Gaetano Musumarra

Current indications for and comparative analysis of three different types of latissimus dorsi flaps.

BACKGROUND Free tissue transfer with lower abdominal flaps for autologous breast reconstruction is not suitable for all patients. The latissimus dorsi (LD) musculocutaneous flap is an alternative, effective method for both immediate and delayed breast reconstruction. OBJECTIVES The authors assess their experience with LD flaps for breast reconstruction, including indications for patient selection, donor site choice, aesthetic outcomes, complications, and patient satisfaction. METHODS Charts for all patients who underwent breast reconstruction with one of three types of LD myocutaneous flaps during a three-year period at a single institution were retrospectively reviewed. Patients (n = 82) were divided into three groups: (1) 35 patients received a standard LD myocutaneous flap with implant, (2) 18 patients underwent a muscle sparing LD flap procedure with implant, and (3) 29 patients had an autologous LD flap. A questionnaire was administered to assess flap and donor site complications, aesthetic outcomes, patient satisfaction, and shoulder function. RESULTS Flap complications occurred in 13 patients (15%). Donor site complications occurred in 24 patients (28%), mostly consisting of back seroma with the autologous LD flap. There was no significant difference in shoulder range of motion or muscle strength between the operated and unoperated sides. Patient satisfaction was high in all three study groups. CONCLUSIONS The LD is a safe, versatile, and reproducible technique for breast reconstruction. The procedure benefits from ease of flap harvesting and setting and may provide satisfactory results in diverse patients, including those for whom an abdominal flap is neither indicated nor feasible. .

Autologous latissimus dorsi flap as an alternative to free abdomen-based flap for breast reconstruction in the morbidly obese.

ence of levator aponeurosis, there were no published studies using elastin stain to identify the levator aponeurosis before our study. We presented our abstract at the 2008 American Society of Ophthalmic Plastic and Reconstructive Surgery fall meeting, and Dr. Marcet’s study was not begun until after that time. We would like to emphasize that we support the notion that the amount of Müller muscle resection does indeed impact the upper eyelid height but that additional mechanisms are occurring to elevate the eyelid in a Müller muscle-conjunctival resection—specifically, advancement of the levator aponeurosis, including plication and sometimes, as in our study, imbrication. While performing numerous external müllerectomy procedures, there is great variability in the appearance of Müller muscle and levator aponeurosis and levator palpebrae superioris with regard to the fatty infiltration and strength. Strictly observing an established algorithm in terms of amount of Müller muscle resection is sometimes not enough to achieve the proper eyelid height desired. The surgeon must sometimes directly plicate and imbricate the levator aponeurosis to obtain the target lid height. While performing external müllerectomy procedures and Hughes flaps, we have observed that the attachments between the levator aponeurosis and the Müller muscle have a range of looseness, with some being extremely more difficult than others to separate. As with intraocular lens calculations, each surgeon must customize his or her formula or algorithm to his or her surgical technique, because the most important goal is to achieve good eyelid height, contour, and symmetry—and, it is hoped, a satisfied patient. DOI: 10.1097/PRS.0b013e31823aefb1

Breast Reshaping with Dermaglandular Flaps After Giant Lipoma Removal: Versatility of Oncoplastic Techniques

Lipomas of the breast are benign lesions that do not raise great interest in the literature and their incidence is unclear. They usually are small, benign soft tissue tumors of fat cells that can be treated by simple excision. Although lipoma is a banal condition, it often causes diagnostic and therapeutic uncertainty. The first reason for this is the normal fatty composition of the breast. Second, it may be difficult to distinguish a lipoma from other benign or malignant lumps. This report presents a rare case involving giant lipoma of the breast that compromised most of the mass of the breast. After resection, the remaining breast was reshaped using multiple dermaglandular flaps to restore the breast mound, and contralateral breast mammaplasty was performed for symmetry. This case is a good illustration of the oncoplastic reconstruction options available after wide local excision.

Reply: The inferiorly based parenchymal flap mammaplasty: the need for measurements to support claims.

125e; discussion 126e–127e. 3. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:1282–1301. 4. Swanson E. A measurement system for evaluation of shape changes and proportions after cosmetic breast surgery. Plast Reconstr Surg. 2012;129:982–992; discussion 993. 5. Graf R, Reis de Araujo LR, Rippel R, Neto LG, Pace DT, Biggs T. Reduction mammaplasty and mastopexy using the vertical scar and thoracic wall flap technique. Aesthetic Plast Surg. 2003; 27:6–12. 6. Brandon HJ, Jerina KL, Wolf CJ, Young VL. In vivo aging characteristics of silicone gel breast implants compared to lot-matched controls. Plast Reconstr Surg. 2002;109:1927–1933. 7. Riml S, Piontke AT, Larcher L, Kompatscher P. Widespread disregard of photographic documentation standards in plastic surgery: A brief survey. Plast Reconstr Surg. 2010;126:274e– 276e.

The Use of Immediate, Delayed-Immediate and Delayed Oncoplastic Reduction Mammaplasty Techniques following Breast Conserving Surgery

Purpose: Oncoplastic surgical techniques are nowadays the gold standard in breast conservation therapy and following the right timing is mandatory in order to obtain a more than average cosmetic and functional result. Materials and methods: The goal of the study is to consider the timing of oncoplastic reduction mammaplasty relative to the radiation by drawing a retrospective study that encompassed 19 consecutive patients who had oncoplastic reduction mammaplasty with patients classified into 3 groups: patients having breast conservation and reduction mammaplasty before radiotherapy, patients having reduction mammaplasty within the time interval between lumpectomy and radiation therapy, and patients having reduction mammaplasty after both lumpectomy and radiation therapy. A questionnaire has been used to assess quality of life and patient satisfaction following reduction mammoplasty. Results: Nine patients had reduction mammoplasty immediately following partial mastectomy, four had reduction surgery in the delayed-immediate period, and six had delayed reduction mammoplasty. Patient satisfaction was very high among the immediate and delayed-immediate groups. Aesthetic assessment for the delayed group was lower but did not reach any significance when compared against the other groups. Conclusion: Ninety percent of patients reported that they would have elected to undergo the procedure again based on their experience and aesthetic outcome. Complications are more frequent in the delayed setting. Clinical implications: Oncoplastic surgery increases the oncological safety of BCT as larger breast volume can be excised resulting in larger respective specimens than with partial mastectomy alone. A contralateral reduction mammaplasty can be performed to obtain symmetry and balance, with consequent “surgical screening” of the contralateral breast.