Charles M. Malata

Incidence of severe capsular contracture following implant-based immediate breast reconstruction with or without postoperative chest wall radiotherapy using 40 Gray in 15 fractions

PURPOSE To determine the incidence of capsular contracture (CC) requiring revisional surgery in patients receiving postoperative radiotherapy (RT) or no RT following mastectomy and immediate breast reconstruction. MATERIAL AND METHODS One hundred and seventy-eight immediate breast reconstructions performed at the Cambridge Breast Unit between 1.1.2001 and 31.12.2005 were identified. RT was delivered using a standard UK scheme of 40 Gray in 15 fractions over 3 weeks. The influence of hormones and chemotherapy as well as postoperative RT on time to development of severe CC after implant-based reconstruction was explored in univariate and multivariate analysis. RESULTS One hundred and ten patients had implant-based reconstructions with a median follow-up of 51 months. In the RT group (41 patients), there were 8 patients with severe CC requiring revisional surgery, a crude rate of 19.5%, with actuarial rates of 0%, 5%, 5%, 21%, 30% and 30% at 1, 2, 3, 4, 5 and 6 years follow-up. In the unirradiated group, there were no cases of severe CC. This difference is highly significant (p<0.001). Hormones and chemotherapy were not significantly associated with severe CC. CONCLUSIONS This series showed a significantly higher rate of severe CC with postoperative RT. This finding has important clinical implications, when counselling patients for immediate breast reconstruction.

Textured or smooth implants for breast augmentation? Three year follow-up of a prospective randomised controlled trial

Silicone breast implant surface texturing has been shown to reduce the short-term incidence of adverse (Baker III/IV) capsular contracture in augmentation mammaplasty in double-blind randomised controlled trials. It is, however, undetermined whether the textured surface merely delays the onset of severe contracture or its effect on capsular contraction is persistent. The current study reviewed, after three years, 49 of the 53 patients who had undergone subglandular breast augmentation mammaplasty in a randomised double-blind study with textured or smooth silicone gel-filled implants in 1989. The incidence of adverse capsular contracture was 59% for smooth implants and 11% for textured ones (P = 0.001; chi 2 = 10.60). Eight patients (31%) with smooth prostheses underwent breast implant exchange for severe capsular contracture between the one and three year assessments, compared with a revisional surgery rate of only 7.4% (2/27 patients) for the textured group (P < 0.04). These adverse capsular contracture and revisional breast implant surgery rates clearly demonstrate that the effect of textured implants in reducing capsular contracture in augmentation mammaplasty found at one year is maintained at three years, and suggest that it may be long lasting.

A systematic approach to the surgical treatment of gynaecomastia

Numerous techniques have been described for the correction of gynaecomastia, and the surgeon is faced with a wide range of excisional and liposuction procedures. There is a paucity of literature describing an integrated approach to the management of this condition and the roles of the different treatment modalities. A review of all gynaecomastia patients operated on by one surgeon over a 2-year period was undertaken. Patient satisfaction was assessed using a linear analogue scale with a maximum score of 10. In total, 48 breasts in 29 patients were treated--31 breasts by liposuction alone (19 by conventional liposuction, 12 by ultrasound-assisted liposuction), eight breasts by liposuction and open excision, and nine breasts by liposuction, open excision and skin reduction (concentric or Lejour mastopexy). There were no early postoperative complications, such as haematoma, seroma or infection, and 91% of patients were very satisfied (score: 8-10) with their cosmetic outcome. The most frequently encountered complication was a residual subareolar lump (five breasts), all in patients treated by conventional liposuction alone. In order to avoid the common complication of an uncomfortable residual subareolar nodule, the threshold for open excision in patients undergoing conventional liposuction should be low. Ultrasound-assisted liposuction extends the role of liposuction in gynaecomastia patients. Although skin excess remains a challenge, it can be satisfactorily managed without excessive scarring. A practical approach to the surgical management of gynaecomastia, which takes into account breast size, consistency, skin excess and skin quality, is proposed.

Ultrasonic liposuction in the treatment of gynecomastia.

Background: Ultrasound-assisted liposuction is a technique that is widely used all over the body for minimal access lipectomy. Recently, it has been reported to be especially suitable for the treatment of gynecomastia. To date, however, there is only one published study that specifically addresses ultrasound-assisted liposuction as a treatment modality for gynecomastia. Methods: A review was undertaken of all the gynecomastia patients treated with ultrasound-assisted liposuction by a single surgeon over a 3-year period. Thirteen consecutive patients (aged 16 to 57 years) with bilateral, diffuse, soft to moderately firm gynecomastia were studied. Results: There were no early postoperative complications of hematoma, seroma, infection, or thermal injury. Similarly, there were no treatment-induced asymmetries, contour deformities, or irregularities. One patient requested “touch-up” ultrasound-assisted liposuction for “residual” breast tissue several months after an initial satisfactory correction of chest contour. None of the patients required initial open-excision or skin-reduction procedures. Patients were asked to rate their cosmetic results in four categories on linear analogue scales with a maximal score of 10. The average scores were 9.1 for overall satisfaction, 9.2 for scars, 9.2 for shape, and 8.9 for improved self confidence. Conclusion: Ultrasound-assisted liposuction is an effective treatment modality in patients with homogenous soft to moderately firm gynecomastia, giving good cosmetic results and a high level of patient satisfaction.

Early experience with an anatomical soft cohesive silicone gel prosthesis in cosmetic and reconstructive breast implant surgery

Recently, an anatomic breast implant filled with soft cohesive silicone gel was introduced by Mentor Medical Systems onto the European market. This study reports the early experience of a single surgeon with this implant. All patients who received a Contour Profile Gel (CPG) implant from March 2001 to October 2002 were studied. Patient satisfaction with breast shape and consistency was assessed using linear analogue scales with a maximum score of 10. Thirty-five patients received CPG implants for cosmetic (10 patients, 20 breasts) and reconstructive (25 patients, 31 breasts) surgery purposes. Patients were satisfied with their breast shape (mean score: 8.3). Eighty-five percent of the breasts were rated as soft (score ≥6). No serious esthetic complications such as implant malposition or significant capsular contracture were observed. Anatomic soft cohesive gel implants provide excellent results in selected cases. They are well accepted by patients and not associated with an increased rate of complications.

An algorithmic approach to abdominal flap breast reconstruction in patients with pre-existing scars – results from a single surgeon's experience

BACKGROUND Breast reconstruction using the TRAM flap and its variations in patients with pre-existing abdominal scars is controversial. In our practice, abdominal scars are considered not to be a contraindication for such reconstruction. We therefore reviewed our experience and reconstructive strategies adopted in such patients over a 7-year period. METHODS Patients with previous abdominal scars undergoing abdominal flap breast reconstruction performed by a single surgeon (Jan 2000-Dec 2006) were retrospectively reviewed with respect to scar types, reconstructive approach, flap outcomes and donor-site complications. RESULTS Thirty patients (mean age=52 years) with pre-existing scars (midline, Pfannenstiel, subcostal, appendicectomy, etc.) underwent unilateral (n=24) or bilateral (n=6) breast reconstruction (36 flaps). The flap design strategies employed included splitting the flap (hemi-TRAM), skewing it to avoid abdominal scars, minimal abdominoplasty flap undermining and selective use of DIEP, SIEA, free and pedicled TRAM flaps. There were no free flap failures (0/30), except for one pedicled TRAM flap failure (one out of six). One bilateral DIEP reconstruction patient developed an abdominal bulge requiring mesh repair. No significant wound dehiscence or frank abdominal hernias were recorded. CONCLUSION Pre-existing scars are not an absolute contraindication to abdominal flap breast reconstruction. With careful preoperative planning and adoption of appropriate reconstructive strategies, it is possible to achieve satisfactory results comparable to patients without abdominal scars. An algorithmic approach to the selection of the relevant techniques is presented.

An application of the LeJour vertical mammaplasty pattern for skin-sparing mastectomy: a preliminary report.

An application of the LeJour vertical mammaplasty skin pattern for skin-sparing mastectomy is presented. The approach provides adequate access for the mastectomy, axillary dissection, and immediate breast reconstruction. The technique is ideal for patients with large or ptotic breasts undergoing a simultaneous contralateral breast reduction or mastopexy. It is particularly suitable for autogenous tissue reconstruction. Its use in mastectomies for cancer and prophylactic subcutaneous mastectomies is described.

Implant-Based Breast Reconstruction Following Mastectomy1

: Post-mastectomy breast reconstruction with prostheses can be performed immediately at the time of mastectomy or delayed for several months or years. It falls into three main categories namely implant-only, expander-implant and expandable implant reconstruction. Sometimes it is combined with the latissimus dorsi myocutaneous flap. Logistically prosthetic reconstruction can be single-stage (with implant-only or expandable implants) or two-stage (traditional expander-implant technique). Over the last decade a wide variety of prostheses has become available which materially vary in shape, surface and consistency. Prosthetic breast reconstruction provides satisfactory results in properly selected patients and has the advantages of simplicity, shorter operating time, hospital stay and recuperation. Additionally there are no extra scars or distant donor site morbidity. It is, however, more prone to additional unplanned revisional surgical procedures than autogenous tissue reconstruction. In general two-stage reconstruction gives more predictable results as it gives the surgeon the opportunity to adjust the reconstruction at the planned 2nd stage, while in practice, single stage reconstruction may be more prone to unplanned revisional surgery. The best results are obtained in patients with small minimally ptotic breasts while those with larger and/or more ptotic breasts often require a contralateral balancing procedure to achieve symmetry. This paper outlines the surgical options and the prosthetic range available at present.

Use of anterolateral thigh and lateral arm fasciocutaneous free flaps in lateral skull base reconstruction.

Lateral skull base defects following tumor ablation are ideally reconstructed with microvascular free tissue transfer. Although the rectus abdominis free flap is the workhorse in skull base reconstruction, it has a number of drawbacks. Anecdotal reports have indicated that fasciocutaneous free flaps may be useful alternatives in selected cases. Patients undergoing lateral arm (4 cases) or anterolateral thigh (8 cases) fasciocutaneous free flap reconstruction of lateral skull base defects between 1999 and 2005 were therefore reviewed. Twelve consecutive patients (4 males, 8 females) with a mean age of 63 years (range, 39 to 74) underwent such reconstruction following resection of lateral (11 cases) and anterolateral (1 case) skull base lesions. Eight patients had squamous cell carcinoma, 3 had infection or osteoradionecrosis, and 1 had adenoid cystic carcinoma. The duration of surgery (from induction of anesthesia to exit from the operating room) averaged 14.5 hours (range, 10 to 19.5 hours). All donor sites were closed directly. All the flap transfers were successful, with minimal reconstructive and donor site morbidity. During the follow-up period (average, 18 months; range, 2–48 months), 2 patients died of metastatic disease, and another 2 died of other unrelated causes. The remaining 8 patients are alive and disease free. It is concluded that lateral arm and anterolateral thigh fasciocutaneous free flaps should be considered as viable reconstructive options for lateral skull base ablative defects.

Anterolateral thigh free flap for complex composite central chest wall defect reconstruction with extrathoracic microvascular anastomoses.

Background: Complex central chest wall resection defects present a challenging management problem for both thoracic and reconstructive surgeons. Although most chest wall defects can be repaired using local and regional flaps, more complicated cases require increasingly sophisticated techniques such as microsurgical free tissue transfer. This study reviews a single plastic surgeons experience over a 4-year period with complex chest wall reconstruction using the anterolateral thigh free flap. Methods: Five female patients who underwent the above procedure between 2004 and 2007 were reviewed retrospectively. The clinicopathologic details recorded included histologic diagnosis, extent of resection, type of skeletal defect, flap size, receipt vessels, ischemia time, and flap/donor-site complications. Skeletal reconstruction used methylmethacrylate/polypropylene mesh sandwich prostheses. Results: The indications for surgery were metastatic breast cancer (n = 3), advanced primary fibrosarcoma (n = 1), and extensive radionecrosis (n = 1). The average surface area of the chest wall resection was 197 cm2 (range, 156 to 270 cm2). The four patients who underwent partial sternectomy and rib resection required skeletal reconstruction and subsequent ventilatory support postoperatively in the intensive care unit. The mean anterolateral thigh flap size was 188 cm2 (range, 143 to 252 cm2); none of the donor sites was skin grafted. There was 100 percent flap survival, and the prostheses remained fully covered in all cases after a mean follow-up of 16 months (range, 5 to 28 months). No major complications were observed. Conclusions: The anterolateral thigh free flap is a safe and reliable option for reconstructing complicated composite chest wall defects. It therefore provides a practical alternative when regional pedicled flap options are unavailable or inadequate.