Paul J. Skoll

Complete one-stage, immediate breast reconstruction with prosthetic material in patients with large or ptotic breasts.

&NA; Immediate prosthetic breast reconstruction is a relatively simple, quick procedure with no donor site morbidity. This report discusses immediate one‐stage breast reconstruction using prostheses in 18 patients (19 breasts) who also required a contralateral reduction or mastopexy. In all cases, an inverted‐T pattern was applied to both breasts. The mean age of the patients was 49 years (range, 32 to 62 years), and the mean size of the gel implant used was 330 ml (range, 120 to 550 ml); the implant was inserted in a total submuscular pocket in seven patients and subcutaneously in 11 patients. In two patients with multiple risk factors, the prosthesis extruded, and one patient required removal for a periprosthetic infection. In 10 patients with early stage disease (T1 or T2) with tumors more than 5 cm from the nipple‐areola complex, the original areola (n = 3) or nipple‐areola complex (n = 7) was retained as a full‐thickness skin graft. The breast shape after submuscular prosthesis insertion is different than that of the contralateral breast after a mastopexy or reduction, and nipple‐areola complex symmetry was difficult to obtain; thus, this technique was abandoned in favor of the subcutaneous position (using a modified Wise keyhole pattern with a de‐epithelialized portion, which still allows two‐layer closure). In the subgroup of patients with large breasts or marked ptosis, a single‐stage breast reconstruction procedure can be performed with symmetrical incisions. The subcutaneous position allows for symmetrical shape and nipple‐areola complex symmetry to be obtained. When the tumors are small and situated in the periphery of the breast, the nipple‐areola complex may be retained as a full‐thickness graft. (Plast. Reconstr. Surg. 110: 487, 2002.)

Repeat Reduction Mammaplasty

Repeat reduction mammaplasty is an uncommonly performed procedure. Currently, no clear operative guidelines of management exist. Sixteen patients (28 breasts) with a mean age of 29 years (range, 13 to 52 years) underwent repeat breast reduction over an 11-year period. Before the first reduction, the mean notch to nipple distance was 29.6 cm (range, 24 to 38 cm) and mean nipple to inframammary crease distance was 15.5 cm (range, 12 to 18 cm). The mean mass of tissue excised was 615 g per breast. A number of different pedicles were used (six inferior, five superior, four superomedial, one unknown). All patients subsequently developed pseudoptosis. The nipple to inframammary crease distance was a mean of 11.4 cm (having initially been set at 7 cm) before the second procedure. At the second operation, two patients (three breasts) had their initial pedicles transected and the nipple-areola complex moved, and both patients developed vascular compromise of the nipple-areola complex (two breasts). Where the same pedicle was used in the second operation (five patients, 10 breasts), one patient developed unilateral nipple-areola complex necrosis. In eight patients, because of the development of pseudoptosis, the nipple was in a satisfactory position, and therefore only an inferior wedge of tissue required excision. This was performed without nipple-areola complex compromise, irrespective of the initial pedicle. The mean mass of tissue excised in the second operation was 325 g per breast (range, 120 to 620 g). Fourteen patients were available for follow-up after a mean of 5.1 years (range, 3 months to 11.7 years) following the repeat reduction mammaplasty. In the repeat breast reduction, where nipple-areola complex transposition is planned, the initial pedicle should be reused to maintain nipple-areola complex perfusion. Where the initial pedicle is not known, a free nipple graft may be the safest option. In patients with pseudoptosis, in whom the nipple does not require transposition, an inferior wedge of tissue can be safely excised, irrespective of the initial pedicle.

Tuberculosis of the upper extremity.

Twelve cases of tuberculosis of the upper extremity over a 5-year period are presented. The average time to diagnosis was 5 months. All patients were treated with a regimen of combination antituberculous chemotherapy for a minimum of 6 months, initial splinting, and intensive physiotherapy. The indications for surgery were limited, with biopsy being the most common procedure. Patients with tenosynovitis underwent tenosynovectomy, and nerve decompression was performed when indicated clinically. Large abscesses were drained. No patient had bony debridement or early arthrodesis to control the infection. The pre- and posttreatment range of motion was recorded, with a mean follow up of 25.4 months. Employing this regimen resulted in resolution of infection and an improved range of motion in 11 patients.

Skin-sparing mastectomy with nipple-areola conservation.

The authors emphasize their indications for skin-sparing mastectomy with nipple-areola complex preservation and present their protocol for treatment of patients with breast cancer.

Aeromonas hydrophila in burn patients

Burn wound infection with Aeromonas hydrophila appears to be very uncommon. This study reports on nine cases of A. hydrophila in burn patients treated over a 21 month period at the New Somerset Hospital Burn Unit. The average age of the patients was 31 years (range 24-60 years) and the average TBSA was 33% (range 16-51%). All patients had positive wound cultures for A. hydrophila, obtained on admission or shortly thereafter. One patient also had a positive blood culture. Two patients with small partial thickness burns did not receive antibiotic therapy, and made an uneventful recovery with topical therapy alone. The other seven patients developed clinical signs of septicaemia and required parenteral antibiotics, in addition to topical therapy. One patient died of ARDS, but the other eight recovered and were discharged. No patient had evidence of myonecrosis. Small, superficial burns which culture A. hydrophila can be treated by topical therapy alone. Large and/or deep burns, require antibiotic therapy and debridement of all necrotic tissue, particularly when myonecrosis is present. The antibiotics of choice are the aminoglycosides or the quinolones.

Tissue expansion for frontal hairline restoration in severe alopecia in a child

Burn alopecia has serious sequelae, both aesthetic and psychological, particularly in children. A case of 70% scalp alopecia due to a flame burn, and the modality of treatment is described. This consisted of an expanded temporo-parietal flap, which was transposed to create a frontal hairline. A relatively simple surgical procedure had both substantial aesthetic, and psychological benefits.

Combined pedicled flaps for grade IIIB tibial fractures in children: a report of two patients.

Severe open tibial fractures in children are associated with notable morbidity and require early aggressive management to ensure a successful outcome. Free flaps are currently the gold standard in distal extremity reconstruction in which large soft-tissue defects exist, as is often the case with grade IIIB fractures. In severe lower limb trauma, however, free flaps are associated with a relatively high risk of failure, particularly when definitive soft-tissue coverage is delayed. Alternative methods of soft-tissue reconstruction may, therefore, occasionally require consideration. The authors describe the combined use of three pedicled flaps to attain soft-tissue coverage in 2 children with grade IIIB tibial fractures. These three flaps are individually in common use for lower limb soft-tissue coverage, are simple to raise, and in combination can cover extensive soft-tissue defects of the lower extremity. The major vascular axes of the limb are not sacrificed; however, the aesthetic result is modest.

The use of the prepuce for reconstruction of an intraoral burn.

Intraoral and commissural burns present a complex challenge for the reconstructive surgeon, with contractures being the main sequela encountered. Various reconstructive techniques have been described, none of which offers an ideal solution. A case of a severe intraoral contracture due to a caustic burn, and the modality of treatment is described. Once the contractures were released, a full-thickness preputial graft was used to cover the resultant buccal mucosal defect, with a satisfactory result. Due to its unique properties, the prepuce should be included as an additional tool in the reconstructive surgeons armamentarium.

Florid juvenile (cellular) fibroadenomatosis in the adolescent: a case for subcutaneous mastectomy?

Abstract. Juvenile or giant fibroadenoma (JF) is an uncommon fibroadenoma variant usually presenting in adolescence. Although these masses are benign, when multiple and bilateral, they present a complex challenge to the attending surgeon, both in diagnosis, and in selection of the most appropriate therapy. Treatment is usually surgical and ranges from simple excision to subcutaneous mastectomy with reconstruction. We report an unusual case of refractory JF, initially treated with combined hormonal and surgical treatment but ultimately requiring bilateral subcutaneous mastectomies to prevent tumor regrowth. This case highlights the occasional difficulty in the management of macromastia in the adolescent female.

Superiorly based rectus abdominis wraparound flap for axillofemoral graft sepsis.

Prosthetic vascular graft sepsis, although uncommon, can lead to catastrophic sequelae for life and limb. Axillofemoral grafts are predisposed to sepsis and perigraft seromas because of their length, subcutaneous tunneling, and infrainguinal anastomosis, and are often performed in elderly, debilitated patients. The authors detail the use of a superiorly based rectus abdominis muscle flap, in combination with a sartorius muscle flap to salvage a Szilagy/Samson grade III septic axillounifemoral graft. The superiorly based rectus abdominis wraparound muscle flap should be considered a salvage option for select cases of sepsis involving axillofemoral grafts.