Ram Silfen

Fascial Suspension Mastopexy

BACKGROUND The objective of this study was to assess a new procedure for breast mastopexy, fascial suspension mastopexy. METHODS Between December of 2001 and July of 2004, 52 patients (102 breasts) underwent fascial suspension mastopexy. Sixteen women had grade 1 ptosis (30 percent), 31 had grade 2 ptosis (60 percent), two had grade 3 ptosis (4 percent), two (4 percent) had breast asymmetry and underwent unilateral mastopexy, and one had pseudoptosis (2 percent). Of the 52 patients, 43 (83 percent) underwent fascial suspension mastopexy only, whereas nine patients (17 percent) underwent fascial suspension mastopexy combined with breast parenchymal excision of less than 120 g in each breast. Three patients (6 percent) underwent combined procedures. RESULTS The complication rate was 7.7 percent (four patients). Two patients underwent conversion of the vertical scar into a horizontal scar. One patient underwent drainage of a hematoma 1 day after her operation, and one patient developed a hypertrophic scar. The average follow-up was 1.4 years, with the longest follow-up being 3.5 years. On a scale of 1 (very poor) to 10 (excellent), postoperative ptosis correction was rated as 8.8, breast symmetry as 8.4, postoperative upper pole fullness as 9.1, postoperative medial breast fullness as 7.8, and overall breast shape and contour as 8.6. CONCLUSIONS Fascial suspension mastopexy is safe, simple, and versatile; does not require pectoralis major flap harvesting; and achieves an excellent suspension of breast parenchyma, creating a projected and rejuvenated breast shape with upper pole fullness and long-standing breast contour.

Breast-areola-nipple proportion.

Studies of breast volume and size have failed to take into account the aesthetic value of the nipple–areola–breast proportion. These data are important to plastic surgeons in planning breast reduction, augmentation, and reconstruction. In the current study, the anatomic size of the nipple, areola, and breast was measured in 37 women aged 20 to 64 years, and their proportions were calculated. The areola–breast and nipple–areola proportions were 1:3.4 and 1:3, respectively. The natural nipple–areola–breast proportion is approximately 1:3. This study provides a general guideline for plastic surgeons for planning breast surgery with optimal aesthetic results.

The use of serial tissue expansion in pediatric plastic surgery.

&NA; There are clinical situations in which even despite the use of simultaneous multiple tissue expanders, complete coverage of a defect cannot be achieved. In this situation, serial, repeated tissue expansion may be indicated. There are few studies that have reported repeated tissue expansion in pediatric plastic surgery. Twelve children (6 girls, 6 boys) with a mean age of 7 years underwent serial tissue expansion for giant hairy nevus (N = 3) or burn reconstruction (N = 9). A total of 63 tissue expanders were used. Serial expansion of the expanded flap was performed a second time in 12 children, a third time in 6 children, and a fourth time in 2 children. The major complication rate was 4% for the first expansion, and 20%, 18%, and 0% for the second, third, and fourth expansions respectively. Clinically, at the time of expander reinsertion, there was no evidence of capsule from the previous expander in any patient. This was confirmed on histological examination of 12 biopsy specimens. Repeated tissue expansion is a safe and effective procedure for use in pediatric plastic surgery. Hudson DA, Lazarus D, Silfen R. The use of serial tissue expansion in pediatric plastic surgery. Ann Plast Surg 2000;45:589‐594

Congenital Volkmann-Lesser ischemic contracture of the upper limb.

Neonatal vascular compromise to limbs has been associated traditionally with perinatal injury of the brachial plexus, fracture of the clavicle or humerus, or iatrogenic causes. Congenital Volkmanns ischemic contracture is an exceptional etiology of ischemic limb in the newborn. Fewer than 10 cases had been described in the literature. The authors report a newborn presenting at birth with partial bluish discoloration of the right forearm. The clinical picture and laboratory studies lead to the diagnosis of congenital Volkmann-Lesser ischemic contracture.

The digital pulp as a presenting site of metastatic esophageal carcinoma.

An unusual skin lesion may be a primary skin cancer or a sign of internal malignancy. Metastatic lesions to the hand are rare. The authors describe a patient who presented with a nodule of the digital pulp. Workup, including X-ray films and biopsy, revealed a metastatic squamous cell carcinoma invading the distal phalanx. The primary site of the tumor was the esophagus. To the best of their knowledge, this is the second case described in the literature of a metastatic carcinoma of the esophagus presenting as a lesion of the digital pulp.

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.

Penile lengthening for traumatic penile amputation due to ritual circumcision: a case report.

Some tribes in South Africa still practice ritual circumcision in adolescent boys. A traditional healer performs the procedure and, not uncommonly, amputation occurs. The authors present a case of a 20-year-old man who sustained a midshaft penile amputation as a result of a ritual circumcision. Treatment was with a modified penile-lengthening technique that incorporates gracilis muscle transposition to fill the dead space created after detaching the penile suspensory ligament. This may help prevent retraction. Almost 3 cm of lengthening was obtained. This is a useful method of treatment for penile amputation.

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.

Staged TRAM breast reconstruction: Combining the advantages of tissue expansion with surgical delay

Abstract. The TRAM flap has become the gold standard in breast reconstruction but suffers from the disadvantages of poor color match, different texture, and impaired sensation compared to the normal breast. This study reports on a two-stage procedure to address these problems. The first stage consists of insertion of a tissue expander and surgical delay of the TRAM flap. The second stage consists of removal of the tissue expander and transposition of a deepithelized TRAM flap into the tissue expanded cavity. (The capsule is excised.) Four cases of breast reconstruction are reported. The advantage of this procedure is that it offers the benefits of tissue expansion, viz., normal color match, texture, and sensation, and in addition, reconstruction is achieved with autologous tissue by a pedicled TRAM flap. The vascularity of the TRAM is enhanced by a surgical delay procedure.

Use of the SpaceMaker balloon in sternal wound closure: comparison with other techniques.

&NA; Sternal wound infection is surgically treated by debridement of the infected sternum and closure of the defect with a muscular flap. These operations tend to be long, stressful, and time‐consuming and to involve heavy blood loss. To facilitate wound closure, the SpaceMaker balloon was applied intraoperatively to expand the pectoralis major muscles and enable tensionless closure with musculocutaneous flaps. The aim of the present study was to compare the effectiveness and feasibility of this technique with a variety of others described in the literature. The study population consisted of 40 consecutive patients with sternal wound infection following median sternotomy who were treated with the advancement flap, turnover flap, transposition flap, or SpaceMaker balloon‐assisted advancement flap technique (n = 10 each). The balloon‐assisted technique was associated with a shorter length of operation and fewer blood transfusions than the other methods. Furthermore, there was no need for reoperation and there were no cases of skin necrosis. In conclusion, closure with the SpaceMaker balloonassisted bilateral pectoralis major musculocutaneous flap may serve as an adjunctive measure in the treatment of sternal wound infection. This technique seems to have advantages over simple pectoralis major musculocutaneous advancement, particularly for midsternal wounds. (Plast. Reconstr. Surg. 108: 1582, 2001.)