Pietro Berrino

Postquadrantectomy breast deformities: classification and techniques of surgical correction.

The deformity which is encountered following quadrantectomy (or similar procedures such as segmentectomy or partial mastectomy) and radiation therapy is difficult to evaluate objectively, and subjective assessment of the cosmetic outcome is extremely variable. In a group of 54 patients who underwent the procedure between 1979 and 1983, the types of cosmetic changes were evaluated and classified according to morphologic criteria. Four types of deformities and their related etiopathologic factors were identified. Type I is characterized by malposition and distortion of the nipple-areola complex and is mainly due to postoperative fibrosis and scar contracture. In type II deformity, localized tissue insufficiency is observed, which may be due to skin deficiency (type IIa), subcutaneous tissue deficiency (type IIb), or both (type IIab). Type III deformity is characterized by breast retraction and shrinkage and is mainly due to the effects of radiotherapy on residual breast parenchyma. In type IV deformity, severe radiation-induced damage to the skin, nipple-areola complex, and subcutaneous and glandular tissues is present. Surgical correction of each type of deformity is discussed, and examples are reported.

Prefabricated engineered bone flaps: An experimental model of tissue reconstruction in plastic surgery

&NA; In light of the recently described experimental technique of in vivo bone reconstitution with biotechnologic methods (from bone marrow stromal cells) and the prefabrication flap procedures, the possibility to obtain autologous bone growth in a myocutaneous flap, thus creating a composite osteomyocutaneous preformed flap, is postulated. Human bone marrow stromal cells were delivered into the latissimus dorsi of athymic mice by a porous hydroxyapatite ceramic model. Eight weeks after the implantation, histologic examination revealed the presence of spongious bone tissue. A simple myocutaneous flap was thus transformed into a composite osteomyocutaneous flap. This flap is called the biotechnologic prefabricated flap, because it was the result of ex vivo expanded osteogenic precursor cells and in vivo bone tissue neoformation. The shape of the bone flap was exactly the same as the shape of the ceramic model used. A possible clinical application may be the correction of skeletal defects. The advantages of this procedure are simple surgical execution, the possibility of preshaping the graft to the exact characteristics of the defect, and the availability of autogenous donor tissue without donor site morbidity.

Psychological evaluation of patients undergoing breast reconstruction using two different methods: autologous tissues versus prostheses.

Breast reconstruction has become an available option for most patients undergoing mastectomy. In fact, many authors agree that breast reconstruction does not interfere with possible therapies and improves the womens quality of life. The aim of this study was to evaluate the psychological adjustment of patients who had immediate or delayed reconstruction using two different methods: implants and autologous tissues. Specifically, it was explored whether the different methods of breast reconstruction have caused significant changes in psychological functioning. The study population (102 patients) was derived from patients who underwent breast reconstruction in the period January 1988 to December 1991 at the Department of Plastic and Reconstructive Surgery of the National Institute for Cancer Research in Genoa, Italy. Fifty-two patients underwent breast reconstruction using implants and 50 using the transverse rectus abdominis myocutaneous (TRAM) flap. Demographic information was gathered from each patient. The psychological instruments consisted of three standardized self-administered questionnaires: Psychological Distress Inventory, State Trait Anxiety Inventory, Form Y, and the Eysenck Personality Inventory. To better assess the changes in body image after breast reconstruction, three more specific questions about sexual desire, physical image, and social relationships were added. The 102 patients assessed in this study indicated a low incidence of psychological distress. Impairment was reported regarding body image by patients who underwent delayed reconstruction; these patients also showed higher distress scores. The type of breast reconstruction also seems to influence body image, showing in the patients with TRAM flap reconstruction more relevant psychological discomfort.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term evaluation of the abdominal wall competence after total and selective harvesting of the rectus abdominis muscle.

Fifty patients who underwent unilateral breast reconstruction by transverse rectus abdominis musculocutaneous flap transposition between January 1987 and December 1989 are the object of this study. Every patient underwent selective harvesting of the medial portion of the muscle, whereas the lateral strip was left in place and studied intraoperatively by selective stimulation of the ninth intercostal motor nerve before closure of the fascial defect. Two separate ecographic scans of the abdominal wall were performed respectively 7 days and 6 months postoperatively, to evaluate the diameters of the residual portion of the rectus muscle and its long-term evolution. Our results show that in a considerable number of patients, the lateral strip of rectus was denervated at surgery. Long-term ecographic scans demonstrate, however, that in spite of this finding, the residual muscle usually maintains its diameters, thus significantly contributing to the competence of the abdominal wall, at least from the static point of view.

The transverse rectus abdominis musculocutaneous flap for breast reconstruction in obese patients

Transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction has often been considered contraindicated in obese women. The morphological characteristics peculiar to this population, however, make obese women ideal candidates for this procedure because the reconstructed breast must often match a large ptotic contralateral breast. About one-third of our postmastectomy patients are corpulent, middle-aged women with “Mediterranean” body structures. Thirty-four obese women underwent TRAM flap breast reconstruction from 1985 to 1988. According to the Body Mass Index, 23 women had type II obesity and 11 had type III obesity. The preoperative and postoperative management and the surgical procedure were adapted to this particular group of women. The complication rate in this series of women was superior to that of a nonobese population; however, no severe complications were observed. The majority of women were extremely satisfied with aesthetic results; the surgeons also judged the final cosmetic outcome to be very favorable and, indeed, superior to that obtainable with simpler methods. Obesity uncomplicated by other risk factors does not represent an absolute contraindication to TRAM flap procedure.

Correction of Type Ii Breast Deformities Following Conservative Cancer Surgery

Breast deformities following conservative cancer surgery are seen with increasing frequency and often represent difficult reconstructive problems. Type II deformities are characterized by localized tissue insufficiency, which can be due to skin insufficiency (type IIa), subcutaneous tissue insufficiency (type IIb), or both (type IIab). Correction of a locally damaged breast is a surgical challenge that can result in a fully restored breast if selection of the surgical procedure is properly carried out. A series of 37 patients who underwent correction of type II deformities from 1980 to 1989 was reviewed. Results obtained with different surgical procedures, including simple submuscular placement of traditional or expandable implants, breast reshaping, transposition of a latissimus dorsi muscle or musculocutaneous flap, TRAM flap, and reverse abdominoplasty, were evaluated. Aesthetic outcome was judged to be good or excellent in 78 percent of patients. Guidelines for selection of the most appropriate surgical procedure according to the defects etiology, morphology, and location and to the breasts size and shape are presented.

Long-lasting complications with the use of polyurethane-covered breast implants

Polyurethane-covered breast implants have been recommended by some authors for aesthetic and reconstructive procedures, since with these implants the incidence of capsular contracture is insignificant and risks of implant displacement or exposure are reduced. Reports on the use of these implants focus merely on aesthetic aspects, and risks associated with disintegration and incorporation of the polyurethane-coating are often overlooked. The authors have observed several complications associated with the use of these prostheses; two cases of long-lasting complication are described, which are ascribed to difficult removal of infected fragments of the coat and to delayed foreign body reaction to polyurethane. The authors believe that the hazards associated with these implants outweigh their advantages for primary use, but suggest their use for secondary procedures in patients who have had recurrent problems with smooth implants.

Immediate reconstruction of the penis using an inferiorly based rectus abdominis myocutaneous flap

A new method for reconstruction of the penis using an inferiorly based rectus abdominis myocutaneous flap is described that seems to be particularly suitable for immediate one-stage reconstruction. Function of the residual portion of rectus muscle is preserved, and the abdominal wall is not significantly weakened.

Vertical Mammaplasty: A Personal Approach

Abstract. We have been using the vertical mammaplasty technique with personal adjustments for reduction mammaplasty and glandular resection since 1989. There were 63 cases of aesthetic reduction mammaplasty and mastopexy and 38 cases of reduction mammaplasty and mastopexy contralateral to breast reconstruction with implants and/or autologous tissues performed during the period from 1989 to 1993. The aim of this work is to discuss the complications, long-term results, and limitations to this technique.

Poland's syndrome: correction of thoracic anomaly through minimal incisions.

A method that minimizes residual scarring following Polands syndrome correction by latissimus dorsi muscle transposition and placement of a submuscular breast implant is described. In order to reduce any resulting unsightly scarring and, in particular, eliminate the anterior thoracic scar, both a dorsal S-shape and an axillary incision were made and the muscle flap was raised. A prosthesis was then inserted and the muscle flap sutured to the anterior chest wall through an anterior incision symmetrical to the inferior border of the contralateral areola. The latter is a previously undescribed approach that produces good cosmetic results.