[Modern breast reconstruction with endoscopically assisted latissimus dorsi flap harvesting]. / Endoszkóposan asszisztált latissimus dorsi izomlebeny alkalmazása a korszeru rekonstrukciós emlosebészetben.

Skin- and nipple-sparing mastectomies made immediate breast reconstruction possible on a systemic level within breast cancer surgery. Mass reconstruction needs brought by the most common malignancy in women can only be met by the use of implant-based techniques, providing excellent cosmetic results and high patient satisfaction. For these postmastectomy reconstructions the replacement of the skin is no longer a challenge, but the well vascularized, good quality soft tissue coverage of the implant. Oncoplastic breast surgery today is able to conduct oncologically radical complete removal of the glandular tissue through an incision of 6-10 cm made in the armpit, with the nearly scarless retention of the natural skin envelope of the breast, and in the same time adequate axillary staging (sentinel node biopsy/axillary lymphadenectomy) is performed, then using the same incision, the implementation of one-step or multi-step breast reconstruction is possible. During these complex interventions, the latissimus dorsi flap formed by endoscopic technique (leaving no scar on the back), rotated to the anterior chest wall can be used for total autologous reconstruction of low-volume breasts as complete coverage of implants placed under the spared skin-envelope or for revitalization of thin or radiation damaged breast skin. This paper presents 4 cases of breast reconstruction with endoscopically assisted latissimus dorsi muscle flap, and the authors demonstrate the surgical technique in detail and conduct a literature review, for the first time in Hungarian.

[Methods and importance of volume measurement in reconstructive and aesthetic breast surgery]. / Az emlotérfogat-meghatározás jelentosége és módszerei a helyreállító és esztétikai emlosebészetben.

Volume measurement of the breast allows for better surgical planning and implant selection in breast reconstructive and symmetrization procedures. The safety and accuracy of tumor removal, in accordance with oncoplastic principles, may be improved by knowing the true breast- and breast tumor volume. The authors discuss the methods of volume measurement of the breast and describe the method based on magnetic resonance imaging digital volume measurement in details. The volume of the breast parenchyma and the tumor was determined by processing the diagnostic magnetic resonance scans, and the difference in the volume of the two breasts was measured. Surgery was planned and implant selection was made based on the measured volume details. The authors conclude that digital volume measurement proved to be a valuable tool in preoperative planning of volume reducing mammaplasty, replacement of unknown size implants and in cases when breast asymmetry is treated.

[Special aspects of breast cancer surgery in the elderly]. / Az emlorák sebészetének speciális szempontjai idoskorban.

Due to the aging population of Western countries and the high-quality health care system, breast cancer in the elderly generally affects women of good or satisfactory performance status pursuing active lifestyle. Over the last decade, it became evident that, in contrast to previous dogmas, age alone cannot be the contraindication to standard oncological treatment, and adequate multidisciplinary therapy aiming full recovery rather than compromise treatment is required. A number of specific aspects needs to be taken into account regarding surgery, such as life expectancy, co-morbidities, individual mobility, mental and emotional status as well as family background, which may result in changes to the individual treatment plan. Objective evaluation of the above mentioned parameters necessitates a close co-operation of professions. Interestingly, the evidence-based protocols of modern oncology often originate from the generalizations of results from clinical trials representing younger population, due to the typical under representation of elderly patients in clinical studies. Clinical trials should be extended to elderly patients as well or should specifically aim this patient population. The authors of the present paper review the special oncological and reconstructive surgical aspects of breast cancer in the elderly, such as breast conserving surgery versus mastectomia, sentinel lymph node biopsy, axillary lymphadenectomy or the omission of surgery in axillary staging, and questions regarding implant based and autologous reconstructive techniques.

[Minimally invasive breast surgery]. / Minimálisan invazív emlosebészet.

Due to the development in medical science and industrial technology, minimally invasive procedures have appeared in the surgery of benign and malignant breast diseases. In general , such interventions result in significantly reduced breast and chest wall scars, shorter hospitalization and less pain, but they require specific, expensive devices, longer surgical time compared to open surgery. Furthermore, indications or oncological safety have not been established yet. It is quite likely, that minimally invasive surgical procedures with high-tech devices - similar to other surgical subspecialties -, will gradually become popular and it may form part of routine breast surgery even. Vacuum-assisted core biopsy with a therapeutic indication is suitable for the removal of benign fibroadenomas leaving behind an almost invisible scar, while endoscopically assisted skin-sparing and nipple-sparing mastectomy, axillary staging and reconstruction with latissimus dorsi muscle flap are all feasible through the same short axillary incision. Endoscopic techniques are also suitable for the diagnostics and treatment of intracapsular complications of implant-based breast reconstructions (intracapsular fluid, implant rupture, capsular contracture) and for the biopsy of intracapsular lesions with uncertain pathology. Perception of the role of radiofrequency ablation of breast tumors requires further hands-on experience, but it is likely that it can serve as a replacement of surgical removal in a portion of primary tumors in the future due to the development in functional imaging and anticancer drugs. With the reduction of the price of ductoscopes routine examination of the ductal branch system, guided microdochectomy and targeted surgical removal of terminal ducto-lobular units or a "sick lobe" as an anatomical unit may become feasible. The paper presents the experience of the authors and provides a literature review, for the first time in Hungarian language on the subject. Orv. Hetil., 2014, 155(5), 162-169.

[Oncoplastic versus conventional breast conserving surgery. A comparison of clinicopathological findings, cosmetic results and quality of life in 60 cases]. / Onkoplasztikus versus hagyományos emlomegtartó sebészet. 60 eset összehasonlító klinikopatológiai, kozmetikai és életminoségi vizsgálata.

Oncoplastic surgical techniques seem to be suitable for realizing the goal of retaining cosmesis following radical removal of breast tumors. The purpose of the present study is to provide a clinical and pathological comparison of conventional (BCS) and oncoplastic (OPS) breast-conserving surgeries, supplemented by a subjective assessment of cosmesis and quality of life of patients, the first time on a Hungarian sample. The authors performed a retrospective assessment of clinicopathological data of 60 advanced oncoplastic and 60 conventional breast-conserving surgery cases, and following adjuvant radiotherapy, the authors also surveyed patients for cosmetic results and quality of life (EORTC BR23). Comparison of the results was performed by statistical methods. The two groups did not differ substantially in age, tumor location, breast size, type of axillary surgery (sentinel node biopsy vs. axillary lymphadenectomy), tumor grade and receptor status. Tumor size was significantly greater (p=0.0009), the rate of quadranectomies was higher (p=0.0032), metastases in the regional lymph nodes (p=0.0043) and the administration of adjuvant chemotherapy (p=0.0122) were more frequent in the OPS group. The duration of surgeries was longer (p<0.001), the weight of the specimens was greater (p=0.0308), the rate of completion surgeries due to microscopically positive surgical margins was significantly smaller (p=0.0306) in the OPS than in the BCS group. There was no difference between the two groups in the rate of complications and the time elapsed to the start of adjuvant treatment. The cosmetic outcome was clearly superior in the OPS group (p<0.001), and OPS patients had fewer arm, shoulder (p=0.0399), and chest pain (of the affected side) (p=0.0304), upper limb movements of the operated side were also better (p=0.006). The short follow-up period of the OPS group (mean 32.2 vs. 8.7 months in BCS and OPS, respectively) did not allow a meaningful assessment of oncologic endpoints. When compared to conventional breast conserving surgery, oncoplastic surgery is suitable for microscopically radical tumor removal even in case of larger lesions and true quadranectomy with longer surgical time but lower rate of complications without delaying the adjuvant treatments and thus not increasing the cancer risk. OPS yields better cosmetic results and higher patient satisfaction compared to BCS. More experience and longer follow-up is needed for the assessment of local tumor control achieved by OPS.

[Autologous fat transplantation in the modern reconstructive surgery of breast cancer]. / Autológ zsírátültetés az emlorák modern rekonstrukciós sebészetében.

Autologous fat transplantation is often used in aesthetic plastic surgery, and is recently becoming increasingly popular in the reconstruction of soft tissue defects following oncological surgery. A still not standardized technique of fat transplantation for breast cancer reconstruction is rapidly getting popular. The procedure is not a passive volume replacement, but transplantation of biologically active tissue bearing endocrine, paracrine, exocrine functions and containing fat-derived stem cells, which in the tumorous environment raises many questions in relation to the oncological safety and diagnostic follow-up. Although long-term results based on prospective, randomized studies are not yet available, published clinical experience is promising and reveals an effective and surgically safe procedure if used with appropriate indications and techniques. The authors conducted a broad review of the literature, presenting indications, technique, molecular interactions, and potential risks of the clinical results of autologous fat transplantation in the breast cancer reconstructive surgery. The authors initiated that breast and plastic surgeons should promote adequate long term follow-up of breast cancer patients who underwent breast reconstruction with autologous fat transplantation by the establishment of national registries.

[Modern breast surgery]. / Modern emlosebészet.

Today, as a result of the complex and coordinated medical treatment of breast malignancies the long-term survival rate reaches 80%. Modern breast surgery plays a prominent role in the multidisciplinary treatment of breast tumors. Breast surgery in the 21st century simultaneously performs medical and aesthetic procedures on the same organ. Modern day breast surgery is founded on a complex view of breast malignancies, multidisciplinary cooperation, oncoplastic practice, and selecting the optimal surgery techniques, based on state of the art tools and a detailed treatment plan. Authors present the evolution of modern breast surgery; discuss the procedures such as mastectomy, breast conservation surgery, axillary lymph node removal, prophylactic mastectomy, as well as possible versions of immediate or delayed breast reconstruction.

[Role of nipple sparing mastectomy in modern breast surgery]. / Az emlobimbó-megtartó mastectomia lehetséges helye a modern emlosebészetben.

Recently an increasing number of reports of clinical experience have been published on nipple-sparing mastectomy. By the preservation of uninvolved skin and the nipple areola complex, this surgical technique greatly facilitates immediate reconstruction and optimal aesthetic outcome. However, the procedure raises serious oncologic concerns regarding the risk of an occult or a newly formed primary tumor due to parenchyma left behind in the nipple and the retroareola. Despite the ever increasing popularity of the method, there is still no evidence based confirmation to it. According to data from scientific literature on nipple-sparing mastectomy, there is no straightforward consequence to be drawn on oncologic safety; therefore the procedure is not generally considered to be alternative to standard mastectomy. In the indication of risk reduction, justification of the intervention seems to be well supported, and is expected to foster a greater rate of acceptance of surgical prophylaxis in patients with higher risk diseases. The procedure should be carried out possibly in the framework of clinical trials, in well selected patients with suitable preoperative and postoperative examinations, applying precise techniques and adequate patient education, according to international guidelines. Further long-term results are needed to form a substantive expert opinion. Authors give a detailed description of the surgical techniques, and provide a wide review of the literature, for the first time in Hungarian language.

[Special considerations in breast cancer treatment of an augmented breast]. / Emlonagyobbító mutét után kialakult emlorákok ellátásának speciális megfontolásai.

Breast augmentation surgery involving the use of implants has been one of the most popular plastic surgical procedures for decades. As the multi-million female population who received breast implants ages, the risk of cancer is increasing rapidly, therefore the incidence of malignant disease in association with breast implants will increase as well. Although there is no relationship between tumor development and implants, these cases require special considerations in diagnostics, therapy and follow-up methods. Appropriate multidisciplinary treatment of tumors in augmented breasts corresponding with modern oncoplastic principles can only be accomplished based on adequate oncological, breast and plastic surgical knowledge. Supposing a possible increase of this condition in Hungary, too, authors provide a wide review of the literature on the special oncological and esthetic considerations, for the first time in Hungarian language.

[The place of skin-sparing mastectomy in oncoplastic breast surgery]. / A bõrtakarékos mastectomia helye a modern onkoplasztikus emlõsebészetben.

Despite its ever increasing popularity, there is no evidence-based confirmation so far on the results of skin-sparing mastectomy, introduced 20 years ago. However, the results of countless published retrospective, long-term trials seem to underpin the ability of the precisely implemeted procedure in early stage invasive and in situ breast cancers to yield the oncological results of modified radical mastectomy. As a result of the procedure involving special surgical techniques, the skin not affected by cancer can be preserved, which facilitates immediate reconstruction and improves cosmetic outcome. The effect of postmastectomy radiotherapy on the reconstruction needs to be considered at the time of the multidisciplinary design of the surgical procedure. The authors give a detailed description of the surgical techniques, and provide a wide review of the literature, for the first time in Hungarian language.

[Challenges in oncologic plastic surgery of the breast]. / A modern emlosebészet onkoplasztikai kihívásai.

Breast screening programs along with advances in diagnostic methods and oncologic treatment have resulted in full recovery for a decisive number of patients diagnosed with early-stage breast cancer. The results of the ultra-radical-, followed by the breast conserving era pose new opportunities and challenges for the oncologic breast surgeon. The focus of oncoplastic surgery is not only on the tumor, but also on the female patient, allowing for individualized immediate breast reconstruction with acceptable esthetic result following radical tumor exstirpation. Modern procedures differ both in concept and technique from that of traditional breast surgery. This paper provides a comprehensive and detailed overview of reconstructive and oncoplastic breast surgery.

[Breast conserving oncoplastic surgery in the treatment of centrally located malignant breast tumors]. / Emlomegtartásos onkoplasztikai sebészi lehetoségek centrális elhelyezkedésu malignus emlotumorok kezelésében.

Central breast neoplasms account for 5 to 20% of breast cancer cases. For decades, they have been traditionally treated with mastectomy. The high incidence of involvement associated with these tumors necessitates nipple and areola resection. Oncoplastic surgical techniques, in well selected cases, enable the achievement of adequate cosmetic results following a radical central quadrantectomy along with the Nipple-Areola Complex. The present paper summarizes the indications, techniques and results of breast conserving surgeries of central breast tumors.

[Radiotherapy and breast reconstruction: the issue of compatibility]. / Sugárterápia és emló-helyreállító mútét: az összeférhetóség kérdése.

BACKGROUND: Breast reconstruction after mastectomy represents an improvement in the quality of life of breast cancer patients. Radiotherapy is also suggested for many of them to prevent local relapse. However, irradiation increases the risk of complications require surgical procedures. PURPOSE: This study was undertaken to analyse the compatibility of breast reconstruction and irradiation in the treatment of breast cancer. METHODS: Computerised searches for publications debating this issue were done of MEDLINE data. Studies were grouped according to the techniques and types of reconstruction: reconstruction with silicone implant or autogenous skin-muscle flap, timing of reconstruction (immediate or delayed), and sequencing of treatments (pre- or post-reconstruction irradiation). The results of studies were assessed and compared in respect to reconstruction related chronic complications. RESULTS: The incidence of complications was significant even in the absence of irradiation, but radiotherapy increased the risk of complications to less or more extent. When reconstruction was done with implant, the most common type of complication was Grade III-IV capsular contracture. In patients subjected to immediate reconstruction, the complication rates with or without radiotherapy were from 0% to 64% and from 0% to 12%, respectively. In women who underwent delayed reconstruction, the incidence of complications with or without irradiation was from 22% to 55%, and from 17% to 34%, respectively. The negative effect of radiotherapy was more significant with immediate than with delayed reconstruction. In patients who underwent reconstruction with skin-muscle flaps, the most common type of complication was skin necrosis. The incidence of complications with or without radiotherapy was from 12% to 39% and from 5% to 25%, respectively. Cancer, developing after cosmetic augmentation mammaplasty in the breast, can be treated with lumpectomy and radiotherapy without removal of the implant. In series with this method of treatment the incidence of complications (mainly capsular contracture) was from 0% to 65%. The use of moderate dose (45-50 Gy), wedge filters, and no use of bolus application decreased the risk of complications. CONCLUSIONS: Radiotherapy and breast reconstruction are not incompatible, but careful consideration of their relative timing and technique is important. Plastic surgeons should counsel patients before starting their cancer disease treatment, and those who choose to have reconstruction need to be informed about risks for specific complications associated with the procedure. Results of the studies debating this issue are controversial. Longer follow-up time, larger patient material and better specified parameters are needed to validate results.

[Radiotherapy and delayed breast reconstruction with implant: examination of compatibility]. / Sugárterápia és halasztott emlôhelyreállító mûtét implantátummal: az összeférhetôség vizsgálata.

PURPOSE: Delayed breast reconstruction with implant is frequently used after mastectomy. However, given that many breast cancer patients receive adjuvant radiotherapy, the adaptation of this method raises questions concerning possible cumulative complications. In the present study the compatibility of post-mastectomy radiotherapy and delayed breast reconstruction with implant was examined. PATIENTS AND METHODS: We evaluated a consecutive series of 66 invasive breast cancer patients who have received delayed breast reconstruction with implant after modified radical mastectomy between January 1997 and June 1999. The average time was 51 months from primary surgery to reconstruction. The median dose of loco-regional irradiation was 50 Gy. Grade III atrophic dermatitis was observed in none of the irradiated women. We identified two patient groups: 29 patients did not and 37 patients did receive post-mastectomy radiotherapy. The types and time of reconstruction related chronic complications (capsular contracture, defect of implant shell and skin necrosis) were recorded. Incidence of complications was estimated by the Kaplan-Meier method. Cancer related events were also studied. RESULTS: When expander was used, minor discomfort of the patients was common during the filling course. At four (11%) irradiated patients the expansion with expander was incomplete, due to severe pain. At a median follow up time of 53 months the incidence of capsular contracture was 24.1% without and 29.7% with radiotherapy (p=0.4121). The five-year estimated rate of late complications was 40% and 50%, respectively (relative risk: 1.29, 95% confidence interval: 0.58-2.89, p=0.5173). The position of implant had an impact on the incidence of capsular contracture: 46.2% with subcutaneous and 22.6% with submuscular position (p=0.0881). Four patients (6%) developed local relapse (three in the skin and one subcutaneous). All were treated with tumor excision without implant removal. CONCLUSION: Delayed breast reconstruction with implant after post-mastectomy radiotherapy can be offered to patients who are interested in breast reconstruction and had no severe late radiation skin toxicity. Post-mastectomy radiotherapy does not significantly increase the risk of complications. The use of skin expander is less tolerated by irradiated patients. Submuscular position of implants moderates the risk of capsular contracture.

Improving the lateral fullness of the upper eyelid.

The lateral fullness of the upper eyelid is its convex surface area from the eyebrow to the eyelid crease. Rejuvenation of upper eyelids can be achieved by accenting their fullness. An S-shaped fusiform skin segment is removed from the upper eyelid, with care taken to spare the orbicularis occuli muscle. Approximately 1 ml of fat tissue is excised from the medial compartment by transmuscular incision. The fat is placed in the crease, and the orbicularis occuli muscle is stitched together over the transplanted fat tissue. Imbrication of the orbicularis occuli muscle and insertion of 1 ml of fat tissue into the muscle layers increase the lateral fullness and significantly emphasizes the aesthetic result of upper eyelid blepharoplasty.