Pectoris major muscle flap in mammaplasty

Due to the late postoperative permanent ptosis recurrence in breast reduction and/or mastopexy, the senior author has introduced a new surgical technique using the inferior third of the pectoralis major muscle which constructed and fashioned according to the anatomo-histological variations. Fixation of this muscle flap to the inferior pole of the mammary gland will avoid any future breast ptosis. Personal experience with 51 consecutive cases of breast reduction and/or mastopexy operated between March 1994 and March 1996 is reported. The procedure is illustrated in details; the main indications, late results, limitations and possible early and late complications are studied and discussed.     

Anchor and Krackow‐“8” Suture for the Fixation of Distal Pole Fractures of the Patella: Comparison to Kirschner Wire

ObjectiveThe study aim was to evaluate the clinical outcomes, functional outcomes, and postoperative complications of anchor and Krackow‐“8” suture fixation (AS) and K‐wire fixation in patients with distal pole patellar fractures.MethodsTwenty‐eight patients with distal pole patella fractures between January 2011 and December 2014 were reviewed retrospectively. The anchor and Krackow‐“8” suture fixation (AS group) was applied in 10 patients and 18 patients underwent K‐wire fixation (K‐wire group). The average age of patients was 46.000 ± 19.476 years in the AS group and 47.556 ± 15.704 years in the K‐wire group, with comparable demographic characteristics. All patients underwent regular follow‐up the operative data and postoperative functional and clinical outcomes were recorded. Complications were recorded by clinical and radiographic assessment. Bostman patellar fracture functional score was used to evaluate knee function after patellar fracture.ResultsA total of 28 eligible patients were included in this study. The mean follow‐up was similar for the AS and the K‐wire groups (P > 0.05). The incision length of AS group was significantly smaller than that of K‐wire group (P < 0.05). The incision length of AS group was significantly smaller than that of K‐wire group (P < 0.05). The final follow‐up on the range of motion of the knee: the average extension lag was similar in two groups (P > 0.05); flexion and flexion–extension angle was slightly better in the AS group than in the K‐wire group. The Bostman patella fracture functional score of AS group were better than K‐wire group at 3 and 6 months after operation. Four kinds of postoperative complications in two groups, one patient (10%) in the AS group and two patients (11.1%) in the K‐wire group had infections. Two (11.1%) cases of nonunion in group K and three patients (16.7%) required re‐operation: one due to infection and two due to early implant failure. In the AS group, all distal pole fractures of the patella showed bony union, without loosening, falling, pulling out and nonunion of the fractures 6 months after operation.ConclusionsAnchor and Krackow‐“8” suture fixation is an easily executed surgical procedure that can significantly reduce incision length and achieve better surgical outcomes than traditional procedures with regard to postoperative complications, knee function and without requiring a second operation. This technique is an effective operation method for the treatment of inferior patellar pole fractures.     

Immediate breast reconstruction with anatomical permanent expandable implants after skin-sparing mastectomy: aesthetic and technical refinements

Use of anatomic permanent expandable implant after skin-sparing mastectomy (SSM) permits a 1-stage immediate breast reconstruction with an optimum breast shape. Preservation of most of the mammary skin after SSM on 1 side and anatomic prosthesis shape on the other makes breast reconstruction easier and enhances the quality of the esthetic results. The authors describe their experience with 40 immediate breast reconstructions after SSM performed over a period of 2 years explaining some technical details. The implant is placed in a submuscular pocket, or preferably, depending upon the condition of the muscles and skin flaps after mastectomy, in a submuscular-subfascial pocket. In this case, the undermining of the pocket is submuscular in its upper part under the major pectoralis muscle and subfascial in the lower part of the breast undermining the adipo-fascial tissues above the anterior serratus muscle. The submuscular dissection is done in continuity with the subfascial dissection to allow the complete closure of the soft tissues over the implant. In this case, the minor consistency of subfascial tissues compared with muscle in the inferior pole of the breast allows the easier and quicker distention of the soft tissue overlying the prosthesis during the inflation phase and ensures a good shape of the breast soon after surgery. Whenever possible, the mastectomy is performed through a periareolar skin incision that is closed with a purse-string suture. Finally, the authors discuss the indications of 2 different-shaped anatomic permanent expandable implants: full-height and short-height prostheses with different shape and fullness of the upper pole of the implant.     

“Tear-Drop Augmentation Mastopexy”: A Technique to Augment Superior Pole Hollow

Breast ptosis classification systems focus on the inferior descent of the nipple, as well as the descent and distribution of the breast parenchyma below the inframammary fold. Common problems, such as development of a superior pole hollow and an excessive width of the superior pole, extending into the axilla, are not addressed. Few procedures specifically address these deficiencies, and even less information is available in terms of preventative maneuvers when augmentation is desired as an adjunct. Round implants worsen the problem by creating a superior pole shelf, and anatomic implants are unreliable alternatives. Here, we present a technique—tear-drop augmentation mastopexy—that addresses superior pole hollow, excess superior pole width, as well as breast ptosis and hypomastia. Patients with moderate to severe breast ptosis (Regnaults classification), tubular breast deformity, and deformities secondary to previous breast surgery are included in the study. Skin is deepithelialized through a circumareolar incision, and a skin-fat flap is elevated completely encircling the breast. A 2-cm area of parenchyma is left attached to the skin in the lower half of the breast. Breast parenchyma in the superior half of the breast is then advanced and plicated in a superiomedial direction to move the nipple areolar complex to the desired new position. Care is taken to redefine the pectoralis major muscle at its axillary border. A 3-cm incision is then placed in the inferior part of the parenchyma at the 6 oclock position to create a subpectoral pocket for placement of the implant. The tunnel is then closed to separate the implant pocket from the subcutaneous dissection. Residual dermal flap is used to define, and add durability to the parenchyma reshaping procedure. A 3-0 mersiline (Ethicon, Somerville, NJ) blocking suture is used for a uniform circumareolar skin closure. Patients (n:35), ages 17–48, underwent tear-drop augmentation mastopexy between January 1999 and September 2002 for correction of the breast ptosis, tubular breast deformity, and deformities secondary to previous aesthetic breast surgery. The average follow-up was 2 years. All patients displayed type 1 or 2 (Baker classification) capsules. One subcutaneous hematoma and one subcutaneous seroma were seen, which were both treated by percutaneous aspiration. No submuscular hematomas, infections, skin or nipple losses, or hypertrophic scars were noted. Patient satisfaction was high. A more natural tear-drop breast shape was created with an improvement in the superior pole hollow and narrowing of the superior breast. The smallest breasts did not benefit from this technique for elimination of the superior pole shelf, as correction was proportional to the amount of breast tissue available for superior advancement. The tear-drop augmentation mastopexy is a novel technique for correction of the breast ptosis with augmentation, avoiding problematic development of superior pole hollow and excess superior width. This technique is also well applied to tubular breast deformity as well as to secondary breast procedures. Long-term follow-up demonstrates a safe and reproducible result with high patient satisfaction. This technique may solve several problems associated with breast ptosis surgery, which before were not specifically addressed, and the technique warrants further investigation.     

Acellular dermal matrix reduces capsule formation in two‐stage breast reconstruction

Acellular dermal matrix (ADM) is commonly employed to create an inferior pocket for the tissue expander in two‐stage breast reconstruction. The authors sought to determine whether placement of ADM during the first stage of reconstruction decreases the amount of capsule formation at implant exchange. Patients who underwent mastectomy and tissue expander reconstruction were included in this study. Two biopsies were obtained at the time of implant exchange, one from the pocket adjacent to the ADM and the other from the area adjacent to the pectoralis muscle. Pathology analysis was performed on each sample. Ten patients underwent immediate breast reconstruction with Alloderm during the 3‐month study period. Capsule thickness was significantly greater in the areas where the expander was in direct contact with the pectoralis muscle (782 ± 194 µm) compared to those in contact with human acellular dermal matrix (hADM) (47·91 ± 110·82 µm; P < 0·05). Analysis of the sub‐pectoral capsule demonstrated diffuse deposition of collagen, neutrophils, contractile myofibroblasts and synovia‐like metaplasia, characteristic of a foreign body response. Conversely, within the inferior pocket where the hADM was in direct contact with the expander, we noted migration of host epithelial cells, fibroblasts, mesenchymal cells and angiogenesis, indicating host tissue regeneration. Acellular dermal matrix, when placed at the first stage of breast reconstruction, significantly reduces thickness and inflammatory character of the capsule in comparison to the patient's native tissue.     

Update on one-stage immediate breast reconstruction with definitive prosthesis after sparing mastectomies

Immediate breast reconstruction after skin and nipple-sparing mastectomies is commonly performed as a two-stage procedure; to overcome the paradox of traditional two-stage tissue expander/implant reconstruction used to create a tight muscular pocket that needs expansion to produce lower pole fullness, while losing the laxity of the mastectomy skin flaps, the authors conceived a subpectoral-subfascial pocket by elevating the major pectoral muscle in continuity with the superficial pectoralis fascia up to the inframammary fold. This alteration allowed for the immediate insertion of the definitive implant.The authors present their experience in 220 cases of immediate one-stage breast reconstructions with definitive prostheses in sparing mastectomies. Immediate and long-term local complications were evaluated. Immediate breast reconstruction with definitive anatomical silicone-filled implants can produce excellent cosmetic results (78.6%) with a low rate of complications (17.7%); these results allow for agreement between oncologic, aesthetic and economic purposes.     

Muscle-Splitting Breast Augmentation: A New Pocket in a Different Plane

Background Breast augmentation usually is performed in subglandular, subfascial, or partial submuscular pockets, including the dual plane. A new pocket has been described and used by the author. The initial pocket was made in the subglandular plane up to the lower level of the nipple–areolar complex, and the submuscular plane was reached by splitting the pectoralis major muscle without its release from the costal margin. The implant lies in this plane simultaneously behind and in front of the pectoralis. Methods From October 2005 to November 2006, 125 patients underwent bilateral breast augmentation using the new technique. Soft cohesive gel microtextured round implants ranging in size from 230 to 440 ml were used. Results All the patients experienced a quick recovery with three-dimensional enhancement and having the benefits of both subglandular and submuscular planes. No rippling, lateral displacement, double-bubble deformity, or muscle contraction–associated deformities were seen. All the patients had aesthetically natural cleavage, with the nipple at the most projected part of the breast. Postoperative analgesia requirements were reduced because of dissection in natural planes. Conclusion For adequate cover of the prosthesis, only the upper part of the pectoralis major muscle is required. This can be achieved by using the pectoralis muscle-splitting technique. The pectoralis major was split in the direction of its fibers, avoiding extensive muscle release. Surgical morbidity was reduced, resulting in a quick postoperative recovery and a more natural three-dimensional appearance of the breast. Oral presentation at the 6th Croatian Congress of Plastic, Reconstructive, and Aesthetic Surgery, Optija–Rijeka, Croatia, 6–11 October 2006     

PR10DUAL PLANE BREAST AUGMENTATION FOR TUBEROUS BREAST DEFORMITY

The tuberous breast deformity is an uncommon congenital breast anomaly which affects young women unilaterally or bilaterally. It is associated with usually a constriction in the lower pole of the breast as a result of the constricting fibrous ring with hypoplasia of the breast gland and pseudo‐herniation of breast tissue into an enlarged areola. Several methods have been suggested to correct this deformity. A retrospective analysis has been undertaken of six consecutive patients with tuberous breast deformity using a dual plane breast augmentation via an inferior peri‐areolar approach creating a dual plane pocket and using Marionette sutures to control the lower pectoralis major edge. Surgical release of the constricting lower pole glandular tissue was undertaken with excellent aesthetic results. Either immediate or delayed areolar reduction was carried out if required. Results show excellent expansion of the lower pole with good soft tissue coverage of the implant by the pectoralis major in the supero‐medial aspect of the breast. The dual plane pocket combined with lower pole release assists lower pole expansion in a one stage procedure without requiring two stage tissue expansion. The results have been uniformly acceptable and compare favourably with those presented in the literature where other methods were used. The dual plane breast augmentation technique is a simple and reliable way to treat tuberous breast deformity.     

Superior Pedicle Mammaplasty without Parenchymal Incisions after Massive Weight Loss

Background: After considerable weight loss, the breast suffers significant deformation. The ptotic breast is characterized by a lack of superior pole, tissue excess in the inferior pole, down-migration of nipple-areola complex (NAC) with redundancy of skin tissue. The authors describe a mastopexy technique based on a modulated and progressive reshaping, back rotation, and suspension of mammary gland parenchyma without parenchymal incisions. Methods: Forty-five patients with bilateral moderate or severe breast ptosis underwent mastopexy from January 2011 to January 2014 with complete detachment of breast from the pectoralis major muscle and the plication of parenchyma without any parenchymal incision. Patients were followed up for one year, reporting any complication, and measuring the jugulum–NAC distance. The outcomes were assessed by the patients as well as the surgical team. Results: The aesthetic outcomes were good or excellent in all patients. The new mammary contour and the distance between the jugular fossa and the nipple were stable during this time with a good filling of upper pole. No major complications were reported. Conclusions: This technique gave good breast shape, long-term projection, and upper pole fullness, without parenchymal incisions. It restores breast shape and projection, especially in post-bariatric patients. A similar technique has not been described yet.     

Optimizing Outcomes in Breast Augmentation: Seven Years of Experience with the Subfascial Plane

Introduction: Breast augmentation has enjoyed worldwide acceptance in the last few decades. In order to optimize the outcomes of this operation, numerous variables such as incision location, pocket plane, implant design, and materials, and individual tissue characteristics must be carefully considered. Although no combination of choices may be considered superior, satisfactory results depend on adjusting the available options to each patient's requirements. In this paper, the authors present a seven-year experience with augmentation mammaplasty using the subfascial plane, analyzing important aspects of surgical technique, benefits and trade-offs when compared to other approaches, and the resulting outcomes. Method: A total of 241 primary and secondary breast augmentation procedures were performed over a seven-year period, employing anatomical high-cohesivity gel textured implants (McGhan 410 Style). After choosing the appropriate approach and performing the skin incision, dissection proceeds parallel to the skin (as in skin-sparing mastectomies) for approximately 4 cm. The breast's parenchyma is then incised in a radial direction (perpendicular to the skin incision) and vertically until the fascial layer is reached. Dissection of the implant's pocket is then performed in the well-defined subfascial plane. After insertion of the implants, the distance between the areola's inferior border and the inframammary fold should be approximately equal to 6–7 cm (or X). The distance between the areola's superior border and the uppermost point of the breast should be approximately equal to 9–10.5 cm (or 1.5X). Another important parameter is the distance between the implants, which should be approximately 2–3 cm. Finally, the distance between the areola's medial border and the midsternal line should be about 9–10 cm. Postoperative care issues are specified. Results: Pleasing long-term results have been obtained, with maintenance of a natural breast shape, a smooth transition between the soft tissues and implant in the upper pole, and low morbidity. The rate of capsular contracture was extremely low and there were no complaints regarding displacement of the implants with contraction of the pectoralis major muscle. Conclusion: The presented technique offers improved long-term aesthetic results due to the creation of a stronger supporting system for the implant's superior pole. This tends to keep the implant's upper third from altering its shape and position over time and combines the potential benefits of the subglandular approach with the improvements that may be achieved by having more tissue available to cover the implant's upper pole. The trade-offs of the subpectoral approach have been significantly reduced and factors such as morbidity and postoperative recovery are acceptable. The presented technique is extremely versatile and may also be used in patients requiring removal and replacement of breast implants.     

THE “-OMAS” and “-OPIAS”: Targeted and Philosophical Considerations Regarding Hamartomas,Choristomas, Teratomas,Ectopias, and Heterotopias in Pediatric Otorhinolaryngologic Pathology

The spectrum of “developmental” lesions that occur in the head and neck predominantly congenital in origin and arising at birth and/or discovered in childhood is broad and fascinating. These have been grouped into categories such as “ectopias”, “heterotopias”, “hamartomas”, and “choristomas”. On a philosophical and consequently systematic level, these lesions, mostly benign tumors seem to lack a true understanding of the pathogenetic foundation on which to base a more unified taxonomic designation. In this review, we will consider some of these select tumors as they represent syndromic associations (nasal chondromesenchymal hamartoma and DICER1 syndrome), the lingual choristoma from the perspective of its nomenclature and classification, lesions with ectopic meningothelial elements, and teratomas and the enigmatic “hairy polyp” in reference to a broader discussion of pathogenesis and pluripotent cells in the head and neck. A consistent thread will be how these lesions are designated with some final thoughts on future directions regarding the investigation of their pathogenesis and taxonomic nomenclature.     

Subpectoral breast augmentation through the abdominoplasty incision

Abdominoplasty and breast augmentation are often performed together, and subglandular augmentation through the abdominoplasty incision has been previously described. Nine cases of subpectoral breast augmentation and abdominoplasty performed through a single low transverse abdominal incision were performed between 2002 and 2005. The selection criteria included women who were healthy, nonsmokers, without true breast ptosis or breast deformity requiring additional shaping. The subpectoral space was accessed and the pectoralis major origins were mobilized under direct vision, and the implant pocket was shaped with the aid of a breast sizer and breast dissector. The mean follow-up was 22 months. The surgical goals were realized in all cases, with no asymmetry or implant-related complications. The standard abdominoplasty incision provides ample exposure for the creation of a subpectoral pocket and precise placement of implants. The procedure should be considered in patients who wish abdominal recontouring and breast augmentation and have minimal ptosis.     

Clinical Comparison of the “Windowing” Technique and the “Open Book” Technique in Schatzker Type II Tibial Plateau Fracture

ObjectiveSurgical treatment for Schatzker type II tibial plateau fractures remains challenging and requires high‐quality research. The aim of the study is to compare the “windowing” and “open book” techniques for the treatment of Schatzker type II tibial plateau fractures.MethodsIn this prospective study, all patients with Schatzker type II tibial plateau fractures between January 2014 and December 2017 were managed by open reduction and internal fixation using an anterolateral incision approach. “Windowing” group included 78 patients (53 men and 25 women), with an average age of 57.7 ± 13.5 years, who underwent the “windowing” technique, in which the procedure was performed through a small cortical window against the depressed zone of the lateral plateau. The “open book” group included 80 patients (56 men and 24 women), with an average age of 54.8 ± 12.4 years, who underwent the technique. The clinical outcomes included the Rasmussen classification of knee function and grading of post‐traumatic arthritis. The radiographic outcome (x‐ray and computed tomography [CT]) was the reduction quality of the lateral plateau based on the modified Rasmussen radiological assessment. The patient‐reported outcome was visual analogue scale (VAS) scores.ResultsThe mean follow‐up time for the158 patients was 32 months (range, 24–42 months). The time elapsed from injury to surgery in “windowing” group and “open book” group were 3.7 ± 1.2 (range, 1–10 days) and 3.5 ± 1.4 days (range, 1–11 days), respectively, with no significant difference between the groups (P > 0.05). The operation times did not differ significantly between the “windowing” group (61.0 ± 8.3 min, range, 45–120 min) and the “open book” group (61.2 ± 10.4 min, range, 40–123 min) (P > 0.05). After surgery, CT revealed five (6.4%) and 15 (18.8%) cases of articular depression in the “windowing” and “open book” groups, respectively. Significant differences were observed in the articular depression of tibial plateau fractures between the groups (P < 0.05). However, condylar widening or valgus/varus did not differ significantly between the groups. Furthermore, no significant differences in knee function were observed during follow‐up (P > 0.05). VAS scores were similar between the groups at 24 months after surgery (P > 0.05). There were significant differences in the number of severe post‐traumatic arthritis (grades 2 and 3) cases between the groups (P < 0.05).ConclusionsThe “windowing” and “open book” techniques are both effective for the treatment of Schatzker type II tibial plateau fractures. However, the “windowing” technique provides better reduction quality, leading to a satisfactory prognosis.     

Position Paper on the Value of Extended Adjuvant Therapy with Neratinib for Early HER2+/HR+ Breast Cancer

BackgroundIn August 2018, neratinib − an oral, irreversible pan-HER-tyrosine-kinase inhibitor − was approved by the European Commission for the extended adjuvant treatment of adult patients with early-stage, hormone receptor-positive (HR+), HER2 overexpressed/amplified (HER2+) breast cancer who completed trastuzumab-based adjuvant therapy within the last year. Despite recent improvements in long-term outcome, there is still an unmet need to further reduce the risk of recurrence, especially in patients with poor response to neoadjuvant treatment.SummaryNational and international guidelines included recommendations for using neratinib. Based on the health technology assessment for neratinib, the Federal Joint Committee (G-BA) in Germany has granted an added benefit for neratinib compared with the standard “watch and wait” strategies. Inclusion in the Reimbursement Code, however, was rejected by the Austrian social insurance companies in July 2020, and neratinib is now in the “No Box” for individual head physician reimbursement.Key MessagesWe analysed the value of extended adjuvant therapy with neratinib in early HER2+/HR+ breast cancer based on current data and made recommendations for the evidence-based and economical use of neratinib in Austria. In particular, prognostic factors associated with an increased risk of recurrence following standard therapy are considered. Extended adjuvant therapy should be offered primarily to nodal-positive patients at surgery. For nodal-negative patients, neratinib therapy may be considered in case of large and/or inflammatory primary tumours (T3–4) without pathological complete response after neoadjuvant therapy. For all other patients, neratinib may be considered depending on additional risk factors on an individual basis that should be evaluated by interdisciplinary tumour conferences.     

Hand Corticosteroid Injections in Patients on “Blood Thinners”

Background: Our study aims to identify any influence that anticoagulation and antiplatelet (“blood thinner”) medications have on hand and wrist corticosteroid injection complication rates. Methods: This retrospective chart review looked at patients between the ages of 18 and 89 years who received corticosteroid injections in the hand or wrist between 2013 and 2017, noting anticoagulation and antiplatelet use, demographics, injection placement, and surgical intervention. Results: Only 152 (20.9%) of the 726 diagnoses that were treated needed eventual surgical intervention. There were 12 overall reported complications after 1473 injections (0.8%). There were 6 complications after 433 injections (1.6%) placed in patients on blood thinners and 6 complications after 1040 injections (0.6%) placed in patients not on blood thinners. Conclusions: With the complication rate of corticosteroid injections being so low, even in patients taking “blood thinners,” the fear of adverse reactions should not preclude a physician from using this treatment modality to prevent surgical intervention.     

Single-Incision Laparoscopic Intraperitoneal Onlay Mesh Repair for the Treatment of Multiple Recurrent Inguinal Hernias

Introduction:

Despite an exponential rise in laparoscopic surgery for inguinal herniorrhaphy, overall recurrence rates have remained unchanged. Therefore, an increasing number of patients present with recurrent hernias after having failed anterior and laparoscopic repairs. This study reports our experience with single-incision laparoscopic (SIL) intraperitoneal onlay mesh (IPOM) repair for these hernias.

Materials and methods:

All patients referred with multiply recurrent inguinal hernias underwent SIL-IPOM from November 1 2009 to October 30 2013. A 2.5-cm infraumbilical incision was made and a SIL surgical port was placed intraperitoneally. Modified dissection techniques, namely, “chopsticks” and “inline” dissection, 5.5 mm/52 cm/30° angled laparoscope and conventional straight dissecting instruments were used. The peritoneum was incised above the symphysis pubis and dissection continued laterally and proximally raising an inferior flap, below a previous extraperitoneal mesh, while reducing any direct/indirect/femoral/cord lipoma before placement of antiadhesive mesh that was fixed into the pubic ramus as well as superiorly with nonabsorbable tacks before fixing its inferior border with fibrin sealant. The inferior peritoneal flap was then tacked back onto the mesh.

Results:

There were 9 male patients who underwent SIL-IPOM. Mean age was 55 years old and mean body mass index was 26.8 kg/m². Mean mesh size was 275 cm². Mean operation time was 125 minutes with hospital stay of 1 day and umbilical scar length of 21 mm at 4 weeks'' follow-up. There were no intraoperative/postoperative complications, port-site hernias, chronic groin pain, or recurrence with mean follow-up of 20 months.

Conclusions:

Multiply recurrent inguinal hernias after failed conventional anterior and laparoscopic repairs can be treated safely and efficiently with SIL-IPOM.     

国产充注式乳房假体62例应用报告

为了评估国产充注式乳房假体的临床效果，总结了１９９４年３月至１９９５年５月间手术的６２例１２３侧隆乳病例。假体由上海地区生产，容量２００～４５０ｍｌ，均置于胸大肌后间隙，术中假体作短暂性超定量注水，扩张周围组织。结果：１例假体因缝针误伤致术后乳房缩小，２例因伴乳房下垂欠满意，其余病例效果满意。３２例３个月随访时乳房外形对称，柔软，未见萎缩。认为，①国产充注式乳房假体的质量是好的。②术中假体短暂的超定量注水，扩张周围组织，优点明显，值得推荐。     

Subincisional muscular coverage of expander implants in immediate breast reconstruction with pectoralis flaps

Immediate breast reconstruction with expander implants is a safe, simple procedure that allows for a rapid physical and emotional postmastectomy recovery. When complications occur, the patient may be left with a prolonged reconstructive course. Such complications may result from thin mastectomy flaps and resulting marginal skin flap necrosis and implant exposure. Muscle coverage of the implant under the skin incision prevents such marginal necrosis of skin flap from becoming a factor in implant loss. This paper demonstrates a simple method for providing subincisional muscle coverage of expander implants with pectoralis muscle flaps. In this technique, a pocket is developed under the pectoralis muscle. The sternal origin of the pectoralis is released from the midsternal position to its inferior origin. The pectoralis muscle is then rotated inferior-laterally and sutured to the dermis of the underside of the inferior mastectomy skin flap, thereby providing subincisional muscle coverage of the expander implant. During a 5-year period, 42 patients between the ages of 36 and 61 underwent breast reconstruction utilizing this technique. In these patients, there were 4 instances of marginal necrosis. In each of these cases, the implants did not become exposed, and all patients completed the expansion process without significant delay and underwent subsequent implant exchange without incident. Five-year follow-up has shown good esthetic results in all patients.     

国产充注式乳房假体62例应用报告

为了评估国产充注式乳房假体的临床效果,总结了1994年3月至1995年5月间手术的62例123侧隆乳病例。假体由上海地区生产,容量200～450 ml,均置于胸大肌后间隙。术中假体作短暂性超定量注水,扩张周围组织。结果:1例假体因缝针误伤致术后乳房缩小,2例因伴乳房下垂欠满意,其余病例效果满意。32例3个月随访时乳房外形对称,柔软,未见萎缩。认为,①国产充注式乳房假体的质量是好的。②术中假体短暂的超定量注水,扩张周围组织,优点明显,值得推荐。     

“Motion-specific Headache”: A Predictor for Diagnosis and Favorable Prognosis after Surgery in Young Patients with Chiari Malformation Type 1

As headache is known as one of the most common symptoms in the patients with Chiari malformation type 1 (CM1), it is difficult to find out CM1-related headache among the symptoms because headache itself is commonly seen. Herein, we retrospectively review the cases of six CM1 patients complaining only of headache by which they complained of deterioration in daily life activities. The symptom of headache worsened during anteflexion (n = 2; 33%), retroflexion (n = 1; 17%), jumping (n = 3; 50%), going up the stairs (n = 1; 17%), and running (n = 1; 17%). Mean age at the onset was 15.7 years old (ranging 11–18) and four out of six were female. These inductive factors were clearly different from “Valsalva-like maneuvers,” although the mechanism might originate from dynamic tonsil changes. We named these headaches as “motion-specific.” These headaches radiated to the posterior side. MRI revealed that the extent of tonsillar ectopia was 11.3 mm, while syringomyelia was observed in three out of six patients (50%). All patients underwent surgical treatment, with the “motion-specific headache” completely disappearing 12.5 days thereafter. Although headaches are common, “motion-specific headache” may be a good candidate symptom to distinguish CM1 patients, especially among teenagers with headaches, and a good predictor for favorable outcomes after surgical treatment.