Michael J. Sundine

Inframammary fold: a histologic reappraisal.

The inframammary fold is a defining element in the shape and structure of the female breast. It should be preserved whenever possible in ablative procedures and recreated accurately when the breast is reconstructed after mastectomy. To date, no accurate anatomic description of this essential structure exists. Previous studies have suggested that the fold is produced by a supporting ligament running from the dermis in the fold region to a variety of locations on the rib cage. This clinic’s experience with mastectomy, augmentation mammaplasty, and breast reconstruction does not support the existence of a ligamentous structure. To define the structure of the inframammary fold, 10 female and 2 male cadavers were studied. The anterior chest wall was removed en bloc and frozen in orthostatic position. Parasagittal sections were made of the inframammary fold with the chest wall intact. After decalcification of the ribs and routine histologic preparation, thin sections were stained with Gomori’s trichrome. On light microscopic examination, no demonstrable ligamentous structure of dense regular connective tissue could be identified in the fold region in any of the 12 specimens. Superficial and deep fascial layers were uniformly observed anterior to the pectoralis major and serratus anterior muscles. The superficial fascia was connected to the dermis in the fold region in a variety of configurations. In some cases, the deep fascia fused with the superficial fascia and dermis at the fold level. In other cases, bundles of collagen fibers arising from the superficial fascial layer were found to insert into the dermis at the inframammary fold, slightly inferior to it, or both. These bundles were observed consistently in sections from the sternum to the middle axillary line. They were distinct from Cooper’s suspensory ligaments, which are seen more superiorly in the glandular tissue. (Plast. Reconstr. Surg. 105: 549, 2000.)

Hemangiomas: An Overview

nderstanding the behavior of hemangiomasand vascular malformations is of paramountimportance to the plastic surgeon. The fre-quency of these lesions would almost dictate that everyplastic surgeon would be involved in the treatmentof a patient with some sort of vascular birthmark. Hemangiomas are vascular lesions that demon-strate a characteristic pattern of rapid postnatalgrowth followed by slow involution. Vascular mal-formations are simply collections of excess vascularchannels that grow proportionately with the child.Because of the predilection of these vascular birth-marks for the head and neck and the variablegrowth of these lesions, which may result in grotesquedeformity, it is extremely important that plasticsurgeons comprehend the biologic behavior ofthese lesions. It is also important to know when tointervene and treat the patients who have vascularbirthmarks.Vascular birthmarks have been described through-out the history of mankind and many famous figuresthrough history have been known to have vascularbirthmarks.

New frontiers in bone tissue engineering

No single scientific field can generate the ideal method of engineering bone. However, through collaboration and expansion of programs in bone tissue engineering, the right combination of materials, cells, growth factors, and methodology will come together for each clinical situation such that harvesting bone grafts will become obsolete. This article reviews the need for engineered bone and provides a historical perspective of bone engineering research, current research efforts, and the future direction of this work.

Mandibular reconstruction: Are two flaps better than one?

This study compared the combined iliac and ulnar forearm flaps with the osteomusculocutaneous fibular free flap for mandibular reconstruction. A retrospective study of 40 patients who had oromandibular reconstruction was performed, of whom 23 patients had a combined iliac crest without skin and ulnar forearm free flap. Seventeen patients had an osteomusculocutaneous free fibular flap. Ten women and 30 men with a mean age of 57.5 years comprised this study population. Ninety percent of the cases were squamous cell carcinoma (55%, T4), of which 11% were recurrent tumors. Anterolateral mandibular defects constituted 52.9% of the fibular reconstructions and 60.9% accounted for the iliac/ulnar reconstructions. The mean bone gaps were 8.79 cm and 8.95 cm respectively. Functional evaluation was based on the University of Washington Questionnaire through phone calls and personal communication. The mean hospital stay was 15.43 days and 10.09 days for the fibular and iliac/ulnar flaps respectively. The facial artery (64.7%) and facial vein (60%) were the main recipient vessels for the fibular reconstructions whereas the external carotid artery (95.6%) and the internal jugular vein (66.7%) were the main recipient vessels for the iliac/ulnar reconstruction. Overall flap survival was 96.8% (100% of fibular flaps and 95.65% of iliac/ulnar flaps). Two flaps were lost in the iliac/ulnar series because of unsalvageable venous thrombosis. Local complications for the iliac/ulnar flaps were 30.4% but were 5.9% for the fibular reconstructions. Function such as speech, swallowing, and chewing were notably better in the fibular than the iliac/ulnar group in 23 of the patients tested. The cosmetic acceptance of 77.8% of the fibular flaps was judged to be excellent and good, whereas 71.4% of the iliac/ulnar flaps were rated good. It appears that within this study population the free osteomusculocutaneous fibular flap had fewer local complications and a higher flap survival rate than the combined iliac/ulnar forearm flaps. Overall functional outcome was also improved. The use of the double flap may be appropriate in massive oromandibular defects, but may be less appropriate in more modest functional reconstructions of mandibular defects.

The use of end-to-side nerve grafts to reinnervate the paralyzed orbicularis oculi muscle.

Facial paralysis is a serious neurologic disorder, particularly when it affects the eye. Loss of the protective blink reflex may lead to corneal ulceration and, possibly, visual loss. The purpose of this study was to compare different nerve-grafting techniques to reanimate the paralyzed eyelid. Sixteen adult dogs (25 kg each) were allocated into four groups. Denervation of the left hemi-face was performed in all cases. One dog served as a control animal (group I). Group II dogs (n = 5) underwent end-to-side coaptation of the nerve graft to the intact palpebral branch and end-to-end coaptation to the denervated palpebral branch. Group III dogs (n = 5) underwent end-to-end coaptation of the nerve graft to the intact palpebral branch and end-to-end coaptation to the denervated palpebral branch. Group IV dogs (n = 5) underwent end-to-side coaptation of the nerve graft to the intact and denervated palpebral branches. The animals were monitored for 9 months after the surgical procedures, to allow adequate time for reinnervation. The dogs were postoperatively monitored with clinical observation, electrophysiologic testing, video motion analysis, and histologic assessments. Clinical observation and electrophysiologic testing demonstrated the production of an eye blink in the denervated hemi-face in all experimental groups. There was a trend toward increased speed of reinnervation for group III animals (end-to-end coaptations). It was concluded that end-to-side coaptation can produce a contralateral synchronous eye blink in a clinically relevant, large-animal model.

Longevity of SMAS facial rejuvenation and support.

Background: One of the most common questions asked by patients when they present for face lift surgery is “How long will this last?” The answer to this question is not clear from the literature. Methods: The purpose of the study was to review a series of secondary face lifts performed between 2001 and 2008 with both the primary and secondary face lift performed by a single surgeon. There were 42 patients with full records available for review. Data were collected with regard to timing, surgical technique, complications, and reasons for early revision. Results: The average age at the primary face lift was 50.2 years (range, 34.9 to 69.9 years) and the average age at the secondary face lift was 61.9 years (range, 43.6 to 77.2 years). The average length of time from the primary to secondary face lift was 11.9 years. Nine patients required a secondary face lift before it had been 5 years since the primary face lift (21.4 percent). Reasons for early secondary face lift (within 5 years of the primary) included loss of skin elasticity in five patients and increase in subplatysmal fat and skin neck folds due to weight gain, loss of elasticity secondary to protease inhibitors for human immunodeficiency virus infection, loss of skin elasticity due to corticosteroid use, and residual fullness of digastric and residual submental fat in one patient each. Conclusions: On average, a well-performed superficial musculoaponeurotic system flap face lift will last 12 years. Those patients who present with very poor skin elasticity secondary to sun damage may require an earlier secondary face lift.

Transfer of the long head of the triceps tendon for irreparable rotator cuff tears.

This study presents the clinical and anatomic findings of the use of the long head of the triceps tendon for treatment of massive, irreparable rotator cuff tears. The clinical study included 19 shoulders in 18 patients with a minimum followup of 2 years who were prospectively reviewed. All patients had preoperative and postoperative functional evaluations using the UCLA scoring system. The anatomic study included 20 upper extremities that had been injected with Microfil. All patients in the clinical study were satisfied with their outcome. There was an improvement in the UCLA pain and function scores. The long head of the triceps tendon is a myotendinous vascularized transfer that is a useful reconstructive procedure in patients with massive, irreparable rotator cuff tears that continue to be symptomatic despite conventional attempts at repair.

Cranial vault reduction cranioplasty in children with hydrocephalic macrocephaly.

Craniofacial surgeons are rarely presented patients with extreme hydrocephalic macrocephaly due to early diagnosis and treatment of the hydrocephalus. Macrocephaly can significantly limit or prohibit mobility, hygiene and can drastically change lifestyle and developmental issues. The authors herein report on four consecutive total cranial vault reduction cranioplasty procedures for correction of hydrocephalic macrocephaly. The patients had a reduction in cranial volume ranging from 111-641 mL. All patients survived the procedure. Improvement in head control and aesthetics were improved in all patients. All of the patients required at least one shunt revision following the procedure. We conclude that total cranial vault reshaping is safe and effective for the treatment of macrocephaly secondary to hydrocephalus.

Pharmacologic enhancement of rat skin flap survival with topical oleic acid.

This study was instituted to investigate in a rat model the effect of topical coadministration of the penetration enhancer oleic acid (10% by volume) and RIMSO-50 (medical grade dimethyl sulfoxide, 50% by volume) on rat skin flap survival. A rectangular abdominal skin flap (2.5 × 3 cm) was surgically elevated over the left abdomen in 40 nude rats. The vein of the flaps neurovascular pedicle was occluded by placement of a microvascular clip, and the flap was resutured with 4-0 Prolene to its adjacent skin. At the end of 8 hours, the distal edge of the flap was reincised to gain access to the clips and the clips were removed. After resuturing of the flaps distal edge to its adjacent skin, the 40 flaps were randomly divided into four groups. Group 1 (control) flaps were treated with 5 g of saline, group 2 (dimethyl sulfoxide) flaps were treated with 2.7 g of dimethyl sulfoxide (50% by volume), group 3 flaps (oleic acid) were topically treated with 0.45 g of oleic acid (10% by volume), and group 4 (dimethyl sulfoxide plus oleic acid) flaps were treated with a mixture of 0.45 g of oleic acid (10% by volume) and 2.7 g of dimethyl sulfoxide (50% by volume) diluted in saline. Each flap was topically treated with 5 ml of drug-soaked gauze for 1 hour immediately after clip removal to attenuate reperfusion injury. Thereafter, drug was applied topically once daily for 4 more days. Digital photographs of each flap were then taken on day 6 and the flaps were then harvested. The percentage of skin survival in each flap was determined by computerized morphometry and planimetry. The mean surviving area of group 3 (oleic acid–treated flaps) was 23.60 ± 4.19 percent and was statistically higher than that in group 1 (control, saline-treated flaps) at 7.20 ± 2.56 percent. The mean surviving area of group 2 (dimethyl sulfoxide–treated flaps) at 18.00 ± 5.23 percent and group 4 (oleic acid–and dimethyl sulfoxide-treated flaps) at 9.90 ± 3.44 percent did not achieve statistically higher mean surviving areas than controls. A topical solution of oleic acid (10% by volume) caused a statistically significant increase in the survival of rat abdominal skin flaps relative to controls. Dimethyl sulfoxide and the two experimental drugs together did not increase the percentage of flap survival when given as a single 5-ml dose released from a surgical sponge at reperfusion for 1 hour and then daily for a total of 5 days. The reasons for the lack of response are unknown but may have included the technical difficulty of delivering an adequate dose of dimethyl sulfoxide topically and immiscibility between dimethyl sulfoxide and oleic acid. Further studies may be warranted.

Delayed silicone breast implant infection with Mycobacterium avium-intracellulare

Mycobacterial breast implant infection is a rare complication after augmentation mammaplasty. A review of the literature demonstrates multiple examples of breast implant infection with Mycobacterium fortuitum, but only rare discussion of Mycobacterium avium-intracellulare (MAC). The authors report an unusual case of MAC breast implant infection in a patient with a complex surgical history.