Petra Pülzl

Hypertrophic scars and keloids--a review of their pathophysiology, risk factors, and therapeutic management

BACKGROUND Hypertrophic scars and keloids result from an abnormal fibrous wound healing process in which tissue repair and regeneration‐regulating mechanism control is lost. These abnormal fibrous growths present a major therapeutic dilemma and challenge to the plastic surgeon because they are disfiguring and frequently recur. OBJECTIVE To provide updated clinical and experimental information on hypertrophic scars and keloids so that physicians can better understand and properly treat such lesions. METHODS A Medline literature search was performed for relevant publications and for diverse strategies for management of hypertrophic scars and keloids. CONCLUSION The growing understanding of the molecular processes of normal and abnormal wound healing is promising for discovery of novel approaches for the management of hypertrophic scars and keloids. Although optimal treatment of these lesions remains undefined, successful healing can be achieved only with combined multidisciplinary therapeutic regimens. The authors have indicated no significant interest with commercial supporters.

Donor-site morbidity of the transverse musculocutaneous gracilis flap in autologous breast reconstruction: short-term and long-term results.

Background: The authors have used the transverse musculocutaneous gracilis flap technique for autologous breast reconstruction after skin-sparing mastectomy since August of 2002. The donor site is closed in the manner of a medial thigh lift. The authors examined the short-term and long-term results of donor-site morbidity in their first 22 patients. Methods: Nineteen patients underwent unilateral and three patients received bilateral breast reconstruction with a transverse musculocutaneous gracilis flap after skin-sparing mastectomy. Using a questionnaire, patients were asked about complaints resulting from elevation of the gracilis muscle and their satisfaction with the result, general condition, and sexuality. Cosmetic evaluations of the thigh donor site were performed independently by two plastic surgeons. Results: To evaluate short-term results, mean follow-up of the 22 patients was 10 months. All patients were satisfied with the scar in the inguinal region. Concerning thigh symmetry, 42 percent of patients showed excellent results, 40 percent had good results, and 18 percent had fair results. With regard to the scars, 24 percent of patients had excellent results, 46 percent had good results, and 30 percent had fair results. Thigh shape was evaluated as excellent by 26 percent, good by 52 percent, and fair by 22 percent. Patients who had a unilateral gracilis donor site had a difference in maximal thigh circumference of 2.368 cm. Four years postoperatively, all patients would choose this kind of operation again. Conclusions: The medial thigh region allows the removal of a moderate amount of tissue, even in thin patients, with a very inconspicuous scar. The transverse musculocutaneous gracilis flap is safe for immediate reconstruction of small and medium-sized breasts, with minimal functional donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Capsular flap for coverage of an exposed implant after skin-sparing mastectomy and immediate breast reconstruction.

Native skin-flap necrosis following skin-sparing mastectomy (SSM) is treated by raising a capsular flap, formed as a consecutive physiological reaction around breast implant. Using this highly vascularised thin tissue layer as an implant coverage withdraws pressure from the defect and allocates a good background for wound healing.

Respecting the aesthetic unit in autologous breast reconstruction improves the outcome.

Background: In postmastectomy breast reconstruction, a patchwork-like appearance and a double-bubble phenomenon may result from scar contracture and the possible destruction of the normal inframammary fold during mastectomy. Restoring an age-related breast ptosis can be difficult, and often contralateral breast surgery has to be performed to achieve symmetry. The purpose of this article is to present a technique that respects the aesthetic unit in autologous reconstruction, improves the outcome, and minimizes secondary surgery. Methods: The area between the resected mastectomy scar and the marked inframammary fold is deepithelialized. The inferior skin margin of the flap is sutured to the lower line of the deepithelialized area, which corresponds to the inframammary fold of the contralateral side. The degree of ptosis can be adjusted by insetting greater or lesser amounts of skin. From December of 2000 to June of 2004, 12 patients underwent secondary breast reconstruction using this technique. The patients’ ages ranged from 39 to 63 years (median, 51 years). Three patients had reduction mammaplasty of the contralateral breast. Results: Mean patient follow-up was 14.7 months (range, 4 to 45 months). There were no free flap failures. Cosmetic evaluation of the reconstructed breasts by two independent plastic surgeons showed good results with regard to symmetry in 10 patients and fair results in two patients. Concerning visibility of the inferior scar, 11 patients had a good result and one patient had a fair result. All patients had a good result in terms of age-appropriate ptosis. Conclusions: The authors’ technique facilitates the formation of an age-appropriate ptosis. Altogether, the aesthetic unit of the breast is restored.

Long-term results of MISTI gold breast implants: a retrospective study.

&NA; MISTI Gold breast implants (Bioplasty, St. Paul, Minn.) filled with polyvinylpyrrolidone‐hydrogel were developed as a promising alternative to silicone‐filled implants. Some studies have reported on the positive effects of the implant, such as improved radiolucency and biocompatibility of the gel; however, there are also reports that such implants increased in volume and were subject to capsular contracture in the human body, resulting in demands for their removal. The purpose of this retrospective study was to analyze the long‐term results of a series of patients with MISTI Gold breast implants. Between 1991 and 1993, the authors inserted 83 MISTI Gold implants in 61 patients with an average age of 46 years (range, 16 to 69). The authors were able to follow up 48 patients with 71 MISTI Gold implants. The average follow‐up was 68 months (range, 10 to 108 months). The retrospective study found that 59 percent of all MISTI Gold implants were removed after an average period of 4.14 years. The main reason for implant removal was an increase in volume of 38 percent, followed by capsular contracture in 14 percent of all 71 MISTI Gold implants. The average increase in volume of all removed MISTI Gold implants was 43 percent. Capsular contracture was graded as Baker I and II in 63 percent and as Baker III and IV in 37 percent. In conclusion, the authors believe that MISTI Gold implants do not fulfill the criteria of safe breast implants, and they agree with the December of 2000 opinion of the Medical Devices Agency of the Department of Health in London that the hydrogelfilled breast implants should not be used until more information about the filler material and its metabolic fate is available.

Transverse musculocutaneous gracilis flap for treatment of capsular contracture in tertiary breast reconstruction.

AbstractCapsular contracture is a common complication associated with implant-based breast reconstruction and augmentation leading to pain, displacement, and rupture. After capsulectomy and implant exchange, the problem often reappears.We performed 52 deepithelialized free transverse musculocutaneous gracilis (TMG) flaps in 33 patients for tertiary breast reconstruction or augmentation of small- and medium-sized breasts. The indications for implant removal were unnatural feel and emotion of their breasts with foreign body feel, asymmetry, pain, and sensation of cold. Anyway, most of the patients did not have a severe capsular contracture deformity. The TMG flap is formed into a cone shape by bringing the tips of the ellipse together. Depending on the contralateral breast, the muscle can also be shaped in an S-form to get more projection if needed. The operating time for unilateral TMG flap breast reconstruction or augmentation was on average 3 hours and for bilateral procedure 5 hours. One patient had a secondary revision of the donor site due to disruption of the normal gluteal fold. Eighty percent of the unilateral TMG flap reconstructions had a lipofilling procedure afterward to correct small irregularities or asymmetry.The advantages of the TMG flap such as short harvesting time, inconspicuous donor site, and the possibility of having a natural breast shape make it our first choice to treat capsular contracture after breast reconstruction and augmentation.

Unilateral breast enlargement 5 years after reduction mammaplasty.

A 26-year-old woman presented with unilateral breast enlargement 5 years after bilateral reduction mammaplasty. After careful physical examination combined with a clinical assessment, mammogram, and histologic tissue examination, the patient underwent bilateral reduction mammaplasty using an inferior wedge resection technique. Histologic examination confirmed the diagnosis of a fibrocystic breast disease in both breasts. The most common differential diagnoses are juvenile fibroadenoma, virginal hypertrophy, fibrocystic disease, and cystosarcoma phylloides.

Inframammary fold reconstruction with a deepithelialized skin flap.

Sagging of the remaining breast behind the inframammary fold after breast reduction or breast augmentation may necessitate revisional surgery. The authors achieved inframammary fold reconstruction by reconstruction of the inframammary crease ligament through a deepithelialized skin flap that is anchored to the periosteum of the fifth or sixth rib. They present their simple and safe technique.

Restoration of elbow flexion after brachial plexus injury by free functional rectus femoris muscle transfer

SUMMARY A 22-year-old patient sustained a complex injury of the left brachial plexus. Primary brachial plexus reconstruction did not lead to any functional recovery. Twenty-six months later, the patient showed an upper brachial plexus palsy, which precluded the possibility for a latissimus dorsi muscle transfer. To re-establish elbow flexion, a free myocutaneous neurovascular rectus femoris flap, harvested from the left thigh, was neurotised to the accessory nerve using a sural nerve graft. Ten months after the free functional rectus femoris transfer, early electromyographic results were detected, and 7 months later, strong reinnervation signs occurred. Due to dissatisfaction with the aesthetic results including an impression in the left shoulder and pectoral region, two silicon implants were inserted 41 months after rectus femoris muscle transfer. A few hours after the operation, the patient experienced palsy of the transplanted muscle. The silicon implants were removed immediately. Initial recovery of muscle function was detected by electromyography 4 months later and complete reinnervation was observed 8 years postoperative. Elbow flexion was rated M4, and the patient had no functional donor-site morbidity. The authors conclude that free rectus femoris muscle transfer offers excellent results when effort is put into postoperative rehabilitation with extensive training programs.

Simplification of Reduction Mammaplasty Using a Specially Designed Ruler

There are well-established techniques for reduction mammaplasty [2 5]. Especially in the beginning of the reduction mammaplasty learning process, inaccurate preoperative marking frequently causes asymmetric results. To prevent this common pitfall, we recommend a simple method for marking exact resection lines with a specially designed ruler for nearly all types of breasts. The ruler, made of transparent plastic, has a triangular shape (Fig. 1). Two straight borders have a centimeter scale including a right angle. The ruler has a red midline and also four black lines marking a 5 distance to the next line. The corner of the scaled borders is the top of the ruler. We perform a modification of the Robbins technique [1]. The initial measurements for the eventual size of the breast and nipple location are performed with them in an upright position. The upper sternal notch and the midclavicular line are marked (Fig. 2). On this line, the new position of the nipple areola is marked at a distance from the upper sternal notch suitable to the size of the patient (as a rule, 19 23 cm). This point should be located at the level of the inframammary crease. Then the top of the pattern is placed on this point, and the midline of the ruler must correspond to the midclavicular line. The lateral borders of the ruler are then marked using an angle of 90 for normal skin or 100 if the skin is flaccid. In the second case, the ruler must be turned to the next black line, which is 5 from the midline. The length of the lateral borders varies 8 to 9 cm depending on the breast size and shape to be achieved. Finally, the submammary fold is marked together with the horizontal incision lines. The lateral incision should not enter the anterior axillary line. The operation is performed with the patient under general anesthesia in a 30 upstanding position. The operation starts with the new size of the areola marked in a circular pattern 4 to 5 cm in diameter suitable to the size of the breast. The site of the inferior pedicle is marked, extending from a 2-cm area around the marked areola superiorly down to a broad base in the inframammary crease. Next, the inferior dermal pedicle to the areola and nipple is denuded. The areola on top of the inferior pedicle is separated from the underlying and adjacent breast tissue by incising around the superior and lateral margins of the areola and the pedicle, separating the areola deeply, but leaving an inner wedge of subcutaneous and breast tissue attached to the pedicle, and also leaving the base of this wedge still attached to the chest wall. The excess of breast tissue is resected along the skin markings, down to the pectoral fascia. A space for the newly formed pedicle is prepared upward of the pectoralis fascia. The breast is reshaped by bringing the medial and lateral skin flaps together, starting with suturing of both lower corners to the appropriate place in the submammary fold. The upper 4 to 4.5 cm of these flaps is temporarily closed (Fig. 3a). The vertical suture line and the inframammary suture line are closed in the usual manner. A suction drain is always used. Finally, the patient is brought to a semi-upright position. The final detailed placement of the nipple areola is always accomplished by comparing one side with the other via fixation of two circular patterns (Fig. 3b). The range of the final location is up to 2 cm. The marked area is denuded, and the temporary suture is removed. Now the nipple is placed in this area. The inferiorly based dermal pedicle technique has been used successfully during the past 10 years. It permits good cosmetic results and appears to satisfy the critical demands of a reduction mammaplasty in terms of safety, reproducibility, and aesthetics (Fig. 3c and d). The Robbins technique for reduction mammaplasty was described in 1977 [4]. The breasts are marked as for the Strömbeck [5] procedure, but the Correspondence to P. Pülzl, M.D.; email: petra.puelzl@ uibk.ac.at Aesth. Plast. Surg. 30:622 624, 2006 DOI: 10.1007/s00266-006-0059-y