“Silicone lymphadenopathia” following augmentation mammaplasty

Summary One year after augmentation mammaplasty the axillary lymph nodes on both sides were found to be heavily loaded with material deriving from the intact gel-filled retromammary prostheses. The histologic and electron microscopic findings were confirmed by the microchemical analyses (Si K--radiation). The route of lymphatic drainage of the material and the differential diagnosis from other storage diseases are discussed and the importance of further observation of distant scattering of Silicone implant particles is emphasized.     

“False bursa” concept in augmentation mammaplasty

Natural feeling breasts are a primary objective to be achieved in the augmentation mammaplasty procedure. Rather than attempt to totally prevent a fibrous capsule from forming about the implant, it should be converted into a larger false bursa containing a freely mobile soft implant of modern design with no fixation patches. This relationship must be maintained through many months of the postoperative period to ensure a lasting result. Failure to achieve the false bursa concept results in a tight immobile noncompressible breast that has an unnatural feel.     

“No-Touch” submuscular saline breast augmentation technique

This article represents a retrospective view of the author's 17-year experience with 2863 saline implants in 1327 patients and details his no-touch technique. The experience included almost an equal number of submammary and subpectoral procedures. The submammary procedures were done early on and were replaced with subpectoral procedures, done exclusively at the present time. There were significantly less complications-capsules, wrinkling (visible folds), and deflations-with the subpectoral procedures. Followup is longer for submammary procedures which could be the reason for the slight difference in number of deflations. Analyzing the results from three different periods, during which the technique changed, the last period in which the no-touch subpectoral technique was used had markedly fewer complications. The no-touch technique, which had been introduced in orthopedic surgery over 50 years ago, was added to the augmentation procedure in an attempt to eliminate any possible contact with skin or breast bacteria. There were no infections in the entire series, and, during the no-touch period, capsules were almost eliminated (0.6%). Saline implants can achieve excellent results when placed subpectorally using the no-touch technique.Presented at ASPRS, PSEF, ASMA 61 st Annual Scientific Meeting, Washington, D.C., September 20–24, 1992     

Silicone or saline - filled implants for breast augmentation?

The use is to oppose silicone and saline implants. Both are used in regular practice. What are the arguments to choose in between the two types? We separated three different criteria groups: prosthesis characteristics, surgical procedures and complications. For each criterion we made a review of literature looking for arguments in favour or against silicone or saline implants. The number of criteria to choose the correct type of prosthesis is very important. We conclude that surgeon experience; desires of the patient and evolution of prosthesis are the most important criteria.     

Slotted acetabular augmentation: is a hip spica necessary?

Between 1988 and 1996, 16 patients who underwent a total of 18 slotted acetabular augmentation procedures were managed postoperatively without a spica cast, by using instead a protocol of limited weight bearing and restriction of hip range of motion. Postoperatively, no patients experienced hip stiffness. No patients exhibited any migration or change of position of their bone graft. Radiographic examination revealed the following: center-edge angle (CEA) averaged 3 degrees preoperatively and 54 degrees postoperatively. Acetabular index averaged 35 degrees preoperatively and 18 degrees postoperatively. No patients experienced any deleterious effects by not using a spica cast. We believe that by obviating the spica cast, we may ease the postoperative recovery for patients, avoid postoperative hip stiffness, and thereby expand the applications of this safe and reliable method of acetabular reconstruction in selected patients.     

Chronic deltoid ligament insufficiency repair with Internal Brace™ augmentation

BackgroundPatients with chronic deltoid ligament insufficiency (CDLI) present a challenging situation. Although numerous procedures have been described, optimal treatment is still a matter of debate. While the treatment armamentarium ranges from simple ligament repair to complex reconstructions with or without realignment osteotomies, direct repair augmented with an Internal Brace? device appears to be an attractive intermediate option. We investigated functional outcomes and complications in patients with CDLI operated on using Internal Brace? augmentation.MethodsA prospective study was conducted. Patients were included if they presented medial ankle pain and/or giving way, exhibited asymmetric flexible hindfoot valgus, failed conservative treatment, and had a positive MRI evaluated by an independent radiologist. Patients with stage IV flatfoot deformity, neuropathy and/or inflammatory arthritis were excluded. CDLI was confirmed intraoperatively with the arthroscopic drive-through sign. Patients were evaluated preoperatively and postoperatively using FAAM, SF-36 and grade of satisfaction. Paired t-tests were used to assess FAAM and SF-36 scores variation.ResultsThirteen patients met inclusion criteria. No patient was lost to follow-up, with a mean follow-up time of 13.5 months (range 6-21). Preoperative FAAM and SF-36 scores improved from 58.7 to 75.3 and from 60.2 to 84.4 postoperatively, respectively (p<.01). Two implant failures were observed, with no apparent compromise of construct stability. No patient was re-operated.ConclusionsOur results suggest that deltoid ligament repair with Internal Brace? augmentation in patients with CDLI is a reliable option with good functional outcomes and high satisfaction grade in short term follow-up.Level of evidence: Level IV.     

Quo vadis? Ureteric reimplantation or ignoring reflux during augmentation cystoplasty

OBJECTIVE: To decide whether antireflux surgery should be used in the presence of vesico-ureteric reflux (VUR) in children, in whom an augmentation procedure is needed, because secondary VUR in children with a neurogenic bladder, infravesical obstruction and primary VUR in the exstrophy-epispadias complex is expected to resolve after augmentation, which decreases the intravesical pressure and increases capacity. PATIENTS AND METHODS: Between 1987 and 2001, the bladder was augmented in 38 children, using no antireflux surgery in group 1 (15 patients) and antireflux surgery in group 2 (23 patients). RESULTS: VUR was detected in all patients on cysto-urethrography before surgery; reflux resolved after augmentation cystoplasty in 97% and 93% of refluxing units in groups 1 and 2, respectively. The increase in the expected bladder capacity was from 35% to 86% in group 1 and from 38% to 90% in group 2. No patient had any deterioration in renal function. CONCLUSIONS: We recommend using only augmentation in patients with low- or high-grade VUR and a neurogenic bladder, infravesical obstruction and exstrophy-epispadias. Combining antireflux surgery with cystoplasty has no significant effect on either the resolution of VUR or renal function.     

Routine needle biopsy during vertebral augmentation procedures. Is it necessary?

Vertebral augmentation procedures are currently widely performed to treat vertebral compression fractures. The purpose of this study was to determine the frequency of underlying previously unrecognized etiology in a consecutive series of patients undergoing kyphoplasty to treat vertebral compression fractures. A prospective histological evaluation of vertebral body biopsy specimens from presumed osteoporotic vertebral compression fractures were performed in order to identify aforementioned causes. Over a 2-year period, vertebral body biopsies from 154 vertebral levels were performed in 75 patients undergoing kyphoplasty for vertebral compression fractures. All patients received a preoperative workup that included plain radiographs, MRI, whole body bone scan, and laboratory examinations. Bone specimens were obtained from affected vertebral bodies and submitted for histologic evaluation to identify the prevalence of an underlying cause. All specimens demonstrated fragmented bone with variable amounts of unmineralised bone, signs of bone-remodeling and/or fracture-healing. In 11 patients underlying pathology other than osteoporosis was identified (prostate cancer, 1; pancreatic cancer, 1; colon cancer, 1; breast cancer, 2; multiple myeloma, 3; leukemia, 1; and lung cancer, 2). In all but one patient the results of the biopsy confirmed the diagnosis suspected from the preoperative workup. For the last patient, namely the one with pancreatic cancer, the workup did not identify the origin of the primary tumor, although the patient was considered to have a compression fracture secondary to metastatic disease of unknown origin, the vertebral biopsy suggested the presence of adenocarcinoma which eventually was proven to be pancreatic cancer. In augmentation procedures for vertebral compression fractures, bone biopsy should be reserved for the patients where the preoperative evaluation raises the suspicion of a non-osteoporotic etiology.     

Enterocystoplasty or detrusor myectomy? Comparison of indications and outcomes for bladder augmentation

PURPOSE: We review our experience with enterocystoplasty and detrusor myectomy to delineate clinical indications and compare operative outcomes with both types of bladder augmentation. MATERIALS AND METHODS: Retrospective analysis of 61 patients who had undergone a total of 37 detrusor myectomies and 32 enterocystoplasties was performed. The patients were categorized into 6 diagnostic subsets representative of the clinical spectrum of indications for bladder augmentation. RESULTS: For most clinical indications detrusor myectomy offered comparable success or significant improvement in bladder function without incurring the significant complication rate of enterocystoplasty. CONCLUSIONS: Detrusor myectomy is a safe, successful method of bladder augmentation for most clinical indications. Myectomy does not hinder subsequent creation of an enterocystoplasty.     

Experience and technical refinements in the “donut” mastopexy with augmentation mammaplasty

Minor ptosis and pseudoptosis of the breast may be corrected by a donut mastopexy. This technique offers the opportunity to reach a good aesthetic result with minimal scarring. A prosthesis is inserted at the time of the mastopexy and the skin is reduced in an elliptical way to achieve a good balance between the breast volume and the skin envelope.     

Submuscle saline breast augmentation: are we making sense in the new millenium?

Historically, it appears that the problems of capsule contracture, the alleged risk of human adjuvant disease, and the problems due to migration of smooth walled breast prosthesis have had a major impact on the techniques used in breast augmentation. As a consequence of the above, the primary cosmetic goal may have been lost (a naturally enlarged aesthetic breast). It is suggested, that from a purely cosmetic point of view, that the best result is obtained with a subglandular textured gel prosthesis. Reasons for selecting this method are advanced and well documented limitations to the submuscle pocket are highlighted. Various incisions are also discussed. The inframammary fold is a critical landmark of the breast and should not be violated in a cosmetic procedure.     

A novel “pelvic ring augmentation construct” for lumbo-pelvic reconstruction in tumour surgery

Aim

Reconstructing or augmenting the lumbo-pelvic junction after resection of L5 and part of the sacrum is challenging. Numerous lumbo-pelvic reconstruction methods based on posterior construct and anterior cages have been proposed for cases involving total sacrectomy and lumbar vertebrectomy. These constructs create long lever arms and generate high cantilever forces across the lumbo-sacral junction, resulting in implant failure or breakage. Biomechanical studies have shown that placing implants anterior to lumbo-sacral pivot point provides a more effective moment arm to resist flexion force and improves the ultimate strength of the construct. We present here a novel method to augment a lumbo-pelvic construction using a pelvic ring construct.

Methods

A 69-year-old lady presented with implant failure of her two previous posterior lumbo-pelvic reconstructions performed by the authors. She initially presented, two and a half years previously with 6?months?history of back pain with normal neurological function. MRI scans of her whole spine showed isolated secondaries in the lumbar spine (L4, L5) and sacrum (S1). An abdominal CT scan revealed a primary tumour in her right kidney. Briefly, the first surgery involved a single-stage removal of posterior elements of L4 and L5 and posterior stabilisation from L2 to pelvis, anterior resection of L4 and L5 and partially S1 with implantation of an expandable Synex II cage. The cage was replaced with an anterior rod construct from L2 and L3 to a trans-sacral screw a week later as it had dislodged. The second revision, 9?months later, involved removal of two posterior broken rods which were replaced and converted into a modified four-rod construct. While monitoring her progress, it was subsequently noted that the trans-sacral rod had broken. Therefore, it was decided to augment her lumbo-pelvic construct to prevent eventual catastrophic posterior construct failure. From a posterior approach, contoured rods were passed bilaterally along the inner table of the pelvis under the iliacus muscle up to the anterior border of the pelvis. Using T-connectors, the rods were connected to the posterior lumbo-pelvic construct. Thereafter, two anterior supra-acetabular pelvic screws were connected to a subcutaneously placed rod matched to the shape of the anterior abdominal wall. The pelvic ring construct was completed on connecting this rod with T-connectors to the free ends of the contoured iliac rods.

Results and conclusion

There were no intra-operative complications. At the end of 12?months, she was mobilising with a frame, with no radiological evidence of failure of the construct. However, she died due to disease progression at the end of 15?months. Experience from one clinical case shows that such a construct is feasible and adds a technical option to the difficult reconstruction of lumbo-pelvic junction after tumour surgery.