Melvyn I. Dinner

The transverse abdominal island flap: part I. Indications, contraindications, results, and complications.

The transverse abdominal island flap is not just another myocutaneous flap. Although it derives its blood supply from myocutaneous perforators, the portion of the skin and fat that overlies muscle comprises only about 20% of its surface. The surface area of the flap by far exceeds the surface area of the entire muscle that carries it. Its hemodynamics are more complicated than usual and consist of delicate communications between the superior and inferior deep epigastric systems and the deep and superficial epigastric systems across the midline. Its use in breast reconstruction has been as exciting as it is complex. We describe our experience with 60 consecutive patients and 65 transverse abdominal island flaps.

The tubular/tuberous breast syndrome

There are various degrees of expression of the fully developed tubular/tuberous deformity. To develop an adequate treatment plan for this condition, the individual deformities constituting the fully expressed syndrome must be diagnosed. The treatment plan must include maneuvers to correct each deficiency within the syndrome itself. We present the spectrum of abnormalities constituting the tubular/tuberous syndrome and the treatment plan thereof.

The Transverse Abdominal Island Flap: Part Ii. Surgical Technique

The purpose of this article—an adjunct to Part I appearing in January—is to describe in detail the surgical technique of the transverse abdominal island flap for reconstructing the female breast after mastectomy. This perioperative and intraoperative management scenario represents the consensus of both authors and is not intended as a rigid set of rules on “how to do it.” Rather it is hoped that these observations, based on our experience, will stimulate further expansion and refinement and more exact definition of the art and science involved in this concept. This portion of the article should not be considered independent of the perspective presentedin Part I regarding patient selection, indications, contraindications, and limitations of the transverse abdominal island flap.

The role of the rectus abdominis myocutaneous flap in breast reconstruction.

The rectus abdominis myocutaneous flap has been used in 10 patients requiring the importation of skin, subcutaneous tissue, and muscle for postmastectomy reconstruction. It was preferred to the latissimus dorsi myocutaneous flap under the circumstances highlighted in Table I. The flap has proved reliable and easy to raise, with a consistent anatomic location of the arterial venous pedicle. In 10 such flaps performed, one partial necrosis occurred in a patient who was extremely obese and had had a previous laparotomy that may have interfered with the integrity of the underlying blood supply to the rectus abdominis muscle. A minor complication of cellulitis in the donor-site wound was due to an idiosyncratic allergy to sutures used in the subcutaneous tissue. One instance of abdominal contour deformity was noticed in a patient in whom the anterior rectus sheath had been reconstituted by advancing the fascia of the external oblique muscle to meet the linea alba in the midline. In summary, we believe that the rectus abdominis myocutaneous flap, in certain select circumstances, produces a reliable, readily accessible myocutaneous flap to import tissue to the anterior chest wall for adequate mound reconstruction after mastectomy.

Results of Testicular Autotransplantation Using the Microvascular Technique: Experience with 8 Intra-Abdominal Testes

Children with intra-abdominal testes comprise a small group presenting for surgical management of the undescended testicle. During the last 4 years 6 children with 8 intra-abdominal testes have undergone testicular surgery. In 7 testicles the technique involved high intraperitoneal division of the testicular pedicle with reanastomosis of the distal spermatic artery and vein to the inferior epigastric artery and vein using the operating room microscope. Microsurgery on the 7 intra-abdominal testicles led to good results in 6 cases. In 1 testicle venous infarction occurred secondary to venous congestion. Although many children with intra-abdominal testes have been managed using the standard Stephens-Fowler technique, we believe that microsurgical reanastomosis will improve the previously reported results.

The Effect of Hyaluronidase and Dimethyl Sulfoxide (DMSO) on Experimental Skin Flap Survival

Hyaluronidase has been shown clinically and experimentally to reduce the effects of tissue ischemia in myocardial infarction and hemorrhagic shock. Dimethyl sulfoxide (DMSO) has been shown to reverse the effects of cerebral ischemia in the primate model. A caudally based dorsal skin flap in the rat was used to study the effects of these two drugs in physiological doses on skin flaps, and to investigate their mechanisms of action.This study demonstrates that both hyaluronidase and DMSO, which are nontoxic in physiological doses, can increase the surviving length of an experimental skin Pap. It is hypothesized that these substances exert their effect by decreasing tissue edema and by aiding in the transport of nutritive substances to the flap during its acute phase.

The rhomboid flap and partial mastectomy.

The use of a rhomboid flap in segmented breast resection is described. This reconstructive technique allows large areas of the breast to be resected with minimal deformity and nipple-areola displacement.

The Inferior Segment Technique for Breast Reduction

The major objectives in any breast reduction operation are to decrease the size of the breasts while providing a normal shape, preserving sensibility of the nipple, and permitting lactation in the premenopausal patient. The inferior segment technique of breast reduction is presented, with emphasis on the points we consider crucial for achieving these objectives.

Application and modification of the circular skin excision and pursestring procedures.

The concept of the circular excision is not new. However, it was complicated by excessive postoperative areolar stretching and scar hypertrophy. The Benelli principle of a permanent subdermal pursestring suture overcame these drawbacks. We present our experiences with the circular skin excision for mastopexy procedures and for circular skin incision for total mastectomy and immediate reconstruction.

Planning the aesthetic foreheadplasty.

Different approaches to aesthetic foreheadplasty have been thoroughly described and well documented. However, there has been a paucity of information in the literature describing indications for the various approaches. We detail our approach to planning the foreheadplasty; most commonly, we opt for the anterior forehead—hairline approach. We believe that proper patient selection with regard to anatomical, aesthetic, and physiological factors is of the greatest importance in planning an aesthetic foreheadplasty.