Richard V. Dowden

Radiation Therapy as a Cause of Capsular Contracture

The effect of radiation therapy on the final result of breast reconstruction has been debated in the literature. We have had 4 patients with bilateral breast reconstruction who then received unilateral radiation therapy. We noted in all 4 that the irradiated side became contracted, whereas the nonradiated breast reconstruction remained soft. These 4 patients were compared with the bilateral breast reconstruction not receiving radiation therapy. The contracture rate in this control group was 10% (19 of 190 breasts). The difference in contracture rate between these two groups was significant (p=0.05). A second group of patients was reviewed, unilateral reconstruction patients receiving radiation therapy to the reconstructed breast. This group was compared with bilateral reconstructions not receiving radiation therapy as a control group. The contracture rate in the unilateral reconstruction group receiving radiation therapy was 67% (7 of 11), versus the control of 10%. This difference is also significant (p=0.001). We conclude that radiation therapy of prosthetic breast reconstruction does increase the rate of capsular contracture. Therefore, we counsel our implant reconstruction patients that the risk of capsular contracture is increased if subsequent radiation therapy is required.

The tubular/tuberous breast syndrome

There are various degrees of expression of the fully developed tubular/tuberous deformity. To develop an adequate treatment plan for this condition, the individual deformities constituting the fully expressed syndrome must be diagnosed. The treatment plan must include maneuvers to correct each deficiency within the syndrome itself. We present the spectrum of abnormalities constituting the tubular/tuberous syndrome and the treatment plan thereof.

The role of the rectus abdominis myocutaneous flap in breast reconstruction.

The rectus abdominis myocutaneous flap has been used in 10 patients requiring the importation of skin, subcutaneous tissue, and muscle for postmastectomy reconstruction. It was preferred to the latissimus dorsi myocutaneous flap under the circumstances highlighted in Table I. The flap has proved reliable and easy to raise, with a consistent anatomic location of the arterial venous pedicle. In 10 such flaps performed, one partial necrosis occurred in a patient who was extremely obese and had had a previous laparotomy that may have interfered with the integrity of the underlying blood supply to the rectus abdominis muscle. A minor complication of cellulitis in the donor-site wound was due to an idiosyncratic allergy to sutures used in the subcutaneous tissue. One instance of abdominal contour deformity was noticed in a patient in whom the anterior rectus sheath had been reconstituted by advancing the fascia of the external oblique muscle to meet the linea alba in the midline. In summary, we believe that the rectus abdominis myocutaneous flap, in certain select circumstances, produces a reliable, readily accessible myocutaneous flap to import tissue to the anterior chest wall for adequate mound reconstruction after mastectomy.

Endoscopic implant evaluation and capsulotomy

Clinical use of breast endoscopy was begun 5 years ago for the purpose of internal endoscopic capsulotomy. This limited role for the endoscope has been entirely displaced by its use for inspection of implants for leaks or rupture. The materials and equipment are readily available, the proper techniques are safe for patient and implant, the method is easily learned, and the evaluation has been reliable. This report describes our first 50 breast endoscopies and details the technique and the means of learning it. The accuracy is far superior to that of mammogram or ultrasound, and to date, there have been no infections or damaged implants from the technique as described.

Complete spontaneous regression of cutaneous primary malignant melanoma

Melanomas may first present as nodal metastasis. Most of these cases have a discernible primary source. A proportion of these, however, have no apparent primary. A very few patients in this latter group actually have an identifiable primary source that regressed and disappeared. There is a set of stringent clinical and histologic criteria that must be met before a melanoma can be classified as complete spontaneous regression, and only 24 cases in the literature meet all these criteria. This report reviews those cases and presents the first report to provide sequential photographic documentation of a complete spontaneous regression of a cutaneous malignant melanoma. It also gives a 10-year follow-up, the longest in the literature.

Dispelling the myths and misconceptions about transumbilical breast augmentation.

Since its invention in 1991, the transumbilical breast augmentation (TUBA) technique has gained popularity, and it has been proven safe and effective. In addition, the technique has several advantages over other methods of breast augmentation. Nevertheless, the method has often been the subject of a great variety of criticisms. Careful examination of those criticisms reveals that most are, in fact, untrue; they are misconceptions at best and falsehoods at worst. In this article, the author examines the 20 most common misconceptions about this procedure, clarifies or corrects them as appropriate, and suggests possible reasons for their having arisen in the first place. In addition, the actual drawbacks of the technique are reviewed. The author also outlines what he considers to be the criteria necessary for a surgeon to criticize any technique being used successfully by others: the surgeon must have proper plastic surgical training and certification, have completed training in the specific technique, and have a personal experience with performing a minimum number of cases.

The Vastus Lateralis Muscle Flap: Technique and Applications

The vastus lateralis muscle can provide a broad sheet of muscle for repair of defects of the lower abdomen, groin, perineum, hip, and ischium. The authors limit the use of the vastus lateralis muscle to situations in which more traditional techniques are not feasible. This muscle is especially suitable for defects involving irradiated tissue, infected bone, or infected prosthetic materials. Although the vastus lateralis muscle has no cutaneous component, it may be used to augment an overlying tensor fascia lata flap.

Achieving a natural inframammary fold and ptotic effect in the reconstructed breast.

Achieving a natural inframammary fold in the reconstructed breast is a challenging but essential aspect of the excellent result for which we strive. Just as there are many methods of reconstruction, so too are there many ways to enhance the effect of a distinct fold in the reconstructed breast. Several of these techniques are discussed here, including methods for use with flaps, advancements, and expanders, with particular emphasis on implant reconstructions, both immediate and delayed. Also covered are the contributions of external massage and open capsulotomy toward this objective.

The Effect of Hyaluronidase and Dimethyl Sulfoxide (DMSO) on Experimental Skin Flap Survival

Hyaluronidase has been shown clinically and experimentally to reduce the effects of tissue ischemia in myocardial infarction and hemorrhagic shock. Dimethyl sulfoxide (DMSO) has been shown to reverse the effects of cerebral ischemia in the primate model. A caudally based dorsal skin flap in the rat was used to study the effects of these two drugs in physiological doses on skin flaps, and to investigate their mechanisms of action.This study demonstrates that both hyaluronidase and DMSO, which are nontoxic in physiological doses, can increase the surviving length of an experimental skin Pap. It is hypothesized that these substances exert their effect by decreasing tissue edema and by aiding in the transport of nutritive substances to the flap during its acute phase.

Muscle flap reconstruction of shoulder defects

Defects of the shoulder area pose difficult problems for the hand surgeon, especially when associated with irradiation or exposed, infected bone. The development of muscle and myocutaneous flaps has greatly simplified the reconstruction of such defects. This report discusses the use of the pectoralis and the latissimus flaps for this purpose, with case examples and emphasis upon technique and applications.