Zdenko Stanec

Nipple-Areola complex preservation : Predictive factors of neoplastic Nipple-Areola complex invasion

Recently, skin-sparing mastectomy (SSM) with nipple–areola complex (NAC) preservation has been promoted as an oncologically safe procedure in practice for selected patients. The criteria of selection have not been yet defined precisely. The focus of this study was to investigate predictive factors of NAC-base neoplastic involvement to define the indications for NAC preservation. A prospective clinical study was conducted of 108 randomly selected female patients with invasive breast cancer. Analyzed markers of NAC involvement were tumor–nipple distance (TND), tumor size, localization, histologic type, grade, lymphovascular invasion (LVI), site, and axillary lymph-node status. The definitive histologic findings of the NAC base were compared with analyzed markers and the frozen section results. NAC base was positive in 23.15% patients at definitive histology with false-negative results in 4.63% patients at intraoperative frozen section. Significant differences were found in TND, tumor size, axillary lymph-node status, and LVI. There were no significant differences in tumor grade and site and not enough cases for statistical evaluation in histologic type and localization. Clinical indications for NAC preservation, according to this study, include tumors ≤2.5 cm, TND >4 cm, negative axillary lymph node status, and no LVI. Considering the possibility of pre- or intraoperative measurement, tumor size, and TND evaluation will result in the lowest possible mistakes in NAC preservation. Frozen section analyses of the NAC base, because of the “false-negative” possibility, could be deemed as a relative prognostic factor until definitive histologic findings. The presence of an extensive intraductal component (EIC) in the “borderline” cases of these criteria could be an additional argument for NAC removal.

Skin and nipple-areola complex sparing mastectomy in breast cancer patients: 15-year experience.

AbstractSkin and nipple-areola complex sparing mastectomy (SNSM) and primary reconstruction have been popular for breast cancer treatment in the last decade. An advantage of the SNSM technique is the removal of all breast tissue as a radical surgical procedure while preserving native breast integrity, nipple-areola complex (NAC), and submammary fold. This retrospective 15-year clinical study analyzes medical records from our breast surgery database collected at our department between 1997 and 2012. A total number of 3757 patients were treated for breast cancer; 411 (10.9%) patients had a skin-sparing mastectomy with the median (range) length follow-up of 63 months. This is the longest follow-up for SNSM in breast cancer patients; 3.7% of patients who underwent SNSM developed disease local recurrence, whereas occult NAC involvement with cancer occurred in 7.7% and local recurrence in the NAC in 1.2%. Partial necrosis of the NAC developed in 9.4% and total necrosis in 0.7% of operated breasts. All disease recurrences occurred in the first 10 years of the follow-up period. Local recurrence developed as first recurrence event has longer median cancer-specific survival time of 70 months than those with only distant metastases with 50 months and locoregional plus distant metastases with 35.5 months. The “Omega” pattern incision combines an oncological radical procedure with a lower incidence of skin flap necrosis. Patients reconstructed with autologous tissue were the group most satisfied. SNSM is an oncological safe procedure for breast cancer treatment with low recurrence in properly selected 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.

A composite forearm free flap for the secondary repair of the ruptured achilles tendon

Full-thickness defects of the posterior heel constitute a reconstructive challenge owing to a lack of regional soft tissue and often a long tendon gap. The remaining tendon is usually short and frayed in the distal segment, and insetting of tendon graft could be unexpectedly difficult. Wound closure and tendon reconstruction will need to be secure enough concerning future demands of full weight-bearing gait. For secondary reconstruction of Achilles tendon defects, various reconstructive approaches have been described. Reconstruction by reflection of a fascio-aponeurotic flap from the gastrocnemius muscle, 1, 2 nonvascularized 3 and vascularized 4-6 fascial or tendon grafts, or with artificial substances such as Marlex mesh 7 have been performed. However, in cases with associated skin loss, these techniques require multiple operations to reconstruct composite defects and are inherently prone to excessive scarring with resultant decreased tendon motion. Free composite flaps enable simultaneous vascularized tendon graft transfer (with its investment of paratenon) and well-vascularized skin cover. We have recently used a vascularized brachioradialis tendon in septofasciocutaneous forearm free flap attached to a distal part of a radial bone for reconstruction of an Achilles tendon rupture with skin loss and have obtained a very satisfactory result.

Omega and inverted omega incision: a concept of uniform incision in breast surgery.

In the history of breast surgery, we have seen a lot of changes in orientation, position, and localization of breast incisions. Most of the biopsy incisions have been made with no consideration of future mastectomy or reconstruction because a wide ellipse of skin removed during the mastectomy included the biopsy site. The primary surgical treatment was in the competence of the oncologic or general surgeon. Reconstruction was not an integral part of breast carcinoma therapy and was considered as a secondary, unimportant treatment to be preformed by a plastic surgeon at a later date if desired by the patient. Wide acceptance of conservative breast operations, skin-sparing mastectomy, and reconstruction as an integral part of breast cancer therapy necessitates new consideration about the initial incisions used for breast biopsy. We consider the omega incision not only as a type of incision but also as a concept that can be used for all breast surgery, including biopsy, lumpectomy, skin-sparing mastectomy, and reconstruction.

Rare complication of breast cancer irradiation: postirradiation osteosarcoma

Radiation-induced osteosarcoma is a rare complication of radiation therapy for breast cancer. The authors present a 60-year-old patient in whom osteosarcoma of the chest wall developed 5 years after modified radical mastectomy and radiation therapy for breast cancer. One year after resection of the chest osteosarcoma, metastasis to the contralateral axillary lymph nodes developed and these were removed. Radiation-induced osteosarcoma is difficult to treat and has a poor prognosis, thus early diagnosis is necessary for optimal treatment.

Algorithm for classification and treatment of poststernotomy wound infections

The treatment of sternal wound infection still carries a high mortality. Treatment preferences range from more conservative treatments that do not include flaps, to more aggressive reconstructions using different types of flaps, and these could be resolved and standardised using a proper classification with a treatment algorithm. We propose modification of the existing classification, with different proposals for treatment, stressing the importance of the radicality of debridement, and report our results in 31 patients, 24 of whom were well satisfied. Eleven were left with some pain in the chest wall, and eight each with some muscular weakness and less than adequate cosmesis. We would also like to recommend the omental flap as the first choice for selected cases. With our selective approach we have achieved good functional and aesthetic results with satisfied patients.

Deep inferior epigastric perforator flap: a modification that simplifies elevation.

The deep inferior epigastric perforator flap is accepted worldwide as a reliable and relatively safe technique for autologous breast reconstruction. Preserving the continuity of the rectus muscle, it reduces donor site morbidity, allowing less postoperative pain, a faster recovery, and a reduced hospital stay. Nevertheless, the more complex nature of this type of surgery leads to increased operating time and a demand for more tedious microsurgical dissection. The authors present a modification of the deep inferior epigastric perforator flap harvesting technique that allows a more safe, simple, and faster elevation of the flap. They have used it successfully for breast reconstruction in 3 patients.

Tumor and breast volume ratio as a predictive factor for axillary lymph node metastases in T1c ductal invasive breast cancer: prospective observational clinico-pathological study.

OBJECTIVE The status of the axilla is the single most important prognostic indicator of overall survival in patients with breast cancer. Sentinel-node biopsy has false-negative rates of 5-10%. The aim of this study was to assess the importance of tumor and breast volume ratio as a predictive factor for axillary lymph node metastases in patients with T1c ductal invasive breast cancer. METHODS This study included 136 consecutive patients with T1c ductal invasive breast cancer. Three tumor diameters were measured. Tumor volume was calculated by the formula for ellipse. Breast volume was measured preoperatively. Tumor and breast volume ratio was calculated and shown per thousand. RESULTS Tumor and breast volume ratio is a new independent predictive factor for axillary lymph node metastase in T1c ductal invasive breast cancer. CONCLUSIONS This predictive factor could help to define a subgroup of patients who will be at a higher risk for axillary lymph node metastase and would benefit from additional close follow up or axillary lymph node dissection.

Tensioning and securing of W-plasty

Abstract Running W-plasty is one of the widely used methods aimed to correct a straight scar. A technique of suturing to ensure proper tensioning and securing of the running W-plasty is presented. The wound is sutured in a running base-apical subcuticular fashion. The suture tension is then correctly adjusted and if optimal edge approximation is achieved, the redundant portions of suture from the wound ends are then tied together. If perfect edge approximation is not achieved, the wound is loosened and an additional running subcuticular suture is placed in the opposite base apical fashion. Both running sutures are then properly tensioned and tied in a similar fashion. This technique of suturing provides precise wound edge approximation, maintains the tensile strength for a long time, does not leave stitch marks, does not compress the subdermal vessels, and is simple and quick to perform.