Moustapha Hamdi

Breast sensitivity after vertical mammaplasty

Breast sensation after reduction mammaplasty is a major concern for surgeons and patients. The sensitivity of 80 breasts that were reduced using Lejours technique (a superior dermoglandular pedicle with resection at the lower quadrants) was assessed in a prospective study. Ten points were selected on each breast for this study, including the nipple, four points on the areola, and five points on the breast skin. The measurements were performed preoperatively and at 3, 6, and 12 months postoperatively. Pressure thresholds were measured with 20 Semmes‐Weinstein monofilaments, temperature sensitivity with hot and cold metal probes, vibratory thresholds with the Biotesiometer, and static and moving two‐point discrimination tests with a Disk‐Criminator. To assess the influence of breast ptosis and hypertrophy on sensitivity, the population was divided into two groups. In group I (19 patients), the sternal notch‐to‐nipple distance was less than 29 cm, and less than 500 g of tissue per breast was removed. In group II (21 patients), the sternal notch‐to‐nipple distance was more than 29 cm, and more than 500 g of tissue was resected. The sensitivity on the nipple and areola was significantly decreased at 3 and 6 months postoperatively for all modalities. At 1 year, sensitivity recovered, and no breast or nipple‐areola complex was insensitive. Pressure sensitivity was not significantly different from the preoperative measurement in any area of the breast or in either group of patients, except for superior breast skin, for which sensitivity was improved in group II (p = 0.0004). Temperature sensitivity in group I was not different preoperatively and postoperatively, but in group II, a significant decrease was observed in sensitivity for the nipple and areola (p = 0.01 and 0.004, respectively). Vibratory sensitivity was significantly decreased on the nipple, the areola, and the inferior breast skin (p = 0.01, 0.01, and 0.001, respectively) in group II but not in group I. In conclusion, ptotic or moderately hypertrophied breasts that were reduced using Lejours technique recovered their preoperative level of sensitivity after an initial postoperative decline. However, in large breasts, although pressure sensitivity recovered after 1 year, temperature and vibration sensitivity remained diminished on the nipple‐areola complex. (Plast. Reconstr. Surg. 107: 970, 2001.)

Oncoplastic and reconstructive surgery of the breast

INTRODUCTIONnOncoplastic surgery has been widely developed during the last decade. The combination of a large tumor resection performed by the breast surgeon and the immediate breast reconstruction by the plastic surgeon has numerous advantages. This technique provides safer resection with larger margins and immediate aesthetic results.nnnMATERIALS & METHODSnDuring the last decade, we have used an algorithm in oncoplastic surgery: Small and moderate size breast tumors (T₁₋₂) are considered the best indications for conserving breast surgery. Depending on the breast size and tumor/breast size relation, determinesthe reconstructive technique is used. A glandular flap, as a part of breast reduction techniques, was raised from the breast itself to fill defects after tumorectomy in large-size breast. However, contralateral breast reduction is necessary to achieve breast symmetry. In the case of smaller breast size, partial breast reconstruction is performed using pedicled flaps (LD or muscle sparing LD, TDAP, LICAP, SAAP) harvested from the back and/or the axillary region. Adequate symmetry is obtained without operating on the contralateral breast. Adjuvant radiotherapy can be started after 4-6 weeks postoperatively.nnnRESULTSnIn total 119 patients, in whom bilateral breast remodeling techniques and pedicled flaps were used in 26 and 93 patients respectively. In three cases, margins were involved with the tumor. Wider excision was done in two patients. Total mastectomy was performed in the third patient. With an average follow-up of 4 years, further surgery was indicated in only three patients because of fat necrosis. Converting to total mastectomy with immediate breast reconstruction with a DIEAP flap was necessary in one patient at 2 years after the initial partial breast reconstruction with a TDAP because of major fat necrosis. Aesthetic results and patient satisfaction are promising, however, longer follow-up is still required to confirm our 4-year-follow-up outcome.nnnCONCLUSIONnOncoplastic surgery offers a better cosmetic outcome as partial breast reconstruction, using various techniques, when performed during the same procedure. In partial breast reconstruction, therapeutic mammaplasty techniques offer creative options for large and pendulous breast. On the other hand, perforator flaps, which spare latissimus dorsi muscle function, provide valuable method for small size breasts.

Distally planned lateral arm flap

The lateral arm flap presents some drawbacks: the vascular pedicle is short (2–6 cm), and the flap is rather thick. An anastomotic network between the posterior radial collateral artery and the recurrent radial artery, demonstrated by our previous anatomical dissections, enables one to locate the skin paddle solely over the epicondylar region and the proximal forearm. Furthermore, since no skin is harvested over the lateral aspect of the arm, a random‐type vascularisation for the distal skin can be excluded. This modification increases pedicle length up to 100% and limits the amount of subcutaneous fat. A series of 13 consecutive distally based lateral arm flaps was performed, and eight patients were followed up for a minimum of 12 months postoperatively. Flap size ranged from 8 × 5.5 cm to 23 × 7 cm (average, 14 × 6 cm), and pedicle length ranged from 9 to 14 cm (average, 10.5 cm). No venous grafts were needed. The mean flap harvesting time was 60 minutes. All the donor sites were closed primarily. One flap suffered from an arterial thrombosis and only partially survived, and another healed uneventfully after successful re‐exploration of a venous thrombosis. Only one flap had to be partially debulked. The donor site scar was enlarged in one patient. Elbow mobility was unaffected by surgery. Patient self‐assessment on the appearance of both the reconstruction and the donor site showed a high satisfaction rate. The distally planned lateral arm flap presents decreased bulk and a longer pedicle when compared with the classical lateral arm flap with no added technical difficulties or morbidity.

The distally planned lateral arm flap in hand reconstruction.

The lateral arm flap is a versatile free flap with straightforward dissection and low donor site morbidity. However, it presents some drawbacks: the vascular pedicle is relatively short (2-6 cm), and the flap is rather thick. Further surgery is often needed to decrease flap volume. An anastomotic network between the posterior collateral radial artery and the recurrent radial artery allows the skin paddle to be safety located over the epicondylar region and proximal forearm. This modification increases pedicle length up to 100% and limits the amount of subcutaneous fat. A series of eight consecutive distally planned lateral arm flaps used for hand reconstruction is presented. The medical records and operative notes were reviewed. Six patients were reviewed. The minimum follow-up was six months. Flap size ranged from 11 x 5.5 cm to 23 x 7 cm (average 15 x 6 cm), pedicle length ranged from 8 to 10 cm (average 9 cm), no venous grafts were needed for the microanastomosis. The mean flap harvesting time was 50 minutes. All donor sites were closed primarily. All flaps survived totally despite postoperative arterial thrombosis in one case that was salvaged by a skin graft over the surviving fascia. To date, no further surgery was needed to debulk the flaps. The donor site scar was enlarged in one patient. Elbow mobility was unaffected by surgery. Patient self-assessment of appearance of both reconstruction and donor site showed a high satisfaction rate. The distally planned lateral arm flap presents decreased bulk and a longer pedicle than the classical lateral arm flap with no added technical difficulties.

Advances in Autologous Breast Reconstruction with Pedicled Perforator Flaps

This article presents an overview of pedicled perforator flaps available in breast surgery. The indications, classification, surgical anatomy, and techniques for safe flap elevation are described. Clinical outcomes and complications are discussed, and illustrative case examples are presented.

Clinical experience with the Pierre Robin sequence

The Pierre Robin sequence manifests itself in the neonatal period with symptoms of respiratory distress and feeding difficulties. We report our experience in the clinical management of this entity over 14xa0years and present an appraisal of risk factors for the surgical treatment of the cleft lip/palate and late outcome. Between 1986 and 1999, out of a series of 159 consecutive patients operated in our department for cleft palate closure, 30 had Pierre Robin sequence. Conservative pediatric management included positioning and cardiorespiratory monitoring. In the case of failure of the conservative treatment, endotracheal intubation and/or different surgical procedures were used. The cleft palate was closed according to Malek’s technique. Associated malformations were found in 10 cases (33%) with cardiorespiratory immaturity in five of those patients. Acute respiratory distress was present in 12 newborns (40%). Among them, endotracheal intubation was necessary in seven cases and maintained for 1 to 4xa0days in three patients. Glossopexy or subperiosteal release of the floor of mouth musculature was done in four of these patients followed by tracheotomy in two. Nasogastric feeding was needed in 14 infants (47%) for a variable period with a mean of 57xa0days (range 1–210xa0days). Polysomnography studies, done in 24 patients, showed significant obstructive apnea episodes in 10 infants. Gastroesophageal reflux was found in 11 patients (37%). Hearing loss was found in 29 infants (96%) with a mean threshold of 40xa0dB. Sensorineural hearing abnormalities were revealed in 10 patients (33%). Palate repair was done at the average age of 5xa0months (range 3–12xa0months). Difficulties of intubation were encountered in all the cases with severe malformations (five infants). Myringotomy and/or ventilation tubes were used in 21 infants at the same time of palate closure. An early palatal plate was used before surgery in 18 cases (60%). Immediate postoperative complications included two local hemorrhages and in one of them a surgical exploration was needed to control the bleeding. Postoperative oronasal fistula occurred in eight patients (23%) and further surgery was needed for five of them (16%). Newborns who had associated malformation or severe respiratory distress presented more postoperative complications than those with minimal clinical problems (6/10 vs 2/20 patients respectively, p=0.007).

The value of 3D images in the aesthetic evaluation of breast cancer conservative treatment. Results from a prospective multicentric clinical trial

PURPOSEnBCCT.core (Breast Cancer Conservative Treatment. cosmetic results) is a software created for the objective evaluation of aesthetic result of breast cancer conservative treatment using a single patient frontal photography. The lack of volume information has been one criticism, as the use of 3D information might improve accuracy in aesthetic evaluation. In this study, we have evaluated the added value of 3D information to two methods of aesthetic evaluation: a panel of experts; and an augmented version of the computational model - BCCT.core3d.nnnMATERIAL AND METHODSnWithin the scope of EU Seventh Framework Programme Project PICTURE, 2D and 3D images from 106 patients from three clinical centres were evaluated by a panel of 17 experts and the BCCT.core. Agreement between all methods was calculated using the kappa (K) and weighted kappa (wK) statistics.nnnRESULTSnSubjective agreement between 2D and 3D individual evaluation was fair to moderate. The agreement between the expert classification and the BCCT.core software with both 2D and 3D features was also fair to moderate.nnnCONCLUSIONSnThe inclusion of 3D images did not add significant information to the aesthetic evaluation either by the panel or the software. Evaluation of aesthetic outcome can be performed using of the BCCT.core software, with a single frontal image.

Cutaneous malignant melanoma of the head and neck: the role of planned definitive surgery

Abstractu2002The chart of 56 patients, consecutively operated on in our institution for malignant melanoma of the skin in the head and neck area from 1977 to 1993, were retrospectively reviewed. The follow-up was 2 to 18 years (average 7.5 years). We considered three kinds of treatment, looking at the adequacy and timing of surgery: (1) Planned definitive surgery (PDS), when surgery with adequate margins and lymph node dissection was done within two months after the initial diagnosis; (2) non-planned definitive surgery (non-PDS), when at least one of the above parameters could not be achieved; (3) and salvage surgery (Ss), for patients who presented with local recurrence or involved lymph nodes. Twenty-four patients were in the first group, ten in the second, and 22 in the third. Elective neck dissection was performed in 16 patients with a superficial spreading melanoma (SSM) or nodular melanoma (NM) lesion thicker than 1 mm, and a therapeutic radical neck dissection in 17 patients with a suspicious lymph node occurring at any stage of the disease. According to the type of surgical management, the five year survival was 90%, 60%, and 25% for PDS, non-PDS, and Ss groups, respectively (p<0.01). Patients who were initially treated with elective lymph node dissection had better prognosis than those who had therapeutic lymph node dissection (88% versus 19% at 8 years, p<0.001). These results further support the benefit of planned surgical treatment, i.e. within two months, for malignant melanoma of the head and neck.