A.K. Shah

Experience with the Mentor Contour Profile Becker-35 expandable implants in reconstructive breast surgery ) ,))

INTRODUCTION Round expander-implants (Beckers 25 and 50) and anatomical expander-prostheses filled with firm cohesive gel (McGhan Style 150) are established choices for single-stage expander breast reconstruction. Because of their drawbacks we selectively adopted the anatomical Becker-35 expander-implant filled with soft cohesive gel from January 2005. PATIENTS AND METHODS All patients undergoing reconstructive breast surgery using the Contour Profile Becker-35 expandable implant over a two-year period were retrospectively reviewed with respect to indication, implant sizes, inflation details, complications and outcomes. RESULTS 36 patients, mean age 48.9 years (r=14-69), received 39 anatomical Becker-35 expanders (three bilaterally). Three quarters of these implants (29) were used for immediate breast reconstruction while the remainder were equally divided between delayed postmastectomy reconstruction (5) and correction of congenital breast asymmetry (5). Half of the patients had simultaneous latissimus dorsi myocutaneous flap coverage of the implants. The median numbers of inflations and deflations needed to achieve the target expansion size and shape were 3 (r=0-7) and 0 (r=0-4), respectively. The mean time from expander insertion to completion of reconstruction was 4.6 months (r=0-13 months). Four patients required surgical intervention for haematoma, implant infection, severe capsular contracture, and palpable rippling. Additionally there were three injection port adjustments, giving a 20% overall revisional surgery rate (8/39 breasts) after a median follow-up of 20 months (r=6-38 months). Four implants (10%) developed significant but asymptomatic rippling. The significant capsular contracture rate was 21% (8/39 breasts), which was related to chest wall radiotherapy. CONCLUSION In this short-term study, the Becker-35 expander was successfully used for single-stage prosthetic breast reconstruction with an incidence of early complications comparable to alternative prostheses. Although it has expanded the range of implants available to the breast surgeon, its exact role in reconstructive breast surgery has yet to be established.

Mid-palm hand amputation: Reconstruction of the superficial palmar arch

1. Rohrich RJ, Gosman AA, Brown SA, Tonadapu P, Foster B. Current preferences for breast reduction techniques: a survey of board-certified plastic surgeons 2002. Plast Reconstr Surg 2004; 114(7):1724e33 [discussion 1734e6]. 2. Davison SP, Mesbahi AN, Ducic I, Sarcia M, Dayan J, Spear SL. The versatility of the superomedial pedicle with various skin reduction patterns. Plast Reconstr Surg 2007;120(6): 1466e76. 3. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg 1999;104(3): 748e59 [discussion 760e3]. 4. James A, Verheyden C. A retrospective study comparing patient outcomes of wise pattern-inferior pedicle and vertical patternmedial pedicle reduction mammoplasty. Ann Plast Surg 2011; 67(5):481e3.

Angiosarcoma of the breast following reconstructive surgery in the absence of radiotherapy or lymphoedema

Primary angiosarcomas following reconstructive surgery are thought to be attributable to radiotherapy or lymphoedema. We report the first case of a patient presenting with breast angiosarcoma demonstrating multiple morphologies (including the rare epithelioid subtype) arising after breast-conserving reconstruction for a previous adenocarcinoma, in the absence of these predisposing risk factors.Level of Evidence: Level V, diagnostic study

The congenital cleft nipple and its surgical treatment.

Congenital variations of the shape and structure of the nipple lacks coverage in the medical literature. We present four cases of a specific and unique congenital nipple anomaly, the cleft nipple. Each woman had a normal contralateral breast and nipple-areola complex. Three of the four cases were corrected surgically with no complications experienced. Included in the discussion is a description of the techniques used in the corrective surgery and a review of the current literature on associated variations of normality.

Histoacryl® to secure the microvascular venous anastomosis using the coupling device.

Venous coupling devices are used by many reconstructive microsurgeons as an aide in their microvascular venous anastomoses during free tissue transfer. They offer an effective, reliable, and fast method for anastomosis with equivalent patency rates when compared with standard suture techniques. The current coupling device, the GEM Coupler, was initially manufactured by 3M Healthcare (St Paul, Minn.) and is currently manufactured by Synovis Micro Companies Alliance, a subsidiary of Synovis Life Technologies (St. Paul, Minn.). The coupling device consists of two disposable rings made of high-density polyethylene, with a series of six to eight (depending on the size of the coupler) stainless steel pins evenly spaced around each ring. The rings are manufactured with inner diameters that range in size from 1.0 to 4.0 mm, allowing anastomoses of vessels that are 1.0–4.0 mm in diameter. The coupler application process involves several steps, once the appropriately sized device is selected, and the two veins are in close proximity, including attaching the donor and recipient veins to their individual coupling components, mating the vessel ends by rotating the instrument knob and using forceps to compress the two rings together as they are pushed out of the instrument. The force of the coupler device is sometimes inadequate to fully pierce the opposing vessel wall with the pins and ensure a tight apposition of the interlocking Figure 1. The GEM Coupler bridging the microvascular venous anastomosis after the application and curing of Histoacryl. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

The "periosteal anchor stitch": opening up the surgical field.

Recent trends in autologous breast reconstruction have moved away from use of the thoracodorsal vessels to use of the internal mammary vessels as the first-choice recipient site. The use of the internal mammary vessels may provide for a shorter operative time and a higher-quality aesthetic reconstruction as they allow medial placement of a flap. However their main disadvantage is the limited exposure of the vessels provided by removal of a segment of the rib cartilage. Clinical and anatomical studies of the internal mammary vessels suggest that the most appropriate sized portion of the recipient artery and vein for microanastomosis are located at the third intercostal space. Most surgeons therefore resect a segment of the third costal cartilage and rib. This is the basis of our practice. Where possible mastectomy scars are periareolar, or positioned as a transverse incision across the breast at the level of the nipple. In the male, the nipple is located over the 4th intercostal space, however this position is not reliable in women and may be considerably lower. As a result the edge of the upper, medial skin flap of a mastectomy overlaps the operative site, and thus requires retraction. This is especially so in immediate reconstructions. The fibers of the pectoralis major muscle are split to expose the third costal cartilage and also require retraction. One of the keys to maximize microsurgical efficiency is to create a wide, clear stable operative field. This means minimizing instrumentation including the number of retractors and pairs of hands. This can be achieved by the use of self-retaining retractors. The design of self-retainers such as the West’s and Travers’ is such that both limbs open outwards at equal distance from the central hinge-point. To provide adequate exposure of the third intercostal space a greater force for retraction is required on the upper, medial skin flap than on the lower skin flap. If both claws are positioned solely on the skin flaps or pectoralis major muscle, the self-retainer drifts caudally and laterally. The muscle is torn and the upper medial skin flap obscures the operative site. To overcome these problems, we use an anchoring suture for the lateral arm of our self-retaining retractor. Using a round bodied needle, a loose, double suture of 0 nylon is placed in the third costal cartilage 1 to 2 cm lateral to the planned cartilage excision. A double suture is used to spread the load and prevent tearing out. Silk was used initially, but this does not glide through the cartilage as easily as a monofilament suture. Once the first quarter of the needle is in the cartilage, the rest of the needle is ‘‘pushed’’ through, thus allowing the curve of the needle to come through the firm cartilage. The claw of the lateral arm of the self-retaining retractor is hooked into the loops of this suture, thereby providing an anchor point for retraction laterally (see Fig. 1). The retractor is opened with the medial claw retracting the upper medial portion of the mastectomy flap and split pectoralis major medially. This prevents stripping of the muscle laterally, allows for maximal medial retraction and exposure of the recipient vessels for further dissection and provides stability to the operative site for subsequent microsurgical anastomosis. We describe a surgical technique to improve the surgical exposure of the internal mammary recipient vessels. We *Correspondence to: Amit K. Shah, M.A.(Hons) M.B./B.Chir. M.R.C.S.(Eng), ST-4 Plastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK. E-mail: as329@hotmail.com

Deltopectoral groove full-thickness skin graft donor site for head and neck skin cancer excisions

Skin grafts have long been a main stay in the reconstruction of skin cancer excision defects. Sun-exposed areas such as the head and neck are common sites for skin cancer and, therefore, postexcision reconstruction. Donor sites for full-thickness skin grafts are myriad. Several sites are well established such as the supraclavicular fossa, inner arm, groin and periauricular regions. We propose the use of the deltopectoral groove as a donor site for reconstruction of selected, larger head and neck skin cancer excision defects. A large graft can be harvested, up to a 12 cm 7 cm skin ellipse in elderly elastic skin. There are

Malignant melanoma re-excision specimens: the need for analysis.

We read McGoldrick’s et al. article titled ‘Malignant melanoma re-excision specimens: is there a need for histopathological specimens’ with much interest. We can only commend their study, the significant numbers audited and its forthright application. However, we have reservations regarding their recommendation stated in their article ‘.that all specimens taken from melanomas that have had originally clear excision biopsies need not be sent for histopathological examination.’ One of the reasons for this difference in opinion lies with three similar cases managed in our unit within the last five years. The most recent case