The ideal intercostal space for internal mammary vessel exposure during total rib-sparing microvascular breast reconstruction: A critical evaluation.

BACKGROUND: Total rib-preserving free flap breast reconstruction (RP-FFBR) using internal mammary vessel (IMV) recipients usually involves vessel exposure in the second or third intercostal spaces (ICS). Although the third one is more commonly used, no direct comparisons between the two have hitherto been performed. OBJECTIVES: To compare the in-vivo topography and vascular anatomy of second and third ICSs in patients undergoing FFBR using the rib-preservation technique of IMV exposure. METHODS: An analysis of prospectively collected data on intercostal space distance (ISD), number and arrangement of IMVs, location of venous confluence, and vessel exposure time was conducted on a single surgeon's consecutive RP-FFBRs. RESULTS: A total of 296 RP-FFBRs were performed in 246 consecutive patients. The second, third, or both second and third spaces were utilized in 282, 28, and 22 cases, respectively. The ISDs were 20.6 mm ±â€¯3.52 for the second ICS and 14.0 mm ± 4.35 for the third ICS (p<0.0001, CI = 5.17-7.97, t-test). The second versus third ICS vein content was as follows: single 81.4% vs. 74%, dual 18.6% vs. 26%, and confluence 3.7% vs. 13%. The second ICS single vein was medial to the artery in 92.6%. The third ICS single vein was medial to the artery in 88.2% Vessel exposure times for second (47.2 mins ±â€¯26.7) and third (46.5 mins ±â€¯31.4) spaces were similar (p = 0.93). The overall intraoperative anastomotic revision rate was 9.1%, and the postoperative flap re-exploration rate was 4.0%, with 99.7% overall flap success. DISCUSSION AND CONCLUSION: Preferential use of the second ICS is supported by its more predictable vascular anatomy, a broader space for performing the microanastomoses and a higher frequency of a single postconfluence (and thus larger) vein facilitating the microsurgery.

Free tissue transfers to the upper limb.

90 consecutive free tissue transfers to the upper limb have been performed in 75 patients (33 children and 42 adults) by one surgeon over a 3-year period. The average age for children was 5 years, and 25 years in adults. 17 transfers were performed as emergency or urgent procedures. The main indications were congenital and traumatic defects. Included in this series were 44 toe transfers, 28 lateral arm flaps and six functional muscle transfers. The overall success rate was 99%. The re-exploration rate was 5.6% with only one failure. There were no failures in children.

Refinements of the LeJour vertical mammaplasty skin pattern for skin-sparing mastectomy and immediate breast reconstruction.

BACKGROUND: Skin-sparing mastectomy (SSM) is a well-established technique for immediate breast reconstruction (IBR). When used for large and/or ptotic breasts, traditional SSM patterns produce long skin flaps prone to necrosis or 'T' junction breakdown. The authors have previously demonstrated the applicability of the LeJour-type vertical mammaplasty skin pattern to this group of patients. With further experience, indications for this procedure have been widened and the technique refined. RESULTS: Over five years, 26 immediate breast reconstructions were carried out in 19 patients using this technique: three expandable implants, seven LDs, three pedicled TRAMs, five free TRAMs, seven DIEPs and one SIEA flap. Fourteen patients (74%) had simultaneous contralateral balancing LeJour breast reductions or mastopexies. The remaining five patients had bilateral mastectomies and reconstructions using the vertical mammaplasty skin pattern for both breasts. All flaps were successful, but there were three cases of minor skin flap necrosis, three of delayed wound healing and two instances of significant post-operative bleeding. Cosmesis was suboptimal in the prosthetic reconstruction group, necessitating revisional surgery. DISCUSSION AND CONCLUSIONS: The vertical mammaplasty skin pattern was successfully used with a wide range of reconstructions. However, to avoid suboptimal cosmetic results and minimise wound healing problems this technique is not recommended in heavy smokers, very obese patients, those undergoing prosthetic reconstructions or neoadjuvant chemotherapy. The skin resection pattern should also be conservative. The LeJour-type vertical mammaplasty pattern is a viable alternative technique for SSM in selected patients, especially those requiring contralateral balancing surgery and undergoing autologous tissue reconstruction.

A systematic approach to the surgical treatment of gynaecomastia.

Numerous techniques have been described for the correction of gynaecomastia, and the surgeon is faced with a wide range of excisional and liposuction procedures. There is a paucity of literature describing an integrated approach to the management of this condition and the roles of the different treatment modalities. A review of all gynaecomastia patients operated on by one surgeon over a 2-year period was undertaken. Patient satisfaction was assessed using a linear analogue scale with a maximum score of 10. In total, 48 breasts in 29 patients were treated--31 breasts by liposuction alone (19 by conventional liposuction, 12 by ultrasound-assisted liposuction), eight breasts by liposuction and open excision, and nine breasts by liposuction, open excision and skin reduction (concentric or Lejour mastopexy). There were no early postoperative complications, such as haematoma, seroma or infection, and 91% of patients were very satisfied (score: 8-10) with their cosmetic outcome. The most frequently encountered complication was a residual subareolar lump (five breasts), all in patients treated by conventional liposuction alone. In order to avoid the common complication of an uncomfortable residual subareolar nodule, the threshold for open excision in patients undergoing conventional liposuction should be low. Ultrasound-assisted liposuction extends the role of liposuction in gynaecomastia patients. Although skin excess remains a challenge, it can be satisfactorily managed without excessive scarring. A practical approach to the surgical management of gynaecomastia, which takes into account breast size, consistency, skin excess and skin quality, is proposed.