Chest Lifting

The male chest has a female appearance in patients with gynecomastia and those who have experienced a huge weight loss. The disadvantages of reduction mammaplasty for men are the visible scars on the chest wall necessitated because of skin redundancy. The aims of the chest-lifting procedure are to reposition the breast, to create a male appearance by thinning the amount of glandular and fatty tissue, to avoid noticeable scars on the chest wall, and to hide the scar in the middle axillar line.     

Carcinoma En Cuirasse Presenting as Keloids of the Chest

Background. Carcinoma en cuirasse is a form of metastatic cutaneous breast malignancy occurring most commonly on the chest as a recurrence of breast cancer, but it can be the primary presentation.
Objective. To discuss the clinical features of carcinoma en cuirasse that distinguish it from hypertrophic scars and keloids of the chest.
Method. We report a 63-year-old woman with primary cutaneous breast carcinoma presenting as keloid nodules on the chest that failed treatments for keloids. Biopsy revealed a pattern of breast carcinoma in the skin.
Results. After further workup, no tumor was found in the deep breast tissue, but metastases were found in her axillary lymph nodes.
Conclusions. Unusual keloid-like nodules or scars on the chest that fail to respond to therapy may be primary or metastatic malignancies, and adequate histologic verification should be obtained to avoid delay in the proper treatment.     

Torsoplasty After Important Weight Loss

Weight loss exceeding 40 kg frequently causes excess skin on the lateral and posterior chest wall. Other authors have suggested surgical dissection of the excess skin using horizontal incision or, alternatively, using a vertical incision positioned in the axillary region. This procedure is incomplete and does not correct the skin ptosis in the subaxillary lateral chest wall. The current authors propose a surgical technique that permits resection of excess skin and lifts the torso on the back, positioning the scars on the anterior axillary pillar and around the breast. This treatment is performed for the patient after significant weight loss. The scar normally is hidden behind the anterior axillary pillar on the axillary fold.     

Gynecomastia: The Horizontal Ellipse Method for Its Correction

BACKGROUND: Gynecomastia is an extremely disturbing deformity affecting males, especially when it occurs in young subjects. Such subjects generally have no hormonal anomalies and thus either liposuction or surgical intervention, depending on the type and consistency of the breast, is required for treatment. If there is slight hypertrophy alone with no ptosis, then subcutaneous mastectomy is usually sufficient. However, when hypertrophy and/or ptosis are present, then corrective surgery on the skin and breast is mandatory to obtain a good cosmetic result. METHODS: Most of the procedures suggested for reduction of the male breast are usually derived from reduction mammaplasty methods used for females. They have some disadvantages, mainly the multiple scars, which remain apparent in males, unusual shape, and the lack of symmetry with regard to the size of both breasts and/or the nipple position. The author presents a new, simple method that has proven superior to any previous method described so far. It consists of a horizontal excision ellipse of the breast's redundant skin and deep excess tissue and a superior pedicle flap carrying the areola-nipple complex to its new site on the chest wall. RESULTS: The method described yields excellent shape, symmetry, and minimal scars. CONCLUSION: A new method for treating gynecomastis is described in detail, its early and late operative results are shown, and its advantages are discussed.     

A reduction mammaplasty operation for Oriental females

There are many reduction mammaplasty operations, e.g., the operations of Strombeck, Skoog, McKissock, Wiener, Pitanguy, Onizuka, etc. All of these operations can produce very good results. Nonetheless, all of these classical procedures when they are used to treat large ptotic breasts of oriental young females, have a serious disadvantage, i.e. they all leave incisional scars at the parasternal region. Which often become hypertrophic or keloid. The skin of the lower lateral part of the chest wall is looser and less likely to have hypertrophic scars than the front sternal region. On account of this, I changed my operative field of reduction mammaplasty from the lower central to the lower lateral region of the large ptotic breast since 1963. After several modifications, my present technique is about the same as the Pitanguy's operation, but there is no visible scars at the anterior surface of the chest wall because no surgery has been done here. This lower lateral technique of reduction mammaplasty had been presented at the First Conference of Aesthetic Plastic Surgery for the Orientals, held in Tokyo, Japan, on Oct. 24-26, 1988. It had received good remarks at the meeting.     

The "aesthetic subunit" principle in late TRAM flap breast reconstruction

The "aesthetic subunit" principle is well established in facial reconstruction. This principle dictates that the margins of regional reconstructions correspond to existing visual boundaries. This will minimize the visual perception of "abnormal." The subunit principle also applies to secondary TRAM flap breast reconstructions in which the available chest wall skin is of poor quality. In these situations, it might be aesthetically advantageous to replace poor quality chest wall skin with a TRAM flap skin paddle that ends at the inframammary fold.     

可扩张乳房假体加背阔肌肌皮瓣的乳房再造术

目的：报告应用带蒂背阔肌肌皮瓣转移术及可扩张的乳房假体（BECKER）置入,修复乳腺癌根治术后的胸壁畸形,同时再造乳房的手术方法。方法：根据乳腺癌病灶清除术后患者胸部的畸形状况,设计患侧带蒂背阔肌肌皮瓣的肌瓣长度、体积以及皮瓣的面积和形状,切取肌皮瓣后经腋部皮下隧道转移至胸前。用肌瓣修复胸前软组织缺损,皮瓣则用于弥补胸部皮肤的不足。肌瓣与胸壁间置入可扩张的乳房假体。术后经注射壶注水,逐步扩张至额定值。6个月后,可抽除注射壶并重建乳头,完成治疗。结果：自1999年以来,对各种乳腺癌术后患者行乳房再造术共26例,获得了满意效果。结论：应用带蒂背阔肌肌皮瓣转移术及可扩张的乳房假体置入,不仅可修复乳腺癌病灶清除术后的胸部软组织的缺损、锁骨下的凹陷畸形而且可重建乳房。该法具有创伤小、恢复快、再造乳房的外形及质感逼真等特点。     

Restoration of the shape, location and skin of the severe burn-damaged breast

Thermal injuries to the anterior chest in pre-pubescent girls result in breast contracture. During puberty, the breast parenchyma develops and grows underneath the scars, resulting in being flattened and disfigured. The breast mound, as well as the nipple–areolar complex, is partially or completely levelled out and displaced. The contours are unclear and the inframammary fold is effaced. This feature of the most severe breast contracture still poses a challenge for most surgeons. This type of breast contracture can be successfully eliminated with the author-suggested, improved free-skin grafting technique. The scars are excised and the shifted area of parenchyma is mobilised symmetrically to the border of the undamaged breast. Then, the shape and positioning of the breast as well as the nipple–areolar complex are reconstructed with the help of circular suturing through the fat layer on two to three breast levels. The suture ends are led beyond the wound area and are affixed with certain tension contralateral to the breast displacement. The suture ends, being in state of tension, are tied into untied knots around bolsters and are retained in place for about 3 months. During this time, the form and the positioning of the breast can be corrected using the traction of the untied sutures; the skin transplants are stabilised, under which the scar tissue is formed. Skin transplant and the scar tissue hold the shape and positioning of the breast and the sutures can be removed at this stage. In this series, 11 patients were operated upon and 13 breasts were reconstructed. Good results were achieved in all cases: the breast's shape and skin was restored and the positioning was corrected.     

Limitations and Complications in the Utilization of Stereotaxic Core Breast Biopsy

Abstract: Stereotaxic core biopsy of the breast is becoming an increasingly utilized tool for the diagnosis of breast disease without surgery. It can increase the speed and decrease the cost and deformity associated with diagnosis. However, some shortcomings in the procedure exist and radiologists and patients should be aware of these.
Lesions that are in thin areas of the breast or close to the skin may be difficult t o biopsy with this technique. Lesions near the chest wall or in the axilla may be inaccessible with some equipment, especially prone tables. Small lesions may be totally removed, making localization of the area for wider surgical excision difficult if they are malignant. Some types of calcifications may be difficult t o sample.
Certain histologies require wider surgical excision when diagnosed with core biopsy. These include ductal atypia and radial scars. Areas of invasion associated with duct carcinoma in situ (DCIS) may be missed on core sampling. Major complications are rare and include bleeding and infection. Minor complications are ecchymosis, pain, and inability t o return t o normal activities for a day or more.     

应用扩张后皮瓣修复乳房下部瘢痕

目的 探寻乳房下部瘢痕挛缩的较佳治疗方法. 方法 对2000年7月-2007年7月笔者单位收治的9例乳房下部瘢痕挛缩女性患者,行乳房周围皮肤扩张术.扩张器埋置切口多选择在乳房下部瘢痕处,置入部位以乳房周围侧胸部、胸部中央剑突附近为佳,且侧胸部置入时尽量使扩张器位置向上,与乳房上级水平齐平.扩张器埋置层次在深筋膜下及腺体表面.Ⅱ期充分松解挛缩的瘢痕,使腺体及乳房恢复正常解剖位置,将扩张后皮瓣设计成直接推进或易位皮瓣修复缺损,或直接拉拢缝合封闭创面. 结果 除1例患者皮瓣尖端4.0 cm×3.0 cm范围发生血运障碍,经植皮后创面愈合外,其余8例皮瓣均成活,创面愈合;所有患者乳晕、乳头均恢复正常解剖位置.其中3例6个月～2年后复诊,效果满意. 结论 应用扩张后皮瓣修复乳房下部瘢痕挛缩,效果良好.     

Omental transposition and skin graft in patients for advanced or recurrent breast cancer

Nine patients, including 4 with primary advanced breast cancer (stage IV) and 5 with local recurrent cancer, underwent chest wall reconstruction using an omental flap and mesh skin grafting. In 2 of these patients the defect of bony chest wall was reconstructed with an acryl-resin plate and omental flap. The postoperative course in all patients was uneventful, except for a slight necrosis on the transposed mesh skin. Flail chest or dypsnea did not occur in those with a bony chest wall reconstruction. The immediate postoperative performans status in 6 of 9 patients and also quality of life improved.     

Omental transposition and skin graft in patients for advanced or recurrent breast cancer

Nine patients, including 4 with primary advanced breast cancer (stage IV) and 5 with local recurrent cancer, underwent chest wall reconstruction using an omental flap and mesh skin grafting. In 2 of these patients the defect of bony chest wall was reconstructed with an acryl-resin plate and omental flap. The postoperative course in all patients was uneventful, except for a slight necrosis on the transposed mesh skin. Flail chest or dyspnea did not occur in those with a bony chest wall reconstruction. The immediate postoperative performance status in 6 of 9 patients and also quality of life improved.     

PRIMARY RECONSTRUCTION AFTER EXTENSIVE CHEST WALL RESECTION

Background : Chest wall resection and reconstruction has been proven to be a safe surgical procedure. This is particularly useful for breast cancer patients with chest wall recurrences or for those who first present with locally advanced cancer in the chest wall where there is both a large soft tissue and bony defect that need repair. In addition, many of these patients have had irradiation or chemotherapy, which can significantly impair wound healing. Methods : Thirty-four patients underwent chest wall resection and primary reconstruction over an 8-year period. Results : Twenty-three patients had breast carcinomas and six had breast and chest wall sarcomas. Of the breast carcinoma patients, 12 had local recurrences and 11 presented with locally advanced primary disease. Bony resection of the chest wall was required in 16 (47%) cases. Thirty myocutaneous flaps (18 rectus abdominis, four pectoralis major, eight latissimus dorsi) and three omental flaps were used for reconstruction. One required a deltovertebral skin flap. Skeletal reconstruction was necessary in four cases. All except one (97%) achieved primary wound healing. There was one mortality (3%) and three patients required further surgery for complications that were related to the reconstruction. Post-resection metastases occurred in 13 (42%) patients and only 2 (6%) had local recurrences. The 2-year survival rate was 78% with a mean survival time of 25.5 months. Conclusions : Primary reconstruction for curative or palliative purposes is a useful and safe surgical procedure for patients with recurrent or locally advanced chest malignancies after extensive chest wall resection. Pedicled myocutaneous flap is the preferred option for skeletal and soft-tissue coverage.     

Cause and prevention of surgical site infection and hypertrophic scars

Surgical site infection (SSI) occurs at the site of surgery within 1 month of an operation or within 1 year of an operation if a foreign body is implanted as part of the surgery. Most SSIs (about 70%) are superficial infections involving the skin and subcutaneous tissues only. The remaining infections are more serious and can involve tissues under the skin, organs, or implanted material. Hypertrophic scars( HSs) occur frequently on particular sites, including the anterior chest wall. The anterior chest wall is frequently subjected to skin stretching caused by the natural daily movements of the body. Most cases of SSIs and HSs can be prevented by (1) suture technique modification to prevent high stretching tension and ischemia, and (2) appropriate wound care after surgery. It would be useful to avoid subjecting wounded skin to sustained mechanical force, thereby permitting the wound to rest and heal normally.     

Chest wall reconstruction for recurrent breast cancer

Some recurrences of breast cancer require wide chest wall resection as curative or palliative therapy. We report a retrospective review of 14 chest wall resections and reconstructions. The width of the anterior chest wall excision was 150 cm(2) (80 to 360 cm(2)). Two defects were full-thickness ones, with sternal or costal resection. The reconstruction required synthetic mesh covered by a latissimus dorsi musculocutaneous flap. The 12 other resections were superficial ones, and have been covered by a skin graft in 5 patients, and by a regional flap in 7 patients (5 latissimus dorsi, 1 DIEP, and 1 bilobed flap). Two patients had a chest wall irradiation after the surgical procedure. We have analysed the factors, which had influenced our choice of the type of reconstruction. The reconstruction is performed by a regional flap, most commonly a latissimus dorsi pedicled flap, in case of full-thickness defect, of nodular isolated recurrence, or when a radiation therapy is provided after the surgical procedure. The coverage is made by a skin graft in case of palliative excision, or of multiple nodular chest wall recurrence (which have a high risk of recurrence in the same form).     

Shoulder adduction contracture after burn: Anatomy and treatment with quadrangular local scar subcutaneous pedicled flap,a new approach

Background

Axillary adduction contracture is caused by scars that tightly surround the shoulder joint impairing the function of the upper limb. Due to severe scar surface deficiency, contracture release presents a challenge for surgeons since a method of release is transfer of tissue in the form of a large pedicled or free flap(s). Thus, development of simpler, less traumatic techniques, using local tissues, persists.

Methods

Anatomic studies of shoulder adduction contractures after burn (pre-operative, during surgery, post-reconstruction) were done in 346 pediatric and adult patients. All were divided into three groups according to contracture types: with edge contractures (80%), medial (6%) and total (14%). Anatomical study covered peculiarities of total contractures and possibilities for their treatment using local scarred tissue.

Results

Total contractures (48 patients) were caused by scars tightly surrounding the joint on three sides: anterior, posterior, and axillary. There were two specific forms of contracture: (a) shoulder close to the chest wall (22 of 48 patients) which was treated with thoracic pedicled or free flaps; (b) in 26 out of 48 patients a flat scar and skin graft surface laid along the shoulder and chest wall, in axillary projection, which were used for contracture release in the form of a subcutaneous pedicled quadrangular flap. The flap was mobilized only peripherally, descending to the apex of the axilla, forming the central axillary zone, and suspension of the axilla on a normal level. Wounds aside the flaps were covered with skin graft. Acceptable functional and cosmetic results were achieved in all 26 patients.

Conclusion

Total shoulder adduction contractures have two forms: (a) shoulder close/fused with the chest wall; and (b) along the chest wall and shoulder there is a flat surface, the tissue of which can be used for reconstruction in a form of scar subcutaneous pedicled quadrangular flap. Based on this flap, a new technique is described which is relatively easy to perform.     

Use of the extended V-Y latissimus dorsi myocutaneous flap for chest wall reconstruction in locally advanced breast cancer

The extended V-Y latissimus dorsi myocutaneous flap described by Micali and Carramaschi provides an innovative method of closing large anterior chest defects after resection of breast cancer. The technique provides robust chest wall coverage that is able to withstand immediate postoperative radiotherapy. The aim of this article is to confirm the usefulness of the flap's design and describe modifications to the technique. The modifications to technique include: a curvilinear design that recruited more skin for closure in patients with wounds extending laterally or superiorly, routine transposition of latissimus dorsi insertion inferio-medially onto the chest wall to maximize pedicle reach, and the use of small split skin grafts or delayed primary closure if there was tension in closing. Twelve patients who underwent resection of locally advanced breast cancer had immediate chest wall reconstruction with the extended V-Y latissimus dorsi musculocutaneous flap. The V to Y design of the flap's cutaneous island allowed primary closure of chest wound and donor defect. There were no instances of chest wound dehiscence. The chest wounds healed, allowing patients to undergo adjuvant radiotherapy in a mean time interval of 6 weeks after surgery.     

Tissue expansion in reconstruction of the burned breast

. Burns of the anterior chest can cause significant distortion of the developing breast. The skin, nipple–areola complex and breast tissue can be injured to a variable degree, leading to abnormal breast development. Reconstruction of the burned breast becomes necessary when the overlying burn scars cause restriction of normal breast growth and development. The use of tissue expansion in the reconstruction of the burned breast provides an alternative to traditional methods. Two clinical cases of breast burn scar reconstruction in young girls using tissue expansion are reported; in one case this was combined with an atypical reduction mammaplasty.     

Reconstruction of the chest wall after full thickness resection: a comparison between myocutaneous flap and acrylic resin plate as reconstructive techniques

Thirty-three patients with chest wall malignancies underwent full thickness resection of the chest wall and immediate reconstruction of the defects with either synthetic materials (acrylic resin plate, 16 patients) or with myocutaneous flaps (rectus abdominis flaps, 17 patients). Although the acrylic resin plate proved to be excellent for maintaining stability of the chest wall, five patients suffered from local skin necrosis, requiring skin grafting, and four suffered from persistent foreign body reactions, necessitating ultimate removal of the plate. The patients receiving myocutaneous flap repair had excellent wound healing, acceptable rigidity of their chest wall, and no foreign body reactions throughout the follow-up period. The 50% post-operative survival time for the entire series was 29 months, suggesting that the procedure in an effective treatment modality for breast cancer involving the chest wall. Reconstruction with a myocutaneous flap is indicated as long as the chest wall defect is not too extensive.     

Ultrasound-Assisted Lipoplasty (UAL) in Breast Surgery

Breast surgery has evolved significantly since the increased demand for reduced scars led to the development of minimal incision techniques. Ultrasound-assisted lipoplasty (UAL) presents important advantages when compared to traditional liposuction, such as preservation of connective structures and significant skin retraction capability. Other factors such as a favorable side-effect profile, satisfactory aesthetic results, and virtually inconspicuous scars have led us to utilize UAL in virtually all of the different breast surgery modalities carried out in our practice. Important aspects of patient selection, markings, surgical technique, and postoperative care are outlined. Ultrasonic energy is applied through superficial tunnels that lie radial to the mammary cone, with preservation of elements such as the areola, mammary ducts, and the central part of the breast's base which contains the perforators that supply the gland. Deep treatment should be applied onto adipose tissue regions and should preferably be performed in the peripheral and subcutaneous layers of the breast, with conservation of the central glandular cone to ensure maintenance of anterior projection. In selected cases, UAL is a valuable adjunct to procedures such as symmetrization, reduction mammaplasty, and breast reconstruction, permitting both volume reduction and shaping through three-dimensional retraction of connective tissue and skin. The excellent preliminary results support new indications and future developments of the technique.