Development of the inframammary fold and ptosis in breast reconstruction with textured tissue expanders

Tissue expansion has become the most important method for postmastectomy breast reconstruction. However, well-defined inframammary fold and ptosis are difficult to achieve with this technique. This study was performed to evaluate the inframammary fold and ptosis achieved in breast reconstruction using a textured tissue expander, later replaced by a textured implant. In ten postmastectomy patients, a textured tissue expander was inserted into a submuscular pocket. Every two to three weeks the volume of the expander was increased by about 30%. About three months after the last filling, the expander was removed and replaced with a permanent textured, gel-filled implant. The profile of the reconstructed breast was recorded before and after the tissue expansion, as well as before and after the change of the implant. The results showed that the inframammary fold did not move significantly upwards or downwards during the expansion period when a textured tissue expander was used. Waiting three months after the last inflation of the expander before replacing it with the permanent implant resulted in a more ptotic breast mound. Usually, however, no real ptosis was achieved, meaning that the angle between the lower part of the breast and the lower chest wall was more than 90 degrees. These findings indicate that a textured expander could help create a pronounced inframammary fold, but without ptosis. A three-month waiting period before inserting the permanent implant may improve the development of an inframammary fold.     

Fingertip reconstruction by nail bed grafting using thenar flap

Ideally, treatment for fingertip injury should involve the least pain possible, using durable and sensate skin with due consideration to aesthetic aspects. This paper presents two cases of fingertip reconstruction through the use of thenar flaps and nail bed grafts. In either case, injury had been due to fingertip crushing and reconstruction was conducted immediately thereafter. A full-thickness nail bed with hyponychium and perionychium from the severed part was used for dorsal reconstruction and thenar flaps for finger pulp reconstruction. In both cases, the grafting was quite satisfactory and good soft-tissue healing was observed. Subsequent nail growth and adherence were good. The outcome was pleasing to both patients. Thus, the presented method may be considered quite satisfactory from aesthetic and functional recovery standpoints.     

Breast Reconstruction by Expansion and Advancement of the Upper Abdominal Flap

Inspired by successful reconstruction obtained using the Lewis–Ryan lower thoracic advancement flap to rebuild missing breast, we have adapted that extremely simple technique to prior serial expansions, in order to create more natural mounds, better defined submammary folds, and when possible, some grade of ptosis, without additional, new scarring. The procedure is introduced and compared to other such flaps as the TRAM and the latissimus dorsii. In our series, 30 patients were evaluated according to the quality of the final results, and the most frequent complications are pointed out and discussed.     

The Top Hat Flap: For One Stage Reconstruction of a Prominent Nipple (Top Hat Flap)

Nipple reconstruction is an important adjunctive procedure in breast reconstruction. Local flap procedures and tattoo-only techniques rarely provide sufficient projection in a patient with prominent nipples. We describe a method to reconstruct such a nipple termed the top hat flap. A retrospective chart review of 38 patients was performed to determine adequacy of projection and complication rates of 46 nipples created between 1989 and 1994. Forty-three (93%) of the nipples resulted in adequate and sustained projection at a minimum of 1-year follow-up. The complication rate was found to be low and patient satisfaction high with this simple outpatient procedure.     

应用下腹部横行腹直肌肌皮瓣的乳房再造

目的 安全应用下腹部横形腹直肌肌皮瓣（TRAM）进行乳房再造。方法 总结42例乳房再造的经验,详尽介绍了病例选择,皮瓣设计和手术方法。结果 应用TRAM再造乳房42例,其中即时再造25例,后期再造17例;单蒂TRAM35例,双蒂TRAM7例,单蒂中有7例附加血管吻合。2例术后腹部供区皮瓣部分坏死,2例TRAM部分坏死,1例双蒂皮瓣术后腹壁疝形成。结论 附加血管吻合或选用双蒂肌皮瓣,以及肌肉内分离是减少并发症的重要措施。     

Mammareconstruction with skin-expander and silicone prostheses: 15 years' experience

We report on 170 breasts that were reconstructed with Skin-Expander and silicone implants over a period of 15 years [1,2]. Reconstruction occurred primarily in only about one-third of the cases, since the information provided by the first doctor in charge regarding the possibilities of breast reconstruction was rather scanty. In cases treated with radiotherapy, reconstruction with Skin-Expander should not be excluded, but it is necessary to proceed with extreme caution and to give patients exact information. The complication rate is higher here than in cases which have not been exposed to radiotherapy. The final result depends directly on the primary surgery and the skin as well as the contralateral breast quality [3]. In most cases reconstruction with Skin-Expander and silicone implants meets the patients' desires: low-risk operation, fewer additional scars, and similar and improved breasts on both sides.     

Staged TRAM Breast Reconstruction: Combining the Advantages of Tissue Expansion with Surgical Delay

The TRAM flap has become the gold standard in breast reconstruction but suffers from the disadvantages of poor color match, different texture, and impaired sensation compared to the normal breast. This study reports on a two-stage procedure to address these problems. The first stage consists of insertion of a tissue expander and surgical delay of the TRAM flap. The second stage consists of removal of the tissue expander and transposition of a deepithelized TRAM flap into the tissue expanded cavity. (The capsule is excised.) Four cases of breast reconstruction are reported. The advantage of this procedure is that it offers the benefits of tissue expansion, viz., normal color match, texture, and sensation, and in addition, reconstruction is achieved with autologous tissue by a pedicled TRAM flap. The vascularity of the TRAM is enhanced by a surgical delay procedure.     

Nasal reconstruction after epithelioma

In this paper we present our procedure for the treatment, histopathological diagnosis, and resection of skin cancer in the nasal pyramid and its subsequent reconstruction. Because we are dealing with the most important anatomical feature of the face our goal is an aesthetic reconstruction [2,4] according to the anatomical subunits criterion of Burget [3]. First, a histopathological diagnosis is made to determine the nature of the tumor. Then, we proceed with the resection according to the Mohs Micrographic Surgery [1,5,7]. Then we begin with the first step of the nasal reconstruction.     

腹壁浅动脉蒂游离腹壁皮瓣乳房再造术的初步临床应用

目的 探讨采用腹壁浅动脉(superficial inferior epigastric artery,SIEA)蒂游离腹壁皮瓣乳房再造术方法 、特点及适应证.方法 术前采用多层螺旋CT(multipledetector-row computed tomography,MDCT)三维血管造影及多普勒血流探测仪检查SIEA的直径、走行及分布,于脐与阴阜上缘之间设计皮瓣,采用单蒂或双蒂SIEA,与胸廓内动,静脉吻合,腹部供区直接拉拢缝合.结果 4例乳房再造病例皮瓣全部存活,皮瓣和腹部供区无脂肪液化、坏死、切口裂开、腹壁薄弱及腹壁疝等并发症的出现,再造乳房外形效果满意.结论 SIEA蒂游离腹壁皮瓣与腹壁下动脉穿支皮瓣(DIEP),横行腹支肌肌(TRAM)皮瓣乳房再造术提供同样的腹部皮肤和组织量,但却减轻了对腹部功能和形态的损害,在做好充分的术前血管评估、严格把握适应证和熟练掌握显微外科技术的前提下,是一种可供选择的乳房再造方法.     

腹壁浅动脉蒂游离腹壁皮瓣乳房再造术的初步临床应用

目的 探讨采用腹壁浅动脉(superficial inferior epigastric artery,SIEA)蒂游离腹壁皮瓣乳房再造术方法 、特点及适应证.方法 术前采用多层螺旋CT(multipledetector-row computed tomography,MDCT)三维血管造影及多普勒血流探测仪检查SIEA的直径、走行及分布,于脐与阴阜上缘之间设计皮瓣,采用单蒂或双蒂SIEA,与胸廓内动,静脉吻合,腹部供区直接拉拢缝合.结果 4例乳房再造病例皮瓣全部存活,皮瓣和腹部供区无脂肪液化、坏死、切口裂开、腹壁薄弱及腹壁疝等并发症的出现,再造乳房外形效果满意.结论 SIEA蒂游离腹壁皮瓣与腹壁下动脉穿支皮瓣(DIEP),横行腹支肌肌(TRAM)皮瓣乳房再造术提供同样的腹部皮肤和组织量,但却减轻了对腹部功能和形态的损害,在做好充分的术前血管评估、严格把握适应证和熟练掌握显微外科技术的前提下,是一种可供选择的乳房再造方法.     

Lip Reconstruction of Comparatively Large Defect Including the Commissure Using Remaining Lip Tissue: A Modification of Reconstructed Method

We present two reconstructed cases after malignant skin tumor of comparatively large defects of lip including the commissure using remaining lip tissue alone. After resecting a tumor including wedge-shaped full-thickness lip tissue, a full thickness oblique incision is made at the site 5 mm distant from the contralateral commissure. The rhomboid-shaped lower lip flap is created, transposed to the defect, and sutured with the defect margin, including the upper lip, to reconstruct the commissure. The cross lip flap is created at the contralateral side of the lower lip, 5 mm from the commissure, and the defect is closed with the crosslip flap. Although our method is applicable only to selected cases, we believe that it is useful in terms of maintaining symmetry of the lip and function of the commissure in the reconstruction of comparatively large defects including the commissure.     

扩大背阔肌肌皮瓣乳房再造

目的　介绍单纯应用扩大背阔肌肌皮瓣进行乳房再造方法。方法　将背阔肌周围脂肪组织分为 5个区 ,在背部设计半月形皮肤切口 ,切取背阔肌及周围脂肪组织 ,不应用乳房假体 ,进行即时或后期乳房再造。结果　应用该方法乳房再造 35例 ,再造乳房形态良好。结论　扩大背阔肌肌皮瓣乳房再造 ,安全有效 ,再造乳房形态良好 ,是乳房再造的重要进展。     

Factors Associated with Breast Implant Rupture: Pilot of a Retrospective Analysis

This pilot study's goal was to test the feasibility of a data collection form which will be used in a scale-up study analyzing multiple surgeons' records. The goal of this expanded study will be to develop identifying factors for women who are at greater risk for having ruptured implants and, if necessary, target them for screening, surveillance, or intervention. In the pilot study, we compared factors associated with implant rupture in women with and without rupture. Similar studies have considered one or a few factors at a time and, generally, have given little attention to implant generation. We developed a data collection form after reviewing records of three surgeons. A total of 92 records was collected and analyzed. An important feature in the pilot was to compare the results of patients whose implants the surgeons had both implanted and explanted (n= 34) with those of patients whose implants the surgeons had only explanted (n= 55) (unknown = 3). This comparison could show if including all explantation patients in a surgeon's practice would bias the sample; however, based on this pilot data, concerns regarding this type of bias seem to be minimal. Similar amounts of data (e.g., implant information, history of capsular contracture, etc.) were collectible on patients whose surgeons both implanted and explanted them (87%) and who had different surgeons for implantation and explantation (84%). Though the data from this limited sample cannot offer firm conclusions on rupture associations, a few factors stood out: size of implants (38.3% of ruptured versus 15.9% of intact implants were 100–200 cm³), history of mammography (46.8% of ruptured versus 24.4% of intact had mammograms, which is likely due to older women with older implants having more mammograms), and history of closed capsulotomy (85.1% of ruptured versus 68.9% of intact). Interestingly, additional procedures performed on the breast (e.g., scar revision, wound repair, etc.) did not affect rupture: both the ruptured and the intact groups had an average of 1.7 procedures performed. The data collection form tested very well in this pilot study. Also, including all patients in the study sample, instead of excluding those who received their implants elsewhere, did not change the results. Though there are not enough data to draw any firm conclusions regarding rupture factors, the collection instrument was rigorously tested and should perform well in an expanded study.     

腹壁浅动脉蒂游离腹壁皮瓣乳房再造术的初步临床应用

目的 探讨采用腹壁浅动脉（superficial inferior epigastric artery,SIEA）蒂游离腹壁皮瓣乳房再造术方法 、特点及适应证.方法 术前采用多层螺旋CT（multipledetector-row computed tomography,MDCT）三维血管造影及多普勒血流探测仪检查SIEA的直径、走行及分布,于脐与阴阜上缘之间设计皮瓣,采用单蒂或双蒂SIEA,与胸廓内动,静脉吻合,腹部供区直接拉拢缝合.结果 4例乳房再造病例皮瓣全部存活,皮瓣和腹部供区无脂肪液化、坏死、切口裂开、腹壁薄弱及腹壁疝等并发症的出现,再造乳房外形效果满意.结论 SIEA蒂游离腹壁皮瓣与腹壁下动脉穿支皮瓣（DIEP）,横行腹支肌肌（TRAM）皮瓣乳房再造术提供同样的腹部皮肤和组织量,但却减轻了对腹部功能和形态的损害,在做好充分的术前血管评估、严格把握适应证和熟练掌握显微外科技术的前提下,是一种可供选择的乳房再造方法.     

应用腹壁下动脉穿支游离皮瓣移植乳房再造

目的 通过应用腹壁下动脉穿支游离皮瓣移植进行乳房再造的手术方法，总结应用该方法进行乳房再造的临床经验。方法 切取以腹壁下动静脉为蒂的穿支游离皮瓣，将腹壁下动静脉与胸廓内动静脉相吻合，进行乳房再造。结果 自2000年以来，临床应用腹壁下动脉穿支皮瓣再造乳房共15例，10例皮瓣100％成活，2例皮瓣远端局部皮肤坏死，1例皮瓣远端脂肪硬结，2例皮瓣完全坏死。随访6个月至1年，再造乳房外形满意，供区无腹壁疝、腹壁膨出、腹壁薄弱等并发症发生。结论 腹壁下动脉穿支游离皮瓣是下腹部横行腹直肌肌皮瓣(TRAM皮瓣)的技术改良与发展，该皮瓣具有血运丰富、组织量大、易于塑形、供区损伤小等优点，是一种安全可靠的乳房再造方法。     

Late and Long-Standing Capsular Hematoma After Aesthetic Breast Augmentation with a Saline-Filled Silicone Prosthesis: A Case Report

Late capsular hematoma is an extremely rare complication after the implantation of silicone breast prostheses for aesthetic or reconstructive objectives. We present a unique case of late capsular hematoma in an aesthetic breast augmentation with a saline-filled, textured silicone implant, which remained for a year after formation.     

改良桡动脉穿支皮瓣在修复额面部组织缺损中的应用

目的 探讨改良桡动脉穿支皮瓣在修复额面部中小面积缺损中的临床应用.方法 以桡动脉腕上皮支动脉和桡动脉伴行静脉为蒂.通过筋膜蒂营养的前臂近端桡侧皮瓣(最大面积10 cm×5 cm),游离移植修复额面部肿瘤切除后的组织缺损10例.结果 修复额部缺损6例,面颊都缺损4例,术后皮瓣全部存活,经随访6～12个月后行皮瓣修薄整形术.10例病例经8～18个月随访,平均随访11.3个月,其中7例于术后6～9个月进行二次整形.所有病例皮瓣柔软,瘢痕不明显,皮色与面颊部基本接近,皮瓣两点分辨率在20～40mm.结论 改良的前臂桡动脉穿支皮瓣是修复额面部中小面积缺损的主要方法之一.     

Histologic Profiles of Breast Reduction Specimens

Reduction mammaplasty is one of the most common procedures performed by plastic surgeons all around the world. This procedure is performed for aesthetic or reconstructive purposes, but also offers the opportunity to examine all resected breast tissue histopathologically. The purpose of this study was to evaluate the histologic diagnoses of the reduction mammaplasty specimens retrospectively and to determine the incidence of breast lesions in otherwise asymptomatic and healthy women. Therefore, 149 patients who had undergone reduction mammaplasty were reviewed with regard to their histologic diagnoses. We found that 61% of these women have pathologic alterations in at least one of their breasts, so each patient who requests a breast reduction surgery should be evaluated carefully and the specimens should be handled with particular care.     

Immediate reconstruction using inframammary adipofascial flap of the anterior rectus sheath after partial mastectomy

Treatment of early breast cancer using breast conservative therapy (BCT) usually ensures local control and acceptable cosmetic results. To repair defects caused by partial mastectomy in the lower region of the breast, some reconstruction should be used. We developed a procedure involving the cranial based adipofascial (anterior rectus sheath) flap from immediately below the inframammary area for the reconstruction of defect due to partial mastectomy for patients with early breast cancer. In this procedure, a skin incision is made at the inframammary line, and the inframammary skin area is undermined. A tongue shaped flap composed of the subcutaneous fat and the anterior sheath of rectus abdominis muscle is pulled up and a C-shaped flap is rotated, gathered, and inserted to reconstruct the breast defect.     

Breast Shape Malformations

Breast shape malformations are deformities of the breast contour involving the inferior breast pole. They range from minor forms such as a high submammary fold to major forms such as the tubular breast. The malformation implies an altered relationship between the mammary parenchyma and the superficial fascial system (SFS). The surgical correction consists of the releasing of the gland from all the connections with the surrounding tissues. In some cases, once the glandular tissue is freed from the constricting SFS, the parenchyma spreads revealing a sufficient volume to obtain a normal breast. If hypoplasia of the breast or inferior quadrant hypoplasia is present, the use of an implant is mandatory.