Breast reconstruction utilizing subcutaneous tissue expansion followed by polyurethane-covered silicone implants: a 6-year experience

Reconstruction of the breast after modified radical mastectomy can be safely and adequately performed in the subcutaneous plane. Placement of a subcutaneous tissue expander (as either an immediate or a delayed procedure), rapid expansion over a 3- to 4-month period, capsulotomy, and placement of a polyurethane-coated implant have led to satisfactory results over a 6-year period. Breast reconstruction methods are well documented; however, the utilization of expanded subcutaneous chest wall skin has not been reported heretofore.     

Mandibular reconstruction using microvascular free flaps: a statistical analysis of 178 cases.

For this article, 178 consecutive cases of mandibular reconstruction using microvascular free flaps and performed from 1979 to 1997 were studied. The purpose of this report is to compare flap success rates, complications, and aesthetic and functional results. The ages of the 131 men and 47 women ranged from 13 to 85 years, with an average of 55 years. Donor sites included the rib (11 cases), radius (one case), ilium (36 cases), scapula (51 cases), fibula (34 cases), and soft-tissue flaps with implant (45 cases). Complications included total flap necrosis, partial flap necrosis, major fistula formation, and minor fistula formation. The rate of total flap necrosis involving the ilium and fibula was significantly higher than that of all other materials combined (p < 0.05). The overall rate of implant plate removal, which resulted from the exposure or fracture of the plate, was 35.6 percent (16 of 45 cases).Each mandibular defect was classified by the extent of the bony defect and by the extent of the soft-tissue defect. The extent of the mandibular bony defect was classified according to the HCL method of Jewer et al. The extent of the soft-tissue defect was classified into four groups: none, skin, mucosal, and through-and-through. According to these classifications, functional and aesthetic assessments of deglutition and contour were performed on 115 subjects, and speech was evaluated in 110. To evaluate the postoperative results, points were assigned to each assessment of deglutition, speech, and mandibular contour. Statistical analysis between pairs of bone-defect groups revealed that there was no significant difference in each category. Regarding deglutition, statistical analysis between pairs of soft-tissue-defect groups revealed there were significant differences (p < 0.05) between the none and the mucosal groups and also between the none and the through-and-through groups. Regarding speech, there was a significant difference (p < 0.05) between the none and the through-and-through groups. Regarding contour, there were significant differences (p < 0.01) between the none and the through-and-through groups and between the mucosal and the through-and-through groups. The points given for each function, depending on the reconstruction material, revealed that there was no significant difference between pairs of material groups.From this prospective study, the authors have developed an algorithm for oromandibular reconstruction. When the bony defect is lateral, the ilium, fibula, or scapula should be chosen as the donor site, depending on the extent of the soft-tissue defect. When the bony defect is anterior, the fibula is always the best choice. When the soft-tissue defect is extensive or through-and-through with an anterior bony defect, the fibula should be used with other soft-tissue flaps.     

The inferior gluteal free flap in breast reconstruction

The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Its arteriovenous pedicle is longer than the superior gluteal musculocutaneous free-flap pedicle and permits microvascular anastomosis in the axilla, avoiding medial rib and cartilage resection. In the thin patient, there is more available donor tissue than with the superior gluteal musculocutaneous free flap. Cadaver dissections confirm the greater pedicle length and the local area of the lower gluteus maximus muscle needed to carry the skin island and have helped define a safe approach to flap elevation. We have used four flaps for breast reconstruction without vascular compromise or the need for reexploration. The low donor-site scar in the inferior buttock fold has been acceptable, especially for a bilateral reconstruction. The anatomy of the gluteal region, the surgical technique for the inferior gluteal free-flap transfer, and a 3-year patient follow-up are presented.     

Breast reconstruction with implants and expanders

Breast reconstruction with expanders and implants provides an excellent option in the properly selected patient. Techniques for reconstruction have evolved significantly over the past 30 years with the development of more sophisticated devices and improvement in surgical procedures. Several options exist, each with its own advantages and disadvantages. Two-stage breast reconstruction using a textured device with an anatomic shape and integrated valve seems to provide the most consistent and reproducible results in most patients. Those patients with small, minimally ptotic breasts may be candidates for either single-stage implant reconstruction or reconstruction with an adjustable device. Advantages of expander and implant reconstruction over other techniques include relative ease of the procedure; no distant donor-site morbidity; use of tissue of similar color, texture, and sensation; reduced operative time; and more rapid postoperative recovery.     

Breast reconstruction with abdominal flaps after abdominoplasties.

After the reported safe transverse rectus abdominis myocutaneous (TRAM) flap after liposuction of the abdomen, two cases of bipedicled reconstruction with this flap after abdominoplasty were successfully performed. This operation has not previously been considered possible because of the transection of the perforator arteries during the undermining of the abdomen. To examine the possible reperfusion of the perforator arteries, the authors studied the perforator arteries of 10 patients before they underwent abdominoplasty and at 1 week, 3 months, and 6 months after the operation. The arteries were studied with color-duplex scanning and power Doppler, using 10-MHz superficial probes, and their position was marked on a map. A cadaver study of a woman who had had an abdominoplasty 10 years before her death is also presented. In every patient, reperfusion of all perforator arteries was documented, starting from the control at 1 month. In no case was the caliber of the reperfused vessels more than 40 percent of the original diameter (maximum: 0.53 mm). This was also confirmed by the cadaver study. In conclusion, after an abdominoplasty operation, constant reperfusion of the perforator arteries of the rectus muscles occurs. However, the diameter of the arteries may not be enough to provide the necessary blood supply for a TRAM flap, which is therefore strongly discouraged by the authors after abdominoplasty in favor of a vertical rectus abdominis muscle (VRAM) flap. A liposuction, which does not necessarily disrupt the perforators, is not an absolute contraindication for a TRAM flap, provided that an accurate color-duplex scanning study is done.     

Thumb reconstruction by free microvascular transfer of an injured index finger

Thumb reconstruction for amputation at the metacarpal phalangeal level was accomplished by microneurovascular transfer of the contralateral damaged index finger ray, including metacarpal phalangeal joint. This transfer accomplished a successful thumb restoration and removed a cumbersome index finger amputation stump, improving function in both hands. This case emphasizes the merits of spare part transfer in hand reconstructive surgery made possible by microneurovascular techniques.     

Microvascular free transfer of iliac bone based on the deep superior branches of the superior gluteal vessels

The findings from dissection, injection studies, corrosion specimens, and angiograms in 300 specimens of the iliogluteal region taken from 150 cadavers are reported. These findings suggest that the deep superior branches of the superior gluteal vessels may serve a nutritive pedicle in microvascular free transfer of iliac bone. Therefore, the operative technique has been developed and applied clinically with good results. The selection of different vessels as a nutritive pedicle for the free transfer of iliac bone is discussed.