Marc D. Pacifico

The safety of autologous fat transfer in breast cancer: Lessons from stem cell biology

Autologous fat grafting is versatile tool in plastic surgery and is increasing used for reconstruction following breast conserving surgery for breast cancer. Part of the reconstructive qualities of the transferred fat may be due to the presence of adipose derived mesenchymal stem cells (ADMSC) playing an angiogenic and an adipogenic role. In this context it must be considered if autologously engrafted fat tissue could contribute to carcinogenesis following breast conserving surgery. In this article we review the current stem cell biology evidence on engraftment, transdifferentiation and potential carcinogenic contribution in the breast and other solid organ stem cell niches in an attempt to highlight possible areas of concern.

Preoperative planning for DIEP breast reconstruction: early experience of the use of computerised tomography angiography with VoNavix 3D software for perforator navigation

The deep inferior epigastric perforator (DIEP) flap is normally the first choice in breast reconstruction; however, due to the considerable vascular anatomical variation and the learning curve for the procedure, muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps are still frequently performed to reduce the rate of complications. Accurate preoperative investigation of the perforators would allow better operative preparation and possibly shorten the learning curve. In an effort to increase accuracy of preoperative planning and to aid preoperative decision-making in free abdominal flap breast reconstruction, we have acquired the use of VoNavix, software that creates three dimensional images from computerised tomography angiography (CTA) data. The use of the VoNavix software for analysis of CTA provides superior imaging that can be viewed in theatre. It, together with CTA, enables decisions to be made preoperatively, including: which side to raise the flap; whether to aim for a medial or lateral row perforator; whether to take a segment of muscle and whether to expect an easy or difficult dissection. We have now performed over 60 free abdominal flap breast reconstructions aided with CTA, and 10 of these cases also used VoNavix technology. This paper presents our initial experience with the use of this software, illustrated with three patient examples. The advantages and disadvantages are discussed.

Should We Be Analysing Breast Reduction Specimens? A Systematic Analysis of Over 1,000 Consecutive Cases

BackgroundReduction mammoplasty (RM) continues to be popular. The reported incidence of occult breast carcinoma in these specimens varies between 0.05 and 1.8xa0%. Literature review reveals a wide discrepancy in study methodology, outcome measures, and even what is constituted as a “significant” result. We set out to identify RM patients at increased risk of occult significant pathological findings to engender a systematic improvement in efficiency of those specimens sent for histopathological examination.MethodsA single-centre retrospective study of the pathology results for 1,388 consecutive RM patients was undertaken. Patients were divided into three groups according to indication for surgery: group 1, macromastia; group 2, developmental asymmetry; and group 3, symmetrising surgery after breast cancer reconstructive surgery.ResultsNine cases of occult carcinoma were found among the 1,388 women (0.65xa0%), all in patients over 35xa0years of age. Forty percent of all patients were under 35xa0years old. Histopathological analysis of 59xa0% of patients revealed nonsignificant findings. Patients with a breast cancer history were 4.3 times more likely to have occult breast cancer. Patients under 30xa0years of age had a significantly higher chance of nonsignificant findings than those over 30 (relative riskxa0=xa02.5).ConclusionsAlthough the overall incidence of occult breast cancer in reduction mammaplasty patients remains low, specific subgroups with a higher risk are identified. It is recommended that histological analysis of specimens should be restricted to high-risk patients and those over 30xa0years of age as significant pathology is uncommon in younger patients. These results will promote health-care-related economic benefits and a reduction of the burden placed on histopathology departments.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A Solution to the High-Riding Nipple–Areola Complex

There are limited techniques described in the literature on how to lower the nipple–areola complex following surgery to the breast. We present a case of successful correction of a high-riding nipple using a Z-plasty technique with an 8-year follow-up in a breast reconstruction patient. The technique described may also be applicable to cases of high-riding nipples following aesthetic breast surgery such as reduction mammaplasty.

Incidence of ‘Incidentalomas’ in over 100 consecutive CT angiograms for preoperative DIEP flap planning

The gold standard in breast reconstruction is the deep inferior epigastric perforator (DIEP) flaps, although muscle-sparing tranverse rectus abdominis myocutaneous (TRAM) flaps are still being performed due to variations in the abdominal vasculature and to reduce flap complications. Recently, there has been a rise in interest in preoperative imaging, in particular, by means of computer tomography angiogram (CTA). CTA has been shown to delineate the vascular anatomy, improve preoperative decision making and possibly reduce operating time and constitutes a routine preoperative investigation in our unit. Of the 104 consecutive patients who had undergone CTA prior to breast reconstruction, we have found a 13% incidence of unexpected findings or incidentalomas in otherwise asymptomatic women. None were malignant, but changes to the initial operative plan included deferring immediate breast reconstruction, further surgery and further investigations for these incidentalomas. We recommend that all women are counselled of the possibilities of incidentalomas prior to CTA. Furthermore, clinicians need to be receptive to the possibility of a delayed or alternative reconstruction, and closely liaise with other specialties to avoid damage to the deep inferior epigastric vasculature.

The Dorsalis Pedis Fascial Flap

The dorsalis pedis fasciocutaneous flap has been used successfully in soft tissue reconstruction both as a pedicled and a free flap. The long-term donor site problems associated with this dorsalis pedis flap prompted us to look at the use of the dorsalis pedis fascial flap in soft tissue reconstruction. We describe the results of our anatomic study and clinical series of the use of the dorsalis pedis fascial flap both as a free flap and a pedicled flap. An anatomic study was performed on a fresh cadaver by injecting India ink into the anterior tibial artery and the fascial and cutaneous staining pattern was documented. Soft tissue reconstruction was performed in six patients, using the dorsalis pedis fascial flap as a free flap in four patients and a pedicled flap in two. The donor site was closed primarily in all cases. The donor and recipient wounds healed well with good aesthetic and functional results. There were no major complications in our series. The dorsalis pedis fascial flap allows us to retain the essential benefits of the dorsalis pedis flap while avoiding donor site morbidity. It provides a useful source of vascularized fascia with a potentially long pedicle.

Exploiting the perforator concept to minimise donor site morbidity in harvesting the radial forearm free flap

Fig. 1. Propeller flap marked by reverse planning technique (note blue dot denoting position of perforator vessel). he radial forearm free flap (RFF) is a highly versatile and eliable workhorse flap but its harvest often leaves a signifiant donor site requiring soft tissue coverage. Most often this s achieved through the use of a skin graft, which aside from eing unaesthetic has been reported to fail (full or partial) ue to the poor “take” observed over the exposed flexor carpi adialis tendon. Even if the skin graft does not fail it may till cause adhesions with the underlying musculo-tendinous tructures.1,2 We describe the use of a propeller flap based on n ulnar artery perforating vessel to avoid these problems. The location and anatomy of the ulnar artery and its perorators have been well described in the literature and can be asily located using a hand-held Doppler device. These ulnar erforators have been shown to be reliable in supporting a arge skin paddle and can be used to form flaps based on the roximal, middle, and distal forearm regions.3 Flaps raised n this territory also leave donor sites that are amenable to irect closure and are aesthetically pleasing.4 Following harvest of the RFF the ulnar border of the donor ite incision in the proximal third/middle third of the forerm is elevated at the subfascial plane. Dissection precedes lnarwards until a suitable perforator is identified. Reverse lanning marks out an elliptical flap (Fig. 1) and the flap is slanded on the perforator (Fig. 2). In the case shown, the ◦ ap was rotated approximately 150 and inset into the donor ite defect (Fig. 3). The mobility of the surrounding skin of

Refining trunk contouring with reverse abdominoplasty.

BACKGROUNDnThe reverse abdominoplasty is an effective technique for selected patients seeking treatment for upper abdominal tissue excess and laxity. Specifically, the procedure is particularly effective in patients who have previously undergone conventional abdominoplasty or liposuction and have residual upper abdominal contour problems. It is a versatile technique that may be combined with a number of adjunctive procedures, notably autologous breast augmentation with the excess upper abdominal tissue.nnnMETHODSnThe authors reviewed their experience with the reverse abdominoplasty in a series of 14 consecutive patients who underwent surgery over a five-year period. Patient case notes, as well as and pre- and postoperative clinical photographs, were analyzed. Furthermore, patients were directly questioned to assess their surgical result.nnnRESULTSnThe mean age of the cohort was 56.6 years and the majority of patients had undergone previous abdominal or breast aesthetic surgery. A mean of 6 cm of upper abdominal tissue was excised, weighing a mean of 326 g. There were no major complications and only three patients had to undergo minor revisional surgery postoperatively.nnnCONCLUSIONSnThe authors present their surgical outcomes and discuss the indications, benefits, and lessons they have learned from their experience with this useful technique in relation to the published literature. The ideal candidate for this procedure appears to be a patient who is older, presents with excess upper abdominal skin, has had a previous conventional abdominoplasty, and who has existing inframammary scars.

Dynamic arteries of the hand

BackgroundWe investigated the previously undescribed phenomenon of ulnar artery occlusion on clenching to make a fist, following the presentation of a patient to our unit with idiopathic ulnar-sided hand pain. This led us to study this unusual finding in a cohort of asymptomatic patients.MethodsNinety-one radial and ulnar arteries were studied in 23 volunteers by color duplex ultrasonography. The subjects were all asymptomatic, their ages ranged from 18 to 78xa0years, and included 10 males and 13 females.ResultsTwenty-two percent of ulnar arteries occluded on clenching a fist, resulting in the hand relying on in-flow solely from the radial artery. All arteries opened up following fist release allowing anterograde flow. Furthermore, 11% of superficial palmar branches of radial arteries occluded on fist-making. The pattern of flow on making a fist showed an initial burst of reverse flow followed by reduced or occluded flow and subsequently an increase in antegrade flow after release of the fist. No subject could occlude both radial and ulnar arteries simultaneously.ConclusionsWe discuss these findings in view of the potential clinical implications in terms of Raynaud’s phenomenon, scleroderma, and importantly, the potential for false-positive findings of pathological ulnar artery occlusion on ultrasonography.

Columella erosion secondary to nasal prongs in the neonate.

There is limited awareness of the risks of pressure necrosis to the columella when using nasal prongs in the neonate. Previous studies have found that signs of skin damage can occur rapidly—within days. This case report aims to illustrate a simple technique of prophylactically lowering the risk of septal injury (if prolonged use of nasal prongs is envisaged), as well as a way of conservatively treating already damaged skin areas. Routine daily skin inspections are also recommended.