Investigation of TRAM flap oxygenation and perfusion by near-infrared reflection spectroscopy and color-coded duplex sonography

Near-infrared reflection spectroscopy, used experimentally for investigation of tissue hemoglobin content and oxygenation in various flaps, was tested in the pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, chosen as a simple clinical model because of its well-known vascular anatomy and clinical relevance. The study intended to answer the following questions: Does the near-infrared reflection spectroscopy system used in this study measure tissue hemoglobin content and oxygenation in the superficial skin layers only, as proposed by the manufacturer? Is near-infrared reflection spectroscopy able to detect differences of tissue hemoglobin content and oxygenation in distinct zones of the TRAM flap skin before, early, and late after surgery? Does tissue hemoglobin content and oxygenation correspond to blood flow in the supplying superior epigastric artery and to clinical signs of TRAM flap perfusion and viability? In 11 patients, tissue hemoglobin content and oxygenation in the lower abdomen/TRAM flap, mastectomy skin flap, and contralateral breast were measured by a new near-infrared reflection spectroscopy system preoperatively, early postoperatively, and late postoperatively. Simultaneously, systolic peak flow in the ipsilateral superior epigastric artery was obtained by color-coded duplex sonography. Routine clinical monitoring was performed throughout the early postoperative period. Tissue hemoglobin content and oxygenation in the lower abdomen, mastectomy skin flap, and contralateral breast were similar before surgery but varied considerably between different patients. There were no significant differences among preoperative, early postoperative, and late postoperative values of tissue hemoglobin content and oxygenation in the mastectomy skin flap and contralateral breast. However, near-infrared reflection spectroscopy measurements of the TRAM flap revealed significant differences between preoperative and early postoperative values of tissue hemoglobin content and oxygenation and among zones I, II, and III early after surgery. Tissue hemoglobin content in the TRAM flap skin increased and oxygenation decreased early after surgery. Near-infrared reflection spectroscopy values corresponded to clinical signs of venous congestion predominantly in zone III. Late postoperative return of hemoglobin content and oxygenation in the TRAM flap toward preoperative values can be attributed to improved venous return by reversed flow across regurgitant valves and development of collateral circulation. Finally, there was a significant increase of systolic peak flow in the ipsilateral superior epigastric artery early after surgery. This could be related to the opening of small-caliber choke arteries between the superior and deep inferior epigastric arteries following ligation of the dominant deep inferior epigastric artery and TRAM flap transfer to the chest. Systolic peak flow returned to preoperative values late after surgery. The near-infrared reflection spectroscopy system used in this study appeared to measure hemoglobin content and oxygenation in the superficial skin layers only. Near-infrared reflection spectroscopy was able to detect differences of tissue hemoglobin content and oxygenation in the TRAM flap between preoperative and postoperative measurements and between distinct zones of the TRAM flap early postoperatively. Postoperative changes in near-infrared reflection spectroscopy values corresponded to clinical observations and blood flow in the superior epigastric artery measured by color-coded duplex sonography. Further experience is needed before near-infrared reflection spectroscopy can be advocated for routine clinical flap monitoring.     

Repeat reduction mammaplasty

Repeat reduction mammaplasty is an uncommonly performed procedure. Currently, no clear operative guidelines of management exist. Sixteen patients (28 breasts) with a mean age of 29 years (range, 13 to 52 years) underwent repeat breast reduction over an 11-year period. Before the first reduction, the mean notch to nipple distance was 29.6 cm (range, 24 to 38 cm) and mean nipple to inframammary crease distance was 15.5 cm (range, 12 to 18 cm). The mean mass of tissue excised was 615 g per breast. A number of different pedicles were used (six inferior, five superior, four superomedial, one unknown). All patients subsequently developed pseudoptosis. The nipple to inframammary crease distance was a mean of 11.4 cm (having initially been set at 7 cm) before the second procedure. At the second operation, two patients (three breasts) had their initial pedicles transected and the nipple-areola complex moved, and both patients developed vascular compromise of the nipple-areola complex (two breasts). Where the same pedicle was used in the second operation (five patients, 10 breasts), one patient developed unilateral nipple-areola complex necrosis. In eight patients, because of the development of pseudoptosis, the nipple was in a satisfactory position, and therefore only an inferior wedge of tissue required excision. This was performed without nipple-areola complex compromise, irrespective of the initial pedicle. The mean mass of tissue excised in the second operation was 325 g per breast (range, 120 to 620 g). Fourteen patients were available for follow-up after a mean of 5.1 years (range, 3 months to 11.7 years) following the repeat reduction mammaplasty. In the repeat breast reduction, where nipple-areola complex transposition is planned, the initial pedicle should be reused to maintain nipple-areola complex perfusion. Where the initial pedicle is not known, a free nipple graft may be the safest option. In patients with pseudoptosis, in whom the nipple does not require transposition, an inferior wedge of tissue can be safely excised, irrespective of the initial pedicle.     

Medial pedicle reduction mammaplasty for severe mammary hypertrophy

Current options in reduction mammaplasty for severe mammary hypertrophy include amputation with free-nipple graft as well as the inferior pedicle and bipedicle techniques. Complications of these procedures include nipple-areola necrosis, insensitivity, and hypopigmentation. The purpose of this study was to determine whether medial pedicle reduction mammaplasty can minimize these complications. Twenty-three patients with severe mammary hypertrophy were studied. The medial pedicle successfully transposed the nipple-areola complex in 44 of 45 breasts (98 percent). Mean change in nipple position was 17.1 cm, and mean weight of tissue removed was 1604 g per breast. Nipple-areola sensation was retained in 43 of 44 breasts (98 percent) using a medial pedicle. Hypopigmentation was not observed, and central breast projection was restored in all patients. This study has demonstrated that medial pedicle reduction mammaplasty is a safe and reliable technique and should be given primary consideration in cases of severe mammary hypertrophy.     

Secondary reduction mammaplasty: is using a different pedicle safe?

Reduction mammaplasty is a frequently performed procedure and one with consistent patient satisfaction. Few patients present for revisional procedures, and even fewer present for a secondary or repeated reduction mammaplasty. This study defines secondary reduction mammaplasty as performing an additional reduction using a pedicled nipple-areola complex. Few reports of secondary reduction are found in the literature. Operative guidelines for secondary reduction mammaplasty have been published recently. However, the experience of others has differed from these guidelines, and herein is presented another experience with secondary reduction mammaplasty. Ten cases of secondary reduction over a 37-year period were identified and reviewed. The initial reductions were performed using six different techniques. An average of 307 g of tissue per breast (range, 130 to 552 g) was removed at the initial operations. The secondary reductions were performed using four different techniques, and an average of 458 g of tissue per breast (range, 147 to 700 g) was removed at the secondary operations. Three of the 10 patients underwent initial and secondary reduction with the same technique. An average of 4 years (range, 1 to 10 years) separated these surgeries. Seven of the 10 patients underwent initial and secondary reductions with different technique. An average of 15 years (range, 5 to 19 years) separated these procedures. There was an average 5-year follow-up (range, 1 to 20 years) in this series. Four of the 10 patients experienced self-limiting complications after secondary reduction, including delay in wound healing, delay in the return of nipple sensitivity, and mild fat necrosis. Three of the four patients with complications had undergone secondary reduction with a different pedicle technique. No significant or long-lasting skin, pedicle, or nipple-areola complex compromise was found after secondary reduction mammaplasty. In contrast to the recently published guidelines, this study demonstrates that secondary reduction mammaplasty is a safe and viable option when performed with either similar or different technique. This finding allows secondary reduction mammaplasty to be tailored to the individual breast type and to the abilities of the specific surgeon.     

Assessment of skin flaps using optically based methods for measuring blood flow and oxygenation

The objective of this study was to compare two noninvasive techniques, laser Doppler and optical spectroscopy, for monitoring hemodynamic changes in skin flaps. Animal models for assessing these changes in microvascular free flaps and pedicle flaps were investigated. A 2 x 3-cm free flap model based on the epigastric vein-artery pair and a reversed MacFarlane 3 x 10-cm pedicle flap model were used in this study. Animals were divided into four groups, with groups 1 (n = 6) and 2 (n = 4) undergoing epigastric free flap surgery and groups 3 (n = 3) and 4 (n = 10) undergoing pedicle flap surgery. Groups 1 and 4 served as controls for each of the flap models. Groups 2 and 3 served as ischemia-reperfusion models. Optical spectroscopy provides a measure of hemoglobin oxygen saturation and blood volume, and the laser Doppler method measures blood flow. Optical spectroscopy proved to be consistently more reliable in detecting problems with arterial in flow compared with laser Doppler assessments. When spectroscopy was used in an imaging configuration, oxygen saturation images of the entire flap were generated, thus creating a visual picture of global flap health. In both single-point and imaging modes the technique was sensitive to vessel manipulation, with the immediate post operative images providing an accurate prediction of eventual outcome. This series of skin flap studies suggests a potential role for optical spectroscopy and spectroscopic imaging in the clinical assessment of skin flaps.     

Preservation of projection after reduction mammaplasty: long-term follow-up of the inferior pedicle technique

In reduction mammaplasty by the inferior pedicle technique, the dermal-breast pedicle can be manipulated to form a central breast mound and enhance breast projection. When this technique is applied both to macromastia and breast asymmetry, excellent early results are reported. To study the effects of time on breast reduction, 22 patients were followed for an average of 4.7 years. Contour of the breast mound and projection are well preserved. However, evaluation of long-term results reveals a gradual increase in the inframammary fold to inferior areola distance. Since no increase in the midclavicle to nipple distance is observed, inferior migration of the breast parenchyma and superior displacement of the nipple-areola with respect to the breast mound occur after reduction mammaplasty with the inferior pedicle technique.     

Hyperbaric Oxygen Therapy to Treat Diabetes Impaired Wound Healing in Rats

Wound healing in diabetes is frequently impaired and its treatment remains a challenge. Hyperbaric oxygen therapy (HBOT) receives a wide attendance and is often used as a last resort treatment option, however, its effectiveness for many conditions is unproven. We tested the effect of HBOT on healing of diabetic ulcers in an animal experimental setting. Experimental diabetes was induced by intraperitoneal injection of streptozotocin. Four weeks after diabetes induction, rats were ulcerated by clamping a pair of magnet disks on the dorsal skin for 16 h. After magnet removal, the animals received HBOT, daily on weekdays, for 4 weeks. To examine the effect of HBOT on diabetes impaired wound healing, the degree of wound tissue perfusion, inflammation, angiogenesis, and tissue breaking strength were evaluated. HBOT effects on the degree of inflammation and number of blood vessels could not be observed. HBOT improved the tissue breaking strength of the wound, however, this did not reach statistical significance. Twenty hours after ending the HBOT, a significantly improved oxygen saturation of the hemoglobin at the venous end of the capillaries and the quantity of hemoglobin in the micro-blood vessels was measured.     

Quantitation of breast sensibility following reduction mammaplasty: a comparison of inferior and medial pedicle techniques

The preservation of sensitivity within the nipple-areola complex is of paramount importance to patients presenting for reconstructive and aesthetic breast procedures. Previous attempts to measure sensation in the breast before and after surgery have relied primarily on the Semmes-Weinstein monofilament test, which is an imprecise study that measures the logarithm of force necessary to bend a series of six to 20 filaments. Within the last 10 years, various authors have published normative pressure threshold data for the breast that have varied by a magnitude of greater than 10-fold. Recently, precise anatomic studies have been performed that have elucidated the innervation of the nipple-areola complex medially and laterally from cutaneous branches of the intercostal nerves. Despite this knowledge, no quantitative sensibility studies have yet been performed that compare postoperative sensation when medially versus laterally innervated pedicles have been used in reduction mammaplasty. The present study is the first to use computer-assisted neurosensory testing to generate normal breast sensation data and to compare sensory outcomes between the inferior and the medial pedicle techniques of reduction mammaplasty.A total of 34 patients were divided into four groups and underwent breast sensory testing (67 breasts total) using the Pressure-Specified Sensory Device, a computer-assisted force transducer that measures static and moving one and two-point discrimination. Sensation in the nipple and in the four quadrants of the areola was measured. Groups I and II were composed of 17 unoperated controls with breast sizes ranging from 34A to 36C (group I; 18 breasts) and 36DD to 46EE (group II; 16 breasts) who presented to a general plastic surgery clinic. Groups III and IV were composed of 17 patients who underwent either medial or inferior pedicle reduction mammaplasty between July of 1997 and March of 1999. Pressure thresholds in the most sensitive breasts were as low as 0.3 g/mm2, a marked contrast to data from previous studies using Semmes-Weinstein monofilaments documenting the lowest recordable pressure threshold as greater than 2 g/mm2. Several findings from previous studies using Semmes-Weinstein monofilament testing were confirmed in unoperated controls, including an inverse relationship between sensitivity and breast size, superior nipple sensitivity when compared with the areola, and significant interpatient variability with respect to static and moving two-point discrimination among women matched according to age and breast size. When comparing medial with inferior pedicle reduction mammaplasty patients, it was found that despite significantly greater reductions using the medial pedicle technique (mean of 1.7 kg versus 1.1 kg of breast tissue removed), there were no significant differences in postoperative sensory outcomes in the sample size of 17 patients. Furthermore, within each group of patients undergoing either the medial or inferior pedicle technique, the amount of breast tissue removed did not correlate with postoperative sensory outcomes.Computer-assisted quantitative neurosensory testing is a highly accurate technique for measuring sensibility. The use of this technology demonstrates a 10-fold difference in measurable sensory thresholds in normal patients from preexisting data using Semmes-Weinstein monofilaments. Advances in measurement methods have allowed the authors to compare postoperative sensory outcomes reliably using two popular techniques of reduction mammaplasty.     

Reduction mammaplasty following radiation therapy for breast cancer.

This report describes an unusual case in which reduction mammaplasty was performed following radiation therapy for breast cancer. While healing was significantly prolonged (compared with the nonirradiated contralateral breast), the final result was satisfactory from both the functional and the aesthetic standpoint. Women with prior radiation therapy may be considered candidates for reduction mammaplasty. Patients should be warned of the increased risks of wound complications, the likelihood of delayed healing, and the possibility of pigmentation changes in the grafted nipple-areola complex. We elected to transpose the nipple as a full-thickness graft, but consideration also might be given to use of an inferiorly based pedicle flap.     

Reduction mammaplasty using the inferior glandular "pyramid" pedicle: experiences with 300 patients

A comprehensive review of 300 patients undergoing reduction mammaplasty (576 breasts) based on an inferior glandular pedicle is presented. The average age was 31.7 years, weight 146.6 lbs., and the amount of tissue removed 1313.6 gm. No deepithelialization of the skin was performed, and average operating time was 174 minutes. The average distance the nipple-areola complex was moved was 12 cm, with the longest being 22.5 cm. Fifty-seven percent had fibrocystic mastopathy on histologic analysis, and no malignancies were found, even in patients who had undergone a previous mastectomy for breast carcinoma. The most common complication (3.1 percent) was minor suture line necrosis along the infra-mammary crease. All healed without intervention. There was no necrosis or sensory loss to the nipple-areola complex in any patient, and cosmesis was excellent. The analysis also showed that the use of epinephrine, injected subcutaneously just prior to the operation, significantly decreased intraoperative blood loss (p less than 0.0005), regardless of the amount of tissue removed, and eliminated the need for transfusions.     

Reduction mammaplasty in postburn breasts.

Thermal injury to the anterior chest in the adolescent girl can lead to severe disfigurement of the breasts. Just as in certain non-burn female patients, mammary hyperplasia can occur in patients with previous full-thickness burns of their breasts. Most plastic surgeons have been reluctant to perform reduction mammaplasty in these patients for fear of devascularizing the skin graft or the nipple-areola complex. A series of six patients with full-thickness burns of the breasts and subsequent skin graft coverage before reduction mammaplasty is reported. Four patients had bilaterally burned breasts requiring reduction. Two patients had one burned breast reduced, and one required a balancing procedure on the unburned side. Reduction mammaplasty was performed using the inferior-pedicle technique. The mean amount of tissue removed for the left and right breasts was 454 and 395 g, respectively. There was no nipple loss, hematoma, infection, or major loss of skin flaps. Reduction mammaplasty in this group of patients is safe and carries minimal risk if certain key concepts are followed carefully.     

Reduction mammaplasty with superior-lateral dermoglandular pedicle: another alternative

During a period of 7.5 years, reduction mammaplasty using a superior-lateral dermoglandular pedicle was performed in 213 mammary glands in 112 patients. This procedure is a modification of the original technique by Skoog that takes advantage of its benefits but adds two basic premises: (1) to preserve the integrity of the galactophorous ducts for future nursing and (2) to cause less innervation injury. Patients were followed for an average of 28 months (range, 3 months to 7.5 years). The quantity of extirpated tissue ranged from 310 to 1380 g, with a median of 520 g. The nipple-areola complex migrated 5 to 14.5 cm (median, 7.8 cm). The most severe complication was partial necrosis of the nipple-areola complex, which occurred in five cases (four patients). This complication occurred only during the first 2 years of the study, in breast resections larger than 800 g, and with migrations larger than 10 cm. This problem resulted in a modification of the technique, and the complication has not occurred for the past 5 years. There were no important alterations in the sensibility of the nipple-areola complex nor in the integrity of the galactophorous ducts. The long-term satisfaction of the patients was high. The authors present an easily designed and accomplishable technique that is applicable to patients with severe hypertrophy and gigantomastia. The technique has a high security index, and the integrity of the mammary gland is maintained to the maximum.     

Breast sensitivity after vertical mammaplasty

Breast sensation after reduction mammaplasty is a major concern for surgeons and patients. The sensitivity of 80 breasts that were reduced using Lejour's technique (a superior dermoglandular pedicle with resection at the lower quadrants) was assessed in a prospective study. Ten points were selected on each breast for this study, including the nipple, four points on the areola, and five points on the breast skin. The measurements were performed preoperatively and at 3, 6, and 12 months postoperatively. Pressure thresholds were measured with 20 Semmes-Weinstein monofilaments, temperature sensitivity with hot and cold metal probes, vibratory thresholds with the Biotesiometer, and static and moving two-point discrimination tests with a Disk-Criminator. To assess the influence of breast ptosis and hypertrophy on sensitivity, the population was divided into two groups. In group I (19 patients), the sternal notch-to-nipple distance was less than 29 cm, and less than 500 g of tissue per breast was removed. In group II (21 patients), the sternal notch-to-nipple distance was more than 29 cm, and more than 500 g of tissue was resected. The sensitivity on the nipple and areola was significantly decreased at 3 and 6 months postoperatively for all modalities. At 1 year, sensitivity recovered, and no breast or nipple-areola complex was insensitive. Pressure sensitivity was not significantly different from the preoperative measurement in any area of the breast or in either group of patients, except for superior breast skin, for which sensitivity was improved in group II (p = 0.0004). Temperature sensitivity in group I was not different preoperatively and postoperatively, but in group II, a significant decrease was observed in sensitivity for the nipple and areola (p = 0.01 and 0.004, respectively). Vibratory sensitivity was significantly decreased on the nipple, the areola, and the inferior breast skin (p = 0.01, 0.01, and 0.001, respectively) in group II but not in group I.In conclusion, ptotic or moderately hypertrophied breasts that were reduced using Lejour's technique recovered their preoperative level of sensitivity after an initial postoperative decline. However, in large breasts, although pressure sensitivity recovered after 1 year, temperature and vibration sensitivity remained diminished on the nipple-areola complex.     

Application of Electron Paramagnetic Resonance (EPR) Oximetry to Monitor Oxygen in Wounds in Diabetic Models

A lack of oxygen is classically described as a major cause of impaired wound healing in diabetic patients. Even if the role of oxygen in the wound healing process is well recognized, measurement of oxygen levels in a wound remains challenging. The purpose of the present study was to assess the value of electron paramagnetic resonance (EPR) oximetry to monitor pO₂ in wounds during the healing process in diabetic mouse models. Kinetics of wound closure were carried out in streptozotocin (STZ)-treated and db/db mice. The pO₂ was followed repeatedly during the healing process by 1 GHz EPR spectroscopy with lithium phthalocyanine (LiPc) crystals used as oxygen sensor in two different wound models: a full-thickness excisional skin wound and a pedicled skin flap. Wound closure kinetics were dramatically slower in 12-week-old db/db compared to control (db/+) mice, whereas kinetics were not statistically different in STZ-treated compared to control mice. At the center of excisional wounds, measurements were highly influenced by atmospheric oxygen early in the healing process. In pedicled flaps, hypoxia was observed early after wounding. While reoxygenation occurred over time in db/+ mice, hypoxia was prolonged in the diabetic db/db model. This observation was consistent with impaired healing and microangiopathies observed using intravital microscopy. In conclusion, EPR oximetry using LiPc crystals as the oxygen sensor is an appropriate technique to follow wound oxygenation in acute and chronic wounds, in normal and diabetic animals. Nevertheless, the technique is limited for measurements in pedicled skin flaps and cannot be applied to excisional wounds in which diffusion of atmospheric oxygen significantly affects the measurements.     

Reliability of inferior pedicle reduction mammaplasty in burned oversized breasts

Heavy pendulous breasts cause physical and psychological trauma. Postburn deformity of breasts results in significant asymmetry, displacement of nipple-areola complex, due to burn scar contracture, and significant scarring; these factors add more psychological discomfort and subsequent behavioral changes. The use of the inferior pedicle procedure in burned breasts can solve many problems. The technique reduces the size of the large breast, eliminates the scar tissue by excising both medial and lateral flaps, and brings the mal-located nipple and areola to a normal position. This study stresses the possibility of harvesting the inferior dermal pedicle flap from within the postburn scar tissue without necrosis of the nipple and areola, because of the excellent flap circulation. Acceptable aesthetic appearance and retainment of nipple viability and sensitivity can be achieved with the inferior pedicle technique even with postburn deformity of the breast. The study was conducted on 11 women, all of whom had sustained deep thermal burns to the breasts and anterior torso and whose breasts were hypertrophied and pendulous.     

Impairments in microvascular reactivity are related to organ failure in human sepsis

Severe sepsis is a systemic inflammatory response to infection resulting in acute organ dysfunction. Vascular perfusion abnormalities are implicated in the pathology of organ failure, but studies of microvascular function in human sepsis are limited. We hypothesized that impaired microvascular responses to reactive hyperemia lead to impaired oxygen delivery relative to the needs of tissue and that these impairments would be associated with organ failure in sepsis. We studied 24 severe sepsis subjects 24 h after recognition of organ dysfunction; 15 healthy subjects served as controls. Near-infrared spectroscopy (NIRS) was used to measure tissue 1) microvascular hemoglobin signal strength and 2) oxygen saturation of microvascular hemoglobin (StO2). Both values were measured in thenar skeletal muscle before and after 5 min of forearm stagnant ischemia. At baseline, skeletal muscle microvascular hemoglobin was lower in septic than control subjects. Microvascular hemoglobin increased during reactive hyperemia in both groups, but less so in sepsis. StO2 at baseline and throughout ischemia was similar between the two groups; however, the rate of tissue oxygen consumption was significantly slower in septic subjects than in controls. The rate of increase in StO2 during reactive hyperemia was significantly slower in septic subjects than in controls; this impairment was accentuated in those with more organ failure. We conclude that organ dysfunction in severe sepsis is associated with dysregulation of microvascular oxygen balance. NIRS measurements of skeletal muscle microvascular perfusion and reactivity may provide important information about sepsis and serve as endpoints in future therapeutic interventions aimed at improving the microcirculation.     

A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity

Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.     

Simplifying the vertical reduction mammaplasty

The vertical reduction mammaplasty is an evolving technique. Its proponents report significantly decreased scarring, better breast shape, and more stable results compared with the standard inverted-T method, but the learning curve is long and cosmetic outcomes can be inconsistent. Many surgeons have experimented with the vertical closure before returning to methods more familiar to them. The authors present their modifications to the vertical reduction mammaplasty. Their changes simplify the preoperative markings and the intraoperative technique to shorten the learning curve while maintaining reliable aesthetic results. With the patient standing, only four preoperative marks are made: (1) the inframammary fold; (2) the breast axis; (3) the apex of the new nipple-areola complex; and (4) the medial and lateral limbs of the vertical incision. In the operating room, a medial or a superomedial pedicle is developed. Excess breast skin is resected with the inferior and lateral parenchyma as a C-shaped wedge. The lateral skin-adipose flap is redraped inferomedially and sutured to the chest wall. The inferior aspect of the breast is aggressively debulked and a gathering subcuticular stitch is started 2 cm below the nadir of the nipple-areola complex. Finally, a 38-mm to 42-mm nipple-areola complex marker is used to create a circular defect that is offset 0.5 cm medial to the vertical axis of the breast. In their series, 56 patients were treated and no major complications were noted. The median follow-up period was 17 months. The average reduction was 554.5 g per breast; however, the reduction was greater than 1000 g per breast in eight patients. The authors found that (1) chest wall anchoring improves lateral contour and minimizes axillary fullness; (2) aggressive debulking inferiorly avoids the persistent inferior bulge; and (3) starting the subcuticular gathering suture 2 cm below the nipple-areola complex followed by placement of a nipple-areola complex marker at the conclusion of the case prevents lateral deviation and corrects the nipple-areola complex teardrop deformity. These innovations accelerate the learning curve by simplifying the preoperative markings and lead to more consistent postoperative results and an improved cosmetic outcome. In conclusion, these modifications yield a simple, easily learned vertical reduction mammaplasty with aesthetically reliable results.     

Maximizing breast projection after free-nipple-graft reduction mammaplasty

In 1922, Thorek described standard free-nipple reduction mammaplasty for gigantomastia. This technique provided a simple and effective way to perform reduction mammaplasty. However, the technique is frequently criticized for producing a breast and nipple with poor projection. Even with the standard modification of the original technique, the resultant breast and nipple may be wide and flat, with unpredictable nipple-areola pigmentation. To create a breast mound and nipple with projection and even pigmentation, the free-nipple-graft breast reduction technique is presented. The Wise pattern skin reduction markings and the superiorly based parenchymal reduction technique are used. After the nipple-areola complex is removed, as a free graft, the inferior pole of the breast is then amputated along the Wise pattern skin markings, leaving lateral and medial pillars of breast tissue, with the apex of the resection corresponding to the new nipple location. The lateral and medial pillars of the superiorly based breast mound are then sutured together. Key interrupted sutures are placed, beginning at the most inferior and posterior point of the pillars, while recruiting tissue centrally to increase the projection. The intersecting point of the inverted T, at 7 cm from the new nipple position, is then sutured to the fasciae of the pectoralis major muscle. If more central projection is desired, the vertical limb design can be lengthened. The tissue inferior to the 7-cm mark is de-epithelialized and tucked under the central breast, if needed, contributing further to the final breast parenchyma projection. The skin of the vertical limb of the Wise pattern is then closed with a dog-ear at the apex to further contribute to nipple projection. The nipple is replaced as a free, thick, split-thickness skin graft. The breast is temporarily closed, and the medial and lateral breast tissue excess is liposuctioned to create a more conical breast. Excessive medial and lateral skin is then resected, keeping the inframammary crease incision under the breast mound. Twenty-five patients underwent free-nipple-graft reduction mammaplasty using this technique between 1992 and 2000. An average of 1600 g of breast tissue per breast was removed. The average follow-up period was 36 months. Patient satisfaction has been very high.     

Monte Carlo simulation of NIR diffuse reflectance in the normal and diseased human breast tissues

The spectral reflectance measurements in tissue reveal physiological meaning. Normally, functional changes like, increase in total hemoglobin concentration, decrease in oxygen saturation, etc., are observed when there is an abnormality creeping in the normal tissue. These functional changes can act together to reveal disease by non-invasive near-infrared (NIR) spectroscopy, as it influence its optical properties. In the present study, a simple two dimensional, four layer model of breast is proposed. The four layers are (i) skin (ii) adipose layer (iii) glandular tissue and (iv) muscle. Each layer is modeled with appropriate biological chromophores like hemoglobin, water, lipid and melanin. From the literature, the concentrations and molar extinction coefficients of the chromophores in various layers of the model are obtained. These values are used to calculate the wavelength dependent absorption characteristics of a particular layer. Monte Carlo simulation of diffuse reflectance (percentage of back reflected photons after multiple scattering with the broad variety of angles) are simulated for the modeled breast tissue with and without diseased condition. Near-infrared wavelengths are chosen, as the depth of penetration in tissue is more compared to UV and visible region. Simulations are carried out on the modeled breast tissue for different races (skin colors) at different NIR wavelengths. Results show significant changes in diffuse reflectance and relative absorbance for normal and diseased breast tissues for differently pigmented model. This model can be used to study the photo dynamical therapy, drug delivery and prognosis of cancer.