human cell types and a collagen matrix that self‐assemble into a connective tissue containing a network of mature microvessels, is covered with a stratified epidermis, expresses biochemical markers, matrix molecules, and cytokines characteristic of normal human skin and matures in 10–15 days. Moreover, two additional cell types, pericytes and monocytes, differentiate in situ adjacent to and within microvessels, respectively providing stability to the micriovessels and the epidermis expresses keratins that are typical of mature skin and not those characteristically produced in response to injury such as keratins 6, 16, 17. This tissue can potentially be developed into a skin replacement for patients with impaired healing. In addition, this tissue responds normally to bological stimuli, providing a powerful vehicle to investigate mechanisms of skin development and regeneration, understand pathological processes, and test drugs and treatments for skin diseases     

Breast reshaping in gynecomastia by the “pull-through technique”: considerations after 15 years

Gynecomastia corresponds to abnormal and excessive development of breast tissue in male patients. It may be unilateral or bilateral and, depending on breast volume and skin redundancy, it can be classified, according to Simon, in four different groups. Standard therapy is surgery and different techniques have been described so far, including different type of incisions in the periareolar or intrareolar skin. In 1996 in this journal we described our personal technique, called “pull-through.” Our technique combines liposuction that is performed on two planes, subcutaneous and subglandular, and sharp parenchymal excision, performed through the small liposuction incisions. These incisions are short (1–1.5 cm) and hidden in the inframammary fold and behind the anterior axillary pillar. Furthermore the operation can be performed under local anesthesia and with a short recovery period. Since then we have operated on 260 patients. We now present our 15 years experience and our review of literature, focused on authors who used and criticized our technique. Results, in terms of breast volume reduction, skin retraction, and minimal visibility of scars, were very good, even in cases more severe than in our first series (Simon's type IIb and female-to-male transsexuals). Patients' satisfaction rate was high as well and the incidence of complications was low. The results we observed in our series and the ones presented by different authors confirmed the validity and feasibility of the “pull-through” technique in terms of esthetic and functional results, patient satisfaction, and a low incidence of complications.     

Reprint of: Why are hemorrhoids symptomatic? the pathophysiology and etiology of hemorrhoids

Hemorrhoids are a normal component of the anorectum and contribute to the mechanism of anal closure, thus providing fine adjustment of anal continence. There are numerous myths and legends associated with the disordered and diseased state of hemorrhoids. Fortunately, information obtained from modern technologies including microscopic histopathology defined first the actual substance and makeup of hemorrhoids and was later combined with anorectal physiology to provide evidence establishing the underlying pathophysiology of this universal finding of the human anorectum. The sliding anal canal theory of Gass and Adams has held up and is further supported by other anatomic studies including the work of WHF Thomson, who popularized the term “cushions” to describe the complex intertwining of muscle, connective tissue, veins, arteries, and arteriovenous communications which constitute hemorrhoids. A loss of muscle mass in favor of connective tissue over time helps explain the role of aging as a predisposing factor for symptomatic hemorrhoids. Other factors include the modern “rich” or low-residue diet leading to constipation and straining which contributes to prolapsing cushions. Pathologic studies also demonstrated arteriovenous communications explaining why hemorrhoid bleeding is typically bright red or arterial in nature as opposed to dark or venous bleeding. Technology associated with anorectal physiology studies have demonstrated an increase in pressures of the internal sphincter, which return to normal following surgical intervention. This information backs the conclusion that high sphincter pressures are not the cause of hemorrhoid symptoms, but rather the effect of symptomatic hemorrhoids because of the observed return to normal baseline pressures after surgical removal. While there may be a genetic component to this disorder, there are no known genetic markers for hemorrhoid disease at this time.     

Visualization of the course of the sciatic nerve in adult volunteers by ultrasonography

Background: The sciatic nerve block by the posterior approaches represents one of the more difficult ultrasound‐guided nerve blocks. Our clinical experiences with these blocks indicated a point slightly distal to the subgluteal fold as an advantageous position to allow good ultrasonic visibility. In this study, we systematically scanned the sciatic nerve from the subgluteal fold to the popliteal crease, to determine an optimal point for ultrasonographic visualization. Methods: After institutional approval and written informed consent, we recruited 15 volunteers to visualize the sciatic nerve from the subgluteal fold to the popliteal crease using a linear ultrasound probe in the range of 7–13 MHz. The ultrasonographic visibility of the sciatic nerve, nerve diameter (width and thickness), and skin‐to‐nerve distance at 20 equidistant points between the subgluteal fold and the popliteal crease were recorded. Results: The sciatic nerve could be successfully visualized in cross‐section as a hyperechoic structure on ultrasound in all volunteers. In the course from subgluteal to the popliteal area, the shape of the sciatic nerve changed from flat to round, while the skin–nerve distance varied with the smallest skin–nerve distances at the popliteal crease and at 5.4 cm (on average) distal to the subgluteal fold. The best ultrasonographic visibility scores were found between 7.2 and 10.8 cm (on average) distal to the gluteal fold. Conclusion: Between 5.4 and 10.8 cm from the subgluteal fold seems to be the best area to scan the sciatic nerve in terms of superficial nerve position and good ultrasonic visibility.     

重睑术中深部组织切除矫正内眦赘皮

目的：探索娇正内眦赘皮手术简便有效的方法。方法：对１２例（２４眼）单睑伴内眦赘皮的患者施行了在赘皮皱褶上做切口,切除赘皮下的肌肉组织,然后将切口缘缝接于深层组织的手术。结果：术后随访３个月～１２个月,医患双方对手术效果很满意者８例,基本满意２例,１便有１侧赘皮娇正不完全,另１例在术后１个月随访时,左眼内眦赘皮复发。结论：本术式方法简单,适于娇正睑型或睑板型内眦赘皮。     

The vascular territories (angiosomes) of the body: experimental study and clinical applications

The blood supply to the skin and underlying tissues was investigated by ink injection studies, dissection, perforator mapping and radiographic analysis of fresh cadavers and isolated limbs. The results were correlated with previous regional studies done in this department. The blood supply is shown to be a continuous three-dimensional network of vessels not only in the skin but in all tissue layers. The anatomical territory of a source artery in the skin and deep tissues was found to correspond in most cases, giving rise to the angiosome concept. Arteries follow closely the connective tissue framework of the body. The primary supply to the skin is by direct cutaneous arteries which vary in calibre, length and density in different regions. This primary supply is reinforced by numerous small indirect vessels, which are "spent" terminal branches of arteries supplying the deep tissues. An average of 374 major perforators was plotted in each subject, revealing that there are still many more potential skin flaps. Our arterial roadmap of the body provides the basis for the logical planning of incisions and flaps. The angiosomes defined the tissues available for composite transfer.     

Restoration of the Gluteal fold by a Deepithelialized Skin Flap: Preliminary Observations

Background The gluteal fold represents an important aspect of the gluteal region. Destruction of this anatomic landmark as a consequence of trauma or tissue harvest can result in an aesthetically disturbing disfigurement. A technique for reconstruction of the gluteal fold and preliminary results are presented.Methods The newly formed gluteal fold is created by fixation of a deepithelialized skin flap to the periosteum of the tuber ischiadicum.Results The operative procedure is quick and easy to apply. The method is used mainly for patients with a distorted gluteal fold after tissue harvest for breast reconstruction. However, it also can be used after trauma such as that associated with burn injuries. In all patients, reconstruction of the gluteal fold yielded aesthetically pleasing and reliable results with high patient satisfaction.Conclusions The authors present a simple and effective technique for reconstruction of the gluteal fold by a deepithelialized skin flap. The technique is applicable for patients who have lost their natural gluteal sulcus, with a resultant altered buttock shape, after trauma or other causes.     

Inframammary fold reconstruction with a deepithelialized skin flap

Sagging of the remaining breast behind the inframammary fold after breast reduction or breast augmentation may necessitate revisional surgery. The authors achieved inframammary fold reconstruction by reconstruction of the inframammary crease ligament through a deepithelialized skin flap that is anchored to the periosteum of the fifth or sixth rib. They present their simple and safe technique.     

Metatarsalgias and pronated foot or peritalar destabilisation syndrome?

Pathological subtalar pronation is often referred as a biomechanical event in the pathogenesis of metatarsalgias due to destabilisation of the structures distal to the subtalar, especially when its pathological set persists during the take-off stage. The skin, the subcutaneous tissue, the metatarsal heads, the metatarsophalangeal joints, the toes and the intermetatarsal neurovascular bundles are all involved.If, however, account is taken of the fact that the normal arrangement of the subtalar joint is established by the talus, the ligaments and tendons and the suprasegmental attitude of the limb, that the subtalar and talonavicular form the so-called “coxa pedis” or peritalar joint, and that this makes a better contribution than the subtalar to the mechanism in the opening and closing of the foot's kinetic chain (talus a bone of the leg when the chain is closed, enarthrodial “coxa pedis”), it is evident that the subtalar, in the absence of any intrinsic disorder, pronates secondarily to other mechanisms to be described in each particular case.In conclusions, one can hardly speak of biomechanical metatarsalgias solely in terms of pronation of the subtalar and if we wish to call them syndromes, it is more correct to say they are the outcome of peritalar destabilisation.The term “peritalar destabilisation syndrome” offers a better access to the biomechanical event underlying global derangement of the foot and forefoot. It also corresponds to intrinsic “coxa pedis” disorders, such as recently acquired degenerative glenopathy, and obviously to the extrinsic causes of the destabilisation (skeletal, ligament, neuromuscular alterations, suprasegmental disarrangements, etc.).     

Soft Tissue Augmentation With Artecoll: 10-Year History,Indications, Techniques, and Complications

Most of the biologic filler materials that increase the thickness of the corium in a wrinkle line are phagocytosed within a certain time. Therefore, a lasting effect can only be achieved with nonresorbable synthetic substances. Artefill consists of 20 volume percent microspheres of polymethyl-methacrylate and 80 volume percent of bovine collagen. Beneath the crease, the microspheres with their exceptional surface smoothness stimulate fibroblasts to encapsulate each individual one of the 6-million microspheres contained in 1 mL of Artefill. Collagen is merely a carrier substance that prevents the microspheres from agglomerating during tissue ingrowth. The 20 volume percent of microspheres in Artefill provides the scaffold for the 80% volume of connective tissue deposition, a complete replacement of the injected collagen. The filler material beneath a crease acts like a splint and prevents the possibility of its further folding, thereby allowing the diminished thickness of the corium in a crease to recover. This recovery process is well known even in older patients with facial paralysis or after a stroke, whose facial wrinkles and furrows on the paralyzed side disappear over time.     

Classification and surgical correction of postburn axillary contractures

Postburn axillary contractures should be surgically corrected as soon as the diagnosis has been established in order to avoid deeper tissue involvement. We have classified axillary contractures based upon local anatomic conditions and present procedures for correction of each type that we find most suitable. Type I contractures are characterized by a linear web at either axillary fold with minimal adjacent scarring. A double Z-plasty with Y-V advancement is the procedure of choice. Type II contractures involve either axillary fold, with adjacent skin scarring. A double incisional release on both sides of the hair-bearing area is the procedure of choice. Type III contractures are characterized by linear webs at both axillary folds without involvement of the adjacent skin. The procedure of choice in these cases is a double incisional release. Type IV axillary contractures involve the hair-bearing area and the periaxillary region. This diffuse scar contracture is best treated by a single incisional release.     

Infragluteal Sulcus: A Combined Histologic and Anatomic Reappraisal

The infragluteal fold is one of the major concerns in reshaping of the gluteal region. This study reevaluated the fold both histologically and anatomically. Five fixed cadavers were used. The infragluteal fold on the right side was explored by dissection, whereas the infragluteal fold of the contralateral side was removed en bloc. Tissue samples (6 cm long × 2 mm thick) were taken at three points from each fold bloc: the most medial point, the middle point, and the most lateral end of the sulcus. Anatomic dissections and histologic examinations showed that the infragluteal fold consists of strong fibrous bands extending from the dermis of the medial one-third of the fold to the ramus of the ischium and sacrum, forming the letter J. The infragluteal fold, which attaches to both the ischium and the sacrum in a continuous fashion, is an anatomic structure in its medial part and only a crease laterally.     

The role of steroid administration in the management of dysphagia in anterior cervical procedures

Dysphagia is a common postoperative symptom for patients undergoing anterior cervical spine procedures. The purpose of this study is to present the current literature regarding the effect of steroid administration in dysphagia after anterior cervical spine procedures. We performed a literature search in the PubMed database, using the following terms: “dysphagia,” “ACDF,” “cervical,” “surgery,” “anterior,” “spine,” “steroids,” “treatment,” and “complications.” We included in our review any study correlating postoperative dysphagia and steroid administration in anterior cervical spine surgery. Studies, which did not evaluate, pre- and postoperatively, dysphagia with a specific clinical or laboratory methodology were excluded from our literature review. Five studies were included in our results. All were randomized, prospective studies, with one being double blinded. Steroid administration protocol was different in every study. In two studies, dexamethasone was used. Methylprednisolone was administrated in three studies. In four studies, steroids were applied intravenously, while in one study, locally in the retropharyngeal space. Short-term dysphagia and prevertebral soft tissue edema were diminished by steroid administration, according to the results of two studies. In one study, prevertebral soft tissue edema was not affected by the steroid usage. Furthermore, short-term osseous fusion rate was impaired by the steroid administration, according to the findings of one study. The usage of steroids in patients undergoing anterior cervical spine procedures remains controversial. Multicenter, large-scale, randomized, prospective studies applying the same protocol of steroid administration and universal outcome criteria should be performed for extracting statistically powerful and clinically meaningful results.     

Superiority of the EF-120-00-3F biopsy forceps in the histopathological evaluation of upper urinary tract specimens

Purpose

The purpose of this study was to analyze the efficacy of two different biopsy forceps with respect to their functionality and quality for histological assessment of upper urinary tract biopsies.

Methods

We compared flow rates, active deflection angle and histological quality of specimens taken from upper urinary tract biopsies of 40 consecutively treated patients between October 2011 and October 2012. Two different biopsy forceps [group A = 20 patients: “Piranha ^® ” (Boston Scientific, Natick, USA) versus group B = 20 patients: “EF-120-00-3F” (Euromedical GmbH, Siegsdorf, GER)] were assessed.

Results

The specimens obtained with the “EF-120-00-3F” were superior in terms of tissue preservation such as intact urothelium/tissue fragmentation and the prevention of artifacts due to tissue compression (existence of artifacts/nucleus evaluation). Furthermore, due to superiority of tissue preservation, tissues obtained with the “EF-120-00-3F” showed better tissue orientation in the sense of anatomic evaluation of invasion and deep layer involvement. Irrigation flow rates did not differ significantly while deflection angle was more impaired with the “Piranha” biopsy forceps. No difference was observed with the handling of both biopsy forceps.

Conclusions

We conclude that the “EF-120-00-3F” biopsy forceps represent a valuable modification of antegradely insertable instruments that qualifies for improved and correct staging as well as diagnosis of upper urinary specimens in comparison with standard biopsy forcipes.