Dennis C. Hammond

Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty.

A method of breast reduction is presented that is based on an inferior pedicle to preserve vascularity to the nipple and areola and uses a combined periareolar and vertical skin excision to reduce the skin envelope. Aggressive suturing of the pedicle and breast flaps is used to control shape. Thus far, 263 breasts in 156 patients have been reduced in this fashion. An aesthetic breast mound is created immediately on completion of the procedure that does not “bottom out” over time. Complications have been few and the results have been superior to those obtained with the traditional Wise-pattern inferior-pedicle reduction mammaplasty. The procedure is technically straightforward, versatile, and easily applicable to reductions of up to 1,000 g. It is recommended as an excellent alternative for patients seeking breast reduction and mastopexy.

Latissimus dorsi flap breast reconstruction.

Background: The latissimus dorsi musculocutaneous flap has reemerged as an effective method for both immediate and delayed breast reconstruction. However, the technique is not without disadvantages, as the quality of the aesthetic result can at times be less than desired and complications at the donor site can be troublesome. It is proposed that modifications related to surgical technique and the use of higher quality expanders and implants can improve the aesthetic results while minimizing the incidence and severity of complications. Methods: Five technical modifications in surgical technique, including orientation of the skin island along the relaxed skin tension lines, harvesting the deep layer of fat with the flap, cutting the thoracodorsal nerve, partially dividing the insertion of the muscle, and using a staged expander/implant sequence, are included in an overall surgical strategy designed to reconstruct the breast in both delayed and immediate settings. Results: As a result of these technical modifications, a thin line and smooth donor-site scar is created in the back. The flap advances completely to the breast because of the partial release of the insertion of the muscle, and the volume provided by the flap is increased by keeping the deep layer of fat attached to the flap. This more effectively softens the contours of the reconstructed breast. Breast animation is minimized as a result of sectioning of the thoracodorsal nerve, and the consistency and quality of the result are improved by using a staged tissue expander/implant strategy. Conclusion: With advancements in surgical technique and improvements in tissue expander and implant design, outstanding results can be obtained using the latissimus dorsi flap in breast reconstruction.

Managing late periprosthetic fluid collections (seroma) in patients with breast implants: a consensus panel recommendation and review of the literature.

Background: The goal of this consensus is to establish an algorithm for the management of patients who develop a late or delayed periprosthetic fluid collection. A work group of practicing plastic surgeons and device industry physicians met periodically by teleconference and discussed issues pertinent to the diagnosis and management of late periprosthetic fluid collections in patients with breast implants. Based on these meetings, treatment recommendations and a treatment algorithm were prepared in association with an editorial assistant. Method: The work group participants discussed optimal care approaches developed in their private practices and from evidence in the literature. Results: The consensus algorithm and treatment and management recommendations represent the consensus of the group. Conclusions: The group concluded that late periprosthetic fluid collection (arbitrarily defined as occurring ≥1 year after implant) is an infrequently reported occurrence (0.1 percent) after breast implant surgery and that, at a minimum, management should include clinically indicated ultrasound-guided aspiration of fluid, with appropriate cultures and cytologic testing. Further evaluation and additional treatment is recommended for recurrence of periprosthetic fluid collection after aspiration, or clinical suspicion of infection or neoplasia.

Klippel-Trenaunay syndrome.

The association of three physical findings including capillary malformation, varicosities, and hypertrophy of bony and soft tissues corresponds to Klippel-Trenaunay syndrome. This triad of findings, described by the two French physicians Klippel and Trenaunay in 1900, differs from Parkes-Weber syndrome, in that Klippel-Trenaunay syndrome does not incorporate significant hemodynamic arteriovenous fistulas. Generally, management of this disease process should be individualized. Surgery should be considered in cases where skin ulcerations lead to persisting and recurrent bleeding, or where digital deformities lead to functional disabilities or where significant limb overgrowth leads to both functional and psychological impairment. Persistent hematochezia, hematuria, and vaginal and esophageal bleeding are considered indications for surgical intervention. Recurrent attacks of thrombophlebitis and cellulitis are treated medically with antiinflammatory agents and antibiotics. Otherwise, management of this syndrome is generally conservative, consisting of psychological encouragement, reassurance, and the continued use of graduated compressive stockings for varicosities and intermittent pneumatic compression pumps for lymphatic edema.

Rectus abdominis muscle innervation: implications for TRAM flap elevation.

Sixteen cadaver dissections were performed to identify the location and course of the intercostal nerves in relation to the rectus abdominis muscle. Histochemical staining of fresh nerve biopsies was performed to assess the motor, sensory, and autonomic content of each nerve. Six to eight nerves passed inferomedially between the internal oblique and transversus abdominis muscles before entering the lateral confluence of the anterior and posterior rectus sheath or, in some cases, the posterior rectus sheath proper. The nerves, which contained varying numbers of sensory, motor, and autonomic fibers, passed under the muscle and became intramuscular at varying points along the width of the muscle, with most nerves entering the muscle in the lateral third in direct association with the lateral intercostal vascular pedicle. Two to three nerves entered the lower portion of the muscle below the umbilicus lateral to the inferior epigastric artery. During a partial muscle harvest of the medial two-thirds of the rectus abdominis muscle in these cadavers, it was possible to preserve innervation to the lateral third in several cadavers and to the portion of the rectus muscle lying below the arcuate line in all the cadavers. Innervation to a preserved medial muscle strip could not be preserved. Postoperative electromyographic evaluation of five patients undergoing TRAM flap breast reconstruction using the partial muscle harvest technique demonstrated that the retained lateral strip of muscle can remain innervated but with greatly diminished function, while the lower portion of the retained rectus muscle maintains near-normal function.(ABSTRACT TRUNCATED AT 250 WORDS)

The dorsal skin-flap model in the rat: factors influencing survival.

Several authors have postulated that the standard McFarlane-type dorsal rat flap model can survive as a graft. Therefore, in an effort to better understand the metabolic support governing the survival of this flap, five flap designs on the dorsal surface of the rat were studied. Each was manipulated to control progressively for the metabolic support to the flap by means of skin-graft and/or skin-flap physiology. The flap designs included (1) a standard McFarlane flap (n = 10), (2) a full-thickness “flap‘’ graft (n = 10), (3) a McFarlane flap separated from the bed with plastic sheeting (n = 9), (4) a McFarlane flap separated from the bed by closing the wound beneath the flap (n = 29), and (5) flaps raised as in group 4 after a 2-week delay procedure (n = 9). Based on direct comparisons of both the pattern of necrosis and the surviving surface area in each group, we conclude that (1) the distal aspect of the dorsal rat flap can survive as a graft when in contact with the underlying bed, (2) the “take” of the flap as a graft is variable, and (3) to serve as a reasonable indicator of human flap behavior, the skin-graft effect must be controlled for by separating the flap from the underlying bed.

The interlocking gore-tex suture for control of areolar diameter and shape

Excessive widening and distortion of the shape of the areola are common complications associated with periareolar surgery.1–5 Various operative strategies designed to prevent and/or treat these complications have been described, including the use of purse-string sutures and periareolar cinching sutures.6–14 Described here is a combination approach that uses a unique suture material (Gore-Tex; W. L. Gore & Associates, Flagstaff, Ariz.) placed in an interlocking purse-string fashion designed to limit postoperative spreading and distortion of the shape of the areola.

Combined use of ultrasonic liposuction with the pull-through technique for the treatment of gynecomastia.

The authors present a method of treatment for gynecomastia that combines the use of two techniques of soft-tissue contouring. This method uses ultrasonic liposuction in conjunction with the pull-through technique of direct excision to effectively remove the fibrofatty tissue of the male breast and the fibrous breast bud through a single 1-cm incision. Fifteen patients were treated in this fashion, and each patient demonstrated a smooth, masculine breast contour with a well-concealed scar, which eliminates the stigma of breast surgery. The procedure is technically straightforward and provides consistent results. It is offered as an additional option for the treatment of gynecomastia.

Comparison of unipedicled and bipedicled TRAM flap breast reconstructions: assessment of physical function and patient satisfaction.

Many variations of the transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction have been attempted since the procedure was first described. One common modification involves the use of both rectus muscles, which may accommodate a bilateral reconstruction or provide a more reliable blood supply to a unilateral reconstruction. Objective studies measuring various aspects of physical strength after bilateral rectus harvest and subjective reports of various physical symptoms have challenged the morbidity of a double-rectus harvest. Whether this represents increased morbidity in practical terms is best clarified by asking the patients. To answer this question, 124 TRAM flap reconstruction patients (62 unipedicled patients and 62 bipedicled patients) completed a survey containing questions regarding postoperative physical activities and abilities, outcome with regard to specific physical symptoms, and satisfaction with the procedure. The overwhelming majority of patients reported no untoward effect postoperatively regarding the following: workday performance (≥90 percent), workday performance involving physical labor (≥78 percent), physical recreation (≥77 percent), abdominal appearance (≥77 percent), standing posture (≥95 percent), and back pain (≥81 percent). When comparing unipedicled and bipedicled TRAM patient groups, there was no statistically significant difference between the two groups for any of these criteria. However, a subjective decrease in abdominal muscle strength was reported by 42 percent of unipedicled and 64 percent of bipedicled TRAM flap patients, and decreased abdominal muscle strength was the most frequently cited reason for dissatisfaction. Interestingly, this decreased strength did not affect the daily activities of the majority of patients, who were happy with the procedure (96 percent) and would recommend it to others (96 percent).

Microsurgical replantation of the amputated nose.

A case of successful replantation of the nose is presented. Two arteries and one vein were anastomosed, providing a stable framework for direct revascularization of the amputated nasal segment. This resulted in complete survival of the nose, with an excellent aesthetic result. However, despite successful microsurgical arterial and venous repair, significant postoperative blood loss still occurred as a result of anticoagulation. In cases of the amputation of specialized structures, the improved functional and cosmetic result obtained with replantation must be weighed against the risk of blood-borne disease transmission when postoperative transfusion is required. Recognizing the potential need for postoperative transfusion in these cases is important in allowing the surgeon to exercise appropriate judgment in deciding whether replantation should be performed.