Exercise-Induced Mondor's Disease of the Chest Wall in a Nigerian Man: A Case Report.

BACKGROUND: Mondor's disease (MD) is a rare cause of chest pain, characterized by thrombophlebitis of the subcutaneous veins of the anterolateral thoracoabdominal wall. It is a benign, self-limiting condition that is often underdiagnosed due to lack of knowledge of the condition. Although the exact aetiology is unclear, several predisposing factors, including excessive physical activity have been postulated. To the best of our knowledge, there is no previous published report of MD of the chest wall in an adult Nigerian man. OBJECTIVE: To describe the association between muscular strain and the development of MD. CASE PRESENTATION: A 40-year-old Nigerian man presented with a one-month history of dull, aching right-sided chest pain. He gave a history of engaging in intense thoracoabdominal exercises for 6 weeks prior to onset of symptoms. Physical examination revealed a tender, subcutaneous cord-like swelling extending from below the right anterior axillary fold to the right hypochondrium and accentuated by overhead abduction of the right arm. Ultrasonography revealed a hypoechoic, noncompressible right thoracoepigastric vein with no flow on Doppler interrogation, in keeping with superficial venous thrombosis. He was treated with nonsteroidal anti-inflammatory agents and paracetamol. The pain and lesion resolved completely within two weeks after presentation and there was no recurrence over the subsequent four months of follow-up. CONCLUSION: MD is an uncommon cause of chest pain that is often underdiagnosed and underreported due to lack of awareness. It can suddenly appear in persons performing extreme thoracoabdominal exercises. Treatment is essentially symptomatic. Prompt diagnosis of this self-limiting condition is essential in distinguishing it from malignant diseases.

CONTEXTE: La maladie de Mondor (MD) est une cause rare de douleur thoracique, caractérisée par une thrombophlébite des veines sous-cutanées de la paroi thoraco-abdominale antérolatérale. Il s'agit d'une maladie bénigne et spontanément résolutive qui est souvent sous-diagnostiquée en raison d'un manque de connaissance de la maladie. Bien que l'étiologie exacte ne soit pas claire, plusieurs facteurs prédisposants, y compris une activité physique excessive, ont été postulés. Au meilleur de notre connaissance, il n'y a aucun rapport publié précédemment de MD de la paroi thoracique chez un homme Nigérian adulte. OBJECTIF: Décrire l'association entre la tension musculaire et le développement de la MD. PRÉSENTATION DE CAS: Un homme Nigérian de 40 ans s'est présenté avec une histoire d'un mois de douleur thoracique sourde et douloureuse du côté droit. Il a indiqué qu'il s'était engagé dans des exercices thoraco-abdominaux intenses pendant 6 semaines avant l'apparition des symptômes. L'examen physique a révélé une tuméfaction sous-cutanée semblable à un cordon s'étendant du dessous du pli axillaire antérieur droit à l'hypochondre droit et accentuée par une abduction au-dessus du bras droit. L'échographie a révélé une veine thoraco-épigastrique droite hypoéchogène, non compressible et sans débit à l'examen Doppler, en rapport avec une thrombose veineuse superficielle. Il a été traité avec des anti-inflammatoires non stéroïdiens et du paracétamol. La douleur et la lésion ont complètement disparu dans les deux semaines suivant la présentation et il n'y a eu aucune récidive au cours des quatre mois suivants de suivi. CONCLUSION: La MD est une cause rare de douleur thoracique qui est souvent sous-diagnostiquée et sous-déclarée en raison d'un manque de sensibilisation. Il peut apparaître soudainement chez les personnes effectuant des exercices thoraco-abdominaux extrêmes. Le traitement est essentiellement symptomatique. Un diagnostic rapide de cette maladie spontanément résolutive est essentiel pour la distinguer des maladies malignes. Mots clés: maladie de Mondor, exercice, douleur thoracique, thrombophlébite.

The Importance of Fifth Anterior Intercostal Vessels following Nipple-Sparing Mastectomy.

BACKGROUND: The authors describe the vascular anatomy of the fifth anterior intercostal artery perforator and its role for perfusion of the nipple-areola complex following nipple-sparing mastectomy. METHODS: Twenty fresh cadavers were injected with 20 cc of colored latex through the internal mammary artery. The catheter was placed at the level of the second intercostal space after removal of the rib. The fifth intercostal space was dissected under magnification to observe the origin and trajectory of the fifth anterior intercostal artery perforator. Six selective computed tomographic angiograms of the fifth intercostal artery perforator were performed. A clinical case of nipple-sparing mastectomy in a woman with mammary hypertrophy is provided to demonstrate the utility of preserving the fifth anterior intercostal artery perforator. RESULTS: The fifth anterior intercostal artery perforator was consistently observed in all the cases and confirmed by angiography. The perforator gives rise to several branches that traverse in all directions. The ascending branches of the fifth anterior intercostal artery perforator are directed toward the nipple-areola complex and course within the subcutaneous layer between the skin and the parenchyma. The fourth and fifth anterior intercostal artery perforators are independent of one another. CONCLUSION: The main ascending branch of the fifth anterior intercostal artery perforator reaches the nipple-areola complex by the subcutaneous tissue independently of the Würinger fascia.

Management challenges of a large upper extremity vascular malformation in a patient with capillary malformation-arteriovenous malformation syndrome.

We describe a 17-year-old boy with capillary malformation-arteriovenous malformation syndrome and a massive vascular malformation of the right chest wall, shoulder, and upper arm. Persistent growth of the malformation caused cutaneous ulcerations and recurrent massive bleeding episodes. We proceeded with a modified shoulder disarticulation preceded by ligation of the subclavian artery and innominate vein by median sternotomy. After a staged debulking resection of the residual chest wall arteriovenous malformation with rotational transverse rectus abdominis myocutaneous flap coverage, the patient was discharged home safely. This report demonstrates that a multidisciplinary approach is critical for management of life-threatening complications in capillary malformation-arteriovenous malformation patients.

A 22-Year-Old Man With Back Pain, Dilated Veins Over Chest, and Mass in Right Atrium.

CASE PRESENTATION: A 22-year-old nonsmoker male, without any previous comorbidity, presented with 4 months' history of right upper back pain. Pain was constant dull aching type, nonpleuritic, aggravated by lying on the right lateral side and partially relieved on taking analgesics. He then developed progressive dyspnea over 2 months and noticed dilated veins over his neck and front of chest. There was associated unintentional weight loss of 6 kg. There was no history of cough, expectoration, wheeze, or hemoptysis, nor any episodes of night sweats or fever.

"Please mind the gap": successful use of ultrasound-assisted spinal anesthesia for urgent cesarean section in a patient with implanted spinal cord stimulation system for giant chest wall arteriovenous malformation - a case report.

BACKGROUND: The use of Spinal Cord Stimulation (SCS) system to treat medically refractory neuropathic pain is increasing. Severe neuropathic pain can be found in giant chest wall arteriovenous malformations (AVMs), exceedingly rare and debilitating abnormalities, rarely reported during pregnancy. CASE PRESENTATION: We present a report of a pregnant patient with implanted Spinal Cord Stimulation (SCS) system because of painful thoracic AVM scheduled for an urgent cesarean section in which we used lumbar ultrasound (US) to rule out the possibility to damage SCS electrodes and to find a safe site to perform spinal anesthesia. CONCLUSIONS: The use of lumbar US to find a safe site for a lumbar puncture in presence of SCS system in a patient affected by painful thoracic AVM makes this case a particularly unique operative challenge and offers a new possible use of ultrasound to detect a safe space in patients with SCS implant.

Anatomical study of the perforator flap based on the acromial branch of the thoraco-acromial artery (abTAA flap): a cadaveric study.

PURPOSE: The aim of this anatomical study was to describe a local perforator flap, for covering shoulder defects, by determining the features of the acromial branch of the thoraco-acromial artery (abTAA), and the supplied cutaneous area. METHODS: Thirteen fresh cadaveric thoraxes were dissected bilaterally. A precise and reproducible protocol was performed. For each abTAA flap cadaveric dissection, the following parameters were measured after arterial injection: distances between the origin of the perforator artery on the abTAA and the sternum, the acromion, the clavicle, diameter of the perforator artery of the abTAA, length of the perforator pedicle course through major pectoralis muscle, and rotation arc. We also calculated the surface of the injected skin paddle. These measurements were related to morphometric parameters evaluated through the distance between sternum and acromion. RESULTS: The mean distances measured from the origin of the perforator artery on the abTAA were 14.25 cm to the sternum, 3.45 cm to the acromion, 5.65 cm to the clavicle. The mean diameter of the abTAA was 1.20 mm ± 0.2. The arc of rotation was 180°, and the length of the perforator pedicle could be extended to 7.46 cm ± 1.15. We observed an colored elliptical cutaneous paddle with a longer radius 18 cm and a small radius 15 cm. CONCLUSIONS: Our results suggest that this type of flap could be useful in clinical practice for reconstruction and covering of the acromial area with a thin cutaneous flap with low sequelae on the donor site.

Visualization of angiogenesis and vasculogenesis in a late tissue radiation injury of the chest wall treated with adjuvant hyperbaric oxygen therapy using fluorescence angiography.

Adjuvant radiation therapy for breast cancer treatment often involves high doses of radiation, making patients more susceptible to late radiation tissue injury (LRTI), severe complications of which involve necrosis and ulceration. Treatment of such wounds is challenging. One modality that can be utilized is hyperbaric oxygen (HBO2) therapy. However, an optimal dose and the objective evidence of its benefit in use as an adjunctive treatment modality is limited. Presented here is a case of a non-surgical candidate in which serial indocyanine green fluorescence angiography (ICGFA) was utilized to determine if it could detect changes in tissue perfusion over the course of treatment. Serial ICGFA allowed for visualization of the current phase of wound healing, angiogenesis and vasculogenesis. Future large studies should be employed to better determine the utility of serial ICGFA to improve HBO2 utilization in patients who are undergoing HBO2 as part of their course of treatment for LRTI.

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.

A thoracic venous aneurysm mimicking a chronic expanding haematoma.

Thoracic venous aneurysms are rare, and bleeding is possible. A 9-year-old female patient presented with a thoracic wall mass. No blood flow was observed in the mass, and a chronic expanding haematoma was suspected based on the differential diagnosis. However, the venous structure was identified in the wall of the mass on pathological examination, and the diagnosis of the venous aneurysm was thereby established. Because the venous aneurysm contains fresh blood and bleeding can be profuse when such lesions are not properly handled during a surgical procedure, making the visibility of the surgeon poor, the venous aneurysm must be included in the differential diagnosis.

VRAM steal syndrome - a unique cause of flap necrosis in chest wall reconstruction.

The pedicled vertical rectus abdominis myocutaneous (VRAM) flap is a robust flap, which is considered to be a 'workhorse' regional option for chest wall reconstruction. We describe a previously unreported complication of partial flap loss due to 'steal syndrome', whereby arterial supply was diverted away from the flap due to dialysis from an ipsilateral arteriovenous fistula.

Giant Chest Wall Arteriovenous Malformation: A Case Report and Literature Review.

BACKGROUND: We present an interesting case of a 55-year-old male with a large left chest mass after significant cutaneous bleeding. Computed tomography angiogram of the chest revealed arteriovenous malformation with blood supply from sub-branches of the left subclavian artery, left internal mammary artery, and left external carotid artery. Measuring 5.0 × 14.0 × 10.8 cm, the mass extended superior to the clavicle and inferior to the third rib with medial and lateral borders at the level of the clavicular head and coracoid, respectively. METHODS: Arteriovenous malformations (AVMs) are characterized by abnormal connections between arteries and veins which bypass the capillary system. Often small and asymptomatic, large AVMs can be painful, prone to bleeding and, if large enough, interfere with activities of daily living. While described involving various parts of the body, most notably in the central nervous system, there is a paucity of literature involving chest wall AVMs. RESULTS: Using a staged, multidisciplinary approach, treatment began with an endovascular exclusion of the arterial blood supply, which involved a combination of coil embolization and stent exclusion of feeder vessels. Two days postembolization, the patient underwent an en bloc resection of affected portion of his chest wall. Reconstruction was completed with a combination rotational flap and split-thickness skin graft. Following the procedures, the patient had an uncomplicated recovery. Three years following procedure, he has no signs of recurrence of his AV malformation. CONCLUSION: Surgical planning and indications for giant arteriovenous malformations remains a unique and difficult problem. The complex anatomy and extreme rarity of a chest wall AVM requires a multidisciplinary staged approach but can be treated with a multistage, multidisciplinary surgical approach with satisfactory and long-lasting results.

Lateral-bilateral costal branch (R. costalis lateralis): a clinically relevant anatomical variation / Rama costal lateral bilateral (R. costalis lateralis): una variación anatómica clínicamente relevante

SUMMARY: The lateral costal branch (LCB) is a variation present in 15-30 % of the population. This blood vessel runs parallel and laterally to the internal thoracic artery from which it originates. Knowledge about the LCB is relevant for thoracic surgeons. In this study we present the findings from the dissection in a practical teaching exercise of the cadaver of a 62-year-old male. The thoracic contents were accessed by raising the anterolateral thoracic wall, the pulmonary pedicles were dissected and both lungs were removed. We observed bilaterally the trajectory of the LCB at the level of the medial axillary line parallel to the internal thoracic artery. On the right side, the LCB originates from the internal thoracic artery at the level of the first rib and extends to the eighth intercostal space, with a length of 26 cm and a caliber of 1.95 mm, communicating with the anterior and posterior intercostal arteries. The left branch originates from the internal thoracic close to their origin artery and extends until the sixth intercostal space, with a length of 14 cm and a caliber of 1.55 mm. it connects with the anterior and posterior intercostal arteries. On both sides the arteries were accompanied by a pair of satellite veins. The lateral costal arteries form part of the circulation of the thoracic wall, constituting an accessory arterial system with a trajectory parallel to the internal thorax and the aorta. Knowledge of it is relevant for invasive procedures, and myocardial revascularization procedure.

RESUMEN: La rama costal lateral es una variación presente en el 15-30 % de los casos, y sigue paralelo y lateral a la arteria torácica interna, de la cual se origina, siendo su conocimiento relevante para los cirujanos de tórax. Se presenta un hallazgo durante una disección en una actividad práctica docente, en un cadáver de sexo masculino de 62 años. Se accedió al contenido torácico levantando la pared esternocostal, procedimiento que comenzó con disección de la piel y musculatura hasta exponer ambas clavículas, se realizó un corte transversal de éstas en su tercio lateral para posteriormente realizar sección bilateral desde la primera hasta la octava costilla siguiendo la línea axilar anterior. Una vez revertida la pared esternocostal, se seccionaron los pedículos pulmonares, y se retiraron ambos pulmones. Se observó bilateralmente en la pared torácica el trayecto de un paquete vascular a nivel de la línea axilar media paralela a la arteria torácica interna. En el lado derecho se originaba a 2 cm del trayecto de la arteria torácica interna y se extendía hasta el octavo espacio intercostal con una longitud de 26 cm y un calibre de 1,95 mm, estableciendo comunicaciones con las arterias intercostales anteriores y posteriores, agotándose en ellas. La rama izquierda se originaba a 1,5 cm del trayecto iniciado por la arteria torácica interna extendiéndose hasta el sexto espacio intercostal; presentó un calibre de 1,55 mm y una de longitud de 14 cm, estableciendo comunicaciones con las arterias intercostales anteriores y posteriores, agotándose en ellas. En ambos lados las arterias eran acompañadas por un par de venas satélites. Las arterias costales laterales forman parte de la circulación de la pared torácica, constituyendo un sistema arterial accesorio al de la arteria torácica interna y la aorta. Su conocimiento es relevante en procedimientos invasivos, además de tener un alto valor docente y formativo.

Five recipient vessels for metachronous chest wall reconstruction: Case report and literature review.

Selecting potential recipient vessel options for free flap anastomosis is an important consideration in microsurgical breast and chest wall reconstruction. In these settings, the most common comprise the internal mammary and thoracodorsal vessels, although alternative anastomotic sites have also been described. On occasion, consideration of these alternatives becomes a necessity. The use of five separate recipient vessels is highlighted in a unique case of recurrent locally advanced breast cancer requiring multiple complex reconstructions using free tissue transfer. A 56-year-old lady presented for delayed breast reconstruction one year after radical mastectomy for locally advanced lobular breast cancer. Despite wide resections, local chest-wall recurrence five times necessitated five microsurgical reconstructions, using separate recipient pedicles: internal mammary vessels, thoracodorsal vessels, serratus branch of thoracodorsal vessels, intercostal vessels and thoracoacromial vessels. All flaps survived completely, without donor or recipient complications. There has not been a subsequent recurrence at 6 months since last reconstruction. The purpose of this report is to present the first reported case of microsurgical chest wall reconstruction using five separate free flaps requiring anastomosis to multiple recipient vessels for anterior chest wall coverage, to present a literature-based and clinical review of the regional vascular anatomy of the anterior chest wall, and to present an operative approach algorithm. In such complex cases, this understanding can facilitate a streamlined approach to management. © 2014 Wiley Periodicals, Inc. Microsurgery 37:66-70, 2017.

Pre-expanded, Prefabricated Monoblock Perforator Flap for Total Facial Resurfacing.

In this article, we present the pre-expanded, prefabricated supercharged cervicothoracic monoblock perforator flap for total or subtotal facial resurfacing. This technique can be a reliable reconstruction option for extensive facial skin defect with undamaged muscles and deep structures, which could provide excellent aesthetic and functional outcomes with acceptable complications. Our approach may replace a conventional "skin-only" face allotransplantation in selected patients.

Pre-expanded Intercostal Perforator Super-Thin Skin Flap.

This article introduces pre-expanded super-thin intercostal perforator flaps, particularly the flap that has a perforator from the first to second intercostal spaces. The key techniques, advantages and disadvantages, and complications and management of this flap are described. At present, the thinnest possible flap is achieved by thinning the pre-expanded flap that has a perforator from the first to second intercostal spaces. It is used to reconstruct large defects on the face and neck, thus restoring function and cosmetic appearance.