Albert Losken

Chest wall resections and reconstruction: a 25-year experience

BACKGROUND Chest wall defects continue to present a complicated treatment scenario for thoracic and reconstructive surgeons. The purpose of this study is to report our 25-year experience with chest wall resections and reconstructions. METHODS A retrospective review of 200 patients who had chest wall resections from 1975 to 2000 was performed. RESULTS Patient demographics included tobacco abuse, hypertension, diabetes mellitus, alcohol abuse, coronary artery disease, chronic obstructive pulmonary disease, and human immunodeficiency virus. Surgical indications included lung cancer, breast cancer, chest wall tumors, and severe pectus deformities. Twenty-nine patients had radiation necrosis and 31 patients had lung or chest wall infections. The mean number of ribs resected was 4 +/- 2 ribs. Fifty-six patients underwent sternal resections. In addition 14 patients underwent forequarter amputations. Immediate closure was performed in 195 patients whereas delayed closure was performed in 5 patients. Primary repair without the use of reconstructive techniques was possible in 43 patients. Synthetic chest wall reconstruction was performed using Prolene mesh, Marlex mesh, methyl methacrylate sandwich, Vicryl mesh, and polytetrafluoroethylene. Flaps utilized for soft tissue coverage were free flap (17 patients) and pedicled flap (96 patients). Mean postoperative length of stay was 14 +/- 14 days. Mean intensive care unit stay was 5 +/- 9 days. In-hospital and 30-day survival was 93%. CONCLUSIONS Chest wall resection with reconstruction utilizing synthetic mesh or local muscle flaps can be performed as a safe, effective one-stage surgical procedure for a variety of major chest wall defects.

Validating three-dimensional imaging of the breast.

The potential to extrapolate accurate data from 3-dimensional (3D) images of the breast is enormous and will greatly improve our ability to qualitatively determine differences in shape, size, and contour. The validity of these calculated measurements is important and needs to be determined before any meaningful data can be evaluated. Part I:Premastectomy 3D images (3dMD patient) were obtained on 19 breasts (14 patients). The volume of the mastectomy specimen was determined intraoperatively using water displacement. Two independent raters then calculated breast volumes using the 3D images and software, and these were compared with the intraoperative volume. Inter- and intrarater reliability was determined. Part II: Surface measurements (nipple to notch) were then evaluated on 20 breasts (10 patients) by comparing the 3D image determined distance to the known measurements. Part I:The average breast volume was 500 mL, compared with 489 mL for rater 1 and 490 mL for rater 2. The relative difference between the measured volume and the calculated volume for rater 1 and rater 2 was about −2%, with a standard deviation of ± 13% to 16%. The coefficient of reproducibility for each reader was excellent, at 0.80 for rater 1 and 0.92 for rater 2. The level of agreement between the readers was also high at 0.975. Part II: The average nipple to notch measurement for each patient was 27.1 cm, compared the calculated average of 25.1 cm for rater 1 and 26.1 cm for rater 2. The mean relative difference between the measured and calculated distances for raters 1 and 2 was about −6%, with a standard deviation of ± 6% to 7%. The level of agreement between readers was high, at 0.975. The ability to objectively determine breast volume and surface measurements using 3D imaging technology is now available with consistent and reproducible accuracy. Measurements are typically underestimated, with more variability when calculating volumes. Although inherent subjectivity will always exist when evaluating breast measurements, 3D technology provides invaluable information, particularly in the longitudinal evaluation of results.

Nipple reconstruction using the C-V flap technique: a long-term evaluation.

Numerous procedures are available for nipple reconstruction with no true universal favorite. This study presents long‐term follow‐up data for nipple reconstruction using the C‐V flap technique. Patients were identified by searching the Breast Reconstruction Database, and they were asked to return for a follow‐up visit. All those who underwent nipple reconstruction using the C‐V flap technique between January of 1992 and December of 1996 were reviewed in an attempt to conduct a long‐term follow‐up evaluation. The response was poor, and 11 patients participated in the study and returned for follow‐up. They all completed a questionnaire, which focused on patient satisfaction using a visual analogue scale. Nipple measurements were taken with a caliper and compared with the opposite breast for symmetry. Fourteen nipple reconstructions were evaluated in 11 patients with an average follow‐up of 5.3 years. All patients had undergone transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. Patient satisfaction was 42 percent with nipple projection, 62 percent with pigmentation, and 26 percent with sensation. Overall patient satisfaction with the procedure was 81 percent. Average nipple projection of the reconstructed nipple was 3.77 mm and was not statistically different when compared with the opposite nipple. Longterm subjective evaluation of the C‐V flap technique does report a loss in nipple projection; however, overall patient satisfaction at 5.3 years is good, as is the ability to restore symmetry with the opposite breast. (Plast. Reconstr. Surg. 108: 361, 2001.)

Return of lymphatic function after flap transfer for acute lymphedema

OBJECTIVE The goals of this work were to develop animal models of lymphedema and tissue flap transfer, and to observe physiologic changes in lymphatic function that occur in these models over time, both systemically with lymphoscintigraphy (LS) and locally using fluorescence microlymphangiography (FM). SUMMARY BACKGROUND DATA Although lymphedema has been managed by a combination of medical and surgical approaches, no effective long-term cure exists. Surgical attempts aimed at reconnecting impaired lymphatic channels or bypassing obstructed areas have failed. METHODS The tails of rats (A groups) and mice (B groups) were used because of their different features. Lymphedema was created by ligation of the lymphatics at the tail base and quantified by diameter measurements there. In the experimental group, rectus abdominis myocutaneous flap was transferred across the ligation. In addition to the ligation (A1 and B1) and ligation + flap (A2 and B2) groups, three control groups were included: sham flap with ligation (B4), sham flap alone (B5), and normal (A3 and B3) animals. Observations were made at weekly time points for lymphatic function and continuity. RESULTS Lymphedema was successfully created in the mouse ligation groups (B1 and B4) and sustained for the entire length of observation (up to 14 weeks). Lymphatic continuity was restored in those animals with transferred flaps across the ligation site (A2 and B2), as seen both by LS and FM. Sham flaps did not visibly affect lymphatic function nor did they cause any visible swelling in the tail. CONCLUSIONS Acute lymphedema developing after ligation of tail lymphatics in mice can be prevented by myocutaneous flap transfer. Restored lymphatic continuity and function were demonstrable using lymphoscintigraphy and fluorescence microlymphangiography.

Trends in unilateral breast reconstruction and management of the contralateral breast: The Emory experience

&NA; Recent trends in breast reconstruction have transitioned toward the skin‐sparing type of mastectomy and immediate reconstruction using autologous tissue. This study was designed to document trends in the management of patients with unilateral breast cancer and to determine how they influence management of the contralateral breast. All patients who underwent unilateral breast reconstruction at Emory University Hospitals from January of 1975 to December of 1999 were reviewed. The cohort was stratified by timing of reconstruction (immediate versus delayed), method of reconstruction, and mastectomy type (skin‐sparing versus non‐skin‐sparing). The methods of reconstruction included implant, latissimus dorsi flap, and transverse rectus abdominis musculocutaneous (TRAM) flap. Contralateral procedures to achieve symmetry included augmentation, mastopexy, augmentation/mastopexy, and reduction. A total of 1394 patients were evaluated, including 689 delayed and 705 immediate reconstructions. Sixty‐seven percent of delayed‐reconstruction patients (462 of 689) had a symmetry procedure performed on the opposite breast, compared with 22 percent for the immediate‐reconstruction patients (155 of 705) (p ≤ 0.001). The percentage of times a contralateral procedure was performed was highest for implant reconstructions (89 percent delayed and 57 percent immediate) and lowest for TRAM flap reconstructions (59 percent delayed and 18 percent immediate). Augmentation mammaplasty was the most common symmetry procedure for implant reconstruction (41 percent), whereas reduction was the most common procedure for autologous tissue reconstruction (57 percent). Immediate unilateral breast reconstructions were stratified into non‐skin‐sparing mastectomy (n = 205) and skin‐sparing mastectomy (n = 500). Thirty‐four percent of patients with a non‐skinsparing mastectomy defect (70 of 205) underwent a contralateral breast procedure, compared with 17 percent of patients with a skin‐sparing mastectomy defect (85 of 500) (p = 0.001). The percentage of times a contralateral procedure was performed in immediate reconstruction, stratified by mastectomy and reconstruction type, was only significant for TRAM flap reconstructions (25 versus 11 percent). Trends in the management of unilateral breast cancer from delayed to immediate reconstruction and from implants to autologous tissue have reduced the incidence of contralateral symmetry procedures. Reduction mammaplasty is the most common symmetry procedure used for autologous tissue reconstruction, with augmentation predominating when implants are used. The type of mastectomy also effects the management of the opposite breast, with skin‐sparing mastectomy further reducing the incidence of contralateral procedures in immediate TRAM flap reconstruction, compared with non‐skin‐sparing mastectomy.

A Meta-Analysis Comparing Breast Conservation Therapy Alone to the Oncoplastic Technique

AbstractWhen immediate reconstruction is applied to breast conservation therapy (BCT), the benefits extend well beyond the minimization of poor cosmetic results. The purpose of this analysis was to compare literature outcomes between BCT alone and BCT with the oncoplastic approach. MethodsA meta-analysis was performed in PubMed using key words “oncoplastic,” “partial breast reconstruction,” and “breast conservation therapy.” Case reports, series with less than 10 patients, and those with less than 1-year follow-up were excluded from the analysis. The 3 comparative groups included BCT with oncoplastic reduction techniques (Group A), BCT with oncoplastic flap techniques (Group B), and BCT alone (Group C). ResultsComparisons were made on 3165 patients in the BCT with oncoplastic group (Groups A and B, 41 papers) and 5494 patients in the BCT alone group (Group C, 20 papers). Demographics were similar, and tumor size was larger in the oncoplastic group (2.7 vs 1.2 cm). The weight of the lumpectomy specimen was 4 times larger in the oncoplastic group. The positive margin rate was significantly lower in the oncoplastic group (12% vs 21%, P < 0.0001). Reexcision was more common in the BCT alone group (14.6% vs 4%, P < 0.0001), however, completion mastectomy was more common in the oncoplastic group (6.5% vs 3.79%, P < 0.0001). The average follow-up was longer in the BCT alone group (64 vs 37 months). Local recurrence was 4% in the oncoplastic group and 7% in the BCT alone group. Satisfaction with the aesthetic outcome was significantly higher in the oncoplastic group (89.5% vs 82.9%, P < 0.001). ConclusionsThe oncoplastic approach to BCT allows a generous resection with subsequent reduction in positive margins. The true value on local recurrence remains to be determined. Patients are more satisfied with outcomes when the oncoplastic approach is used.

Management algorithm and outcome evaluation of partial mastectomy defects treated using reduction or mastopexy techniques

Background:Reconstruction of the partial mastectomy defect has become increasingly popular becaue of poor cosmetic results in select patients. The purpose of this series was to try to create a treatment algorithm based on patient selection, diagnosis, margins, and recurrence in an attempt to maintain oncologic safety, as well as to improve esthetic outcome. Methods:A retrospective review of all patients treated at Emory University Hospital with partial mastectomy and reduction/mastopexy was performed. Reconstruction was performed either simultaneously or following confirmation of negative histologic margins. Results:Sixty-three women were included in the series. Histology was invasive carcinoma (n = 33), ductal carcinoma in situ (DCIS) (n = 20), fibroadenoma (n = 6), and benign breast tissue (n = 4). The Wise pattern was used 84% of the time (n = 53/63). The most common tumor location was upper outer quadrant, and the various pedicles used were superomedial (n = 22), inferior (n = 20), central (n = 7), and other (n = 14). Eight patients had reduction/mastopexy once final pathology confirmed negative margins. The average biopsy weight was 236 g. Total specimen weight on the tumor side was 762 g and 858 g on the contralateral side, to accommodate for radiation fibrosis. Immediate complications were seen in 22% of cases and included delayed healing (n = 9), infection (n = 1), partial nipple loss (n = 1), hematoma (n = 1), and skin necrosis (n = 1). In patients with breast cancer (n = 53), 26% required either fine needle aspiration or excisional biopsy for cancer surveillance postoperatively. Oncoplastic surgery was the definitive procedure 93% of the time. Completion mastectomy with reconstruction was required in 4 patients, 3 for positive margins extensive DCIS and 1 for residual microcalcifications (stereobiopsy DCIS) despite adequate specimen radiograph and negative margins initially. All 4 patients who failed the combined approach were younger women with the diagnosis of extensive DCIS. The locoregional recurrence rate was 2%, and all patients had no evidence of disease at an average follow-up of 3.25 years. Conclusion:Therapeutic mammaplasty is a useful procedure for shape and symmetry preservation in women with large or ptotic breasts. Versatility exists using various pedicles and skin patterns to reconstruct all breast shapes and defect locations. Younger patients with extensive DCIS are poor candidates for simultaneous reconstruction, and should be deferred until confirmation of negative margins. If surgical management of residual disease requires completion mastectomy, immediate reconstruction is possible, with skin preservation and no adverse effects.

The role of reduction mammaplasty in reconstructing partial mastectomy defects

&NA; The management of breast tumors in women with macromastia can be challenging. Reconstructive options are limited and breast conservation therapy is often not indicated or results in poor cosmetic outcomes. The purpose of this report was to present a series of women with macromastia who underwent simultaneous reconstruction of a partial mastectomy defect with bilateral reduction mammaplasty. A retrospective review was performed and included all women who underwent partial mastectomy with simultaneous reduction mammaplasty. Data points included patient demographics, preoperative assessment, operative intervention, adjuvant treatment, and outcomes. Twenty women were included in the series (mean age, 43 years; range, 11 to 72 years) with an average body mass index of 32.6 (range, 24.9 to 44.1). Tissue diagnosis was ductal carcinoma (n = 8), ductal carcinoma in situ (n = 6), fibroadenoma (n = 4), and benign breast tissue (n = 2). The various reduction mammaplasty techniques were documented with regard to tumor size and location. The superior medial and inferior pedicles seemed to be the most versatile techniques. One patient required completion mastectomy with autologous tissue reconstruction given positive margins. All patients were disease‐free at follow‐up (mean, 23 months) and postoperative cancer surveillance was not impaired by the combined procedures. The versatility of reduction mammaplasty allows this procedure to be performed in conjunction with partial mastectomy for any tumor location. Combining these procedures in patients with macromastia provides numerous therapeutic benefits at low cost, while reducing breast distortion and preserving symmetry. (Plast. Reconstr. Surg. 109: 968, 2002.)

An objective evaluation of breast symmetry and shape differences using 3-dimensional images.

Background:The concept of natural breast asymmetry is well known; however, actual documentation in the literature is limited. New technology is currently available which provides 3-dimensional surface images of the breast and the ability to qualitatively determine differences in breast size, shape, and contour. The purpose of this report is to objectively determine the extent to which this natural breast asymmetry exists. Methods:Eighty-seven women without a history of breast cancer or previous breast surgery were included. Images were obtained using 3dMD technology. Data points queried included age, parity, body mass index (BMI), ethnicity, and bra size. Left/right images were superimposed and the distance between the 2 surfaces, and contour was calculated. The degree of asymmetry was determined and comparisons were made. Similar differences in nipple-to-notch measurements were calculated and compared. Subjective evaluations were included for clinical relevance. Results:The average age was 49.6 years (range: 19–77), with an average BMI of 25 (range: 18.5–36.7). The average nipple to notch on the left was 24.3 cm and 23.8 cm on the right. The nipple-to-notch asymmetry was on average 3.2%, with the left breast measurement being greater the majority of the time (62%). The mean distance between each breast demonstrated consistent breast asymmetry, with an average measurement of +0.5 mm (left breast being larger than the right). The degree of breast asymmetry was documented by a root mean square value (RMS) of 5.93 mm. This was not related to age, parity, or ethnicity; however, it was significantly higher in those patients with larger BMI, cup size, and chest-wall circumference. Only 10% of women were found to have severe breast asymmetry on subjective evaluation, which correlated objectively with the RMS in that group being significantly higher at 9.8 mm (P < 0.05). There were no predictable patterns of asymmetry; however, the most common pattern was larger laterally and smaller medially, found in 32% of the women. Conclusion:Natural breast asymmetry does exist, demonstrated objectively using 3-dimensional surfaces images. The left breast is on average larger than the right, with differences in size and shape being consistent but fairly unpredictable. It is important that we know baseline differences in breast symmetry prior to objectively analyzing results following esthetic and reconstructive breast surgery.

Results of immediate breast reconstruction after skin-sparing mastectomy.

Skin sparing mastectomy (SSM) removes the breast, nipple–areolar complex, previous biopsy incisions, and skin overlying superficial tumors. Preservation of the native skin envelope facilitates immediate breast reconstruction. The procedure has been adopted for the treatment of breast cancer. All cases of SSM and immediate breast reconstruction performed by the senior author (G.W.C.) from January 1, 1993, through December 12, 1997, were reviewed. Patient demographics, cancer staging, treatment, types of surgery performed, and postoperative outcomes were examined. Aesthetic outcomes were measured using four 3-point subscales. A total of 100 patients underwent 118 SSMs during the study period. The American Joint Committee on Cancer staging was as follows: stage 0, 27 patients; stage I, 25 patients; stage II, 39 patients; stage III, 7 patients; stage IV, 3 patients; recurrent, 2 patients; and cystosarcoma phylloides, 1 patient. The mean follow-up was 42.7 months. Local recurrence occurred in 2 patients (2.7%). Reconstructive methods included the transverse rectus abdominis musculocutaneous flap (N = 82; pedicled, 73; free, 9), the latissimus flap (N = 18), and tissue expansion (N = 20). Two patients underwent contralateral delayed reconstruction. The aesthetic results achievable with the three methods were similar. The failure rate was higher for expander reconstruction (10%) than those observed for transverse rectus abdominis musculocutaneous (4.9%) and latissimus (5.6%) flaps. SSM can be used in the treatment of invasive breast cancer without compromising local control. The aesthetic results of the three methods were similar, but tissue expander reconstruction had a higher failure rate.