The comparison of effectivity in breast cancer prevention between skin sparing and subcutaneous mastectomy - 20 years of experience.

INTRODUCTION: Breast cancer is the leading cause of neoplasm mortality among women. Several prevention strategies have been implemented to early detect and prevent the cancer occurrence. The most effective protocol includes prevention mastectomy for the high-risk patients. In our study, we have compared the efficacy of subcutaneous mastectomy (SCM) and skin sparing mastectomy (SSM) in long-term follow up. METHODS: We have included 201 female patients who have been treated at our department over the course of 20 years between 2000 and 2019. All the patients were at high risk of developing breast cancer and therefore were indicated for the prophylactic mastectomy. The main indication was the presence of the mutation in the BRCA1 or BRCA2 cluster, however, even in the lack of such mutation, the family history was sufficient for the mastectomy indication. Patients underwent either SCM, SSM or areola sparing mastectomy (ASM), and were allocated to aforementioned groups, respectively. We have collected the data regarding the reconstruction method along with age, weight, height, body mass index (BMI) and presence of predisposing genetic mutations such as BRCA positivity. RESULTS: The patients who underwent SSM compared to those who underwent SCM were of higher age, with higher BMI and body mass. The patients in SSM group had statistically significantly higher BMI than in ASM. There was no difference in efficacy between patients who underwent SSM and SCM. The majority of patients (91.5%) were positive for BRCA1 or BRCA2 mutation. In our study, only four patients were tested negative for known breast cancer inducing mutation (three in SCM and one in SSM). The most common reconstruction method was an abdominal flap and breast implant. CONCLUSIONS: Prophylactic mastectomy is a reliable strategy for significantly reducing the number of breast cancer incidence in high-risk patients regardless of the selected method of mastectomy. These operations allow for the subsequent reconstruction with the whole spectrum of reconstructive options.

INTRAOPERATIVE FAT GRAFTING INTO THE PECTORALIS AND LATISSIMUS DORSI MUSCLES-NOVEL MODIFICATION OF AUTOLOGOUS BREAST RECONSTRUCTION WITH EXTENDED LATISSIMUS DORSI FLAP.

BACKGROUND: The latissimus dorsi flap is a reliable and one of the most commonly used methods of both immediate and delayed breast reconstruction. Its disadvantage is the limited volume of transferred tissue. The authors present their experience with the use of extended latissimus dorsi flap associated with immediate fat grafting into the pectoralis and latissimus dorsi muscles for secondary breast reconstruction. METHODS: From 2013 to 2016, 14 patients underwent secondary unilateral total breast reconstruction with extended latissimus dorsi flap associated with primary fat grafting into the pectoralis major and latissimus dorsi muscles. Fat was injected under visual control between muscle fibers. Fat injected into the pectoralis muscle formed an apparent bulging - autoprosthesis. RESULTS: Mean patient age was 48.2 years (range, 34 to 64 years). Mean injected fat volume was 86.4 ml (range, 50 to 160 ml) and majority of this volume was injected into the pectoralis muscle. All flaps healed uneventfully and no fat grafting-related complications were observed. The most common complication was donor site seroma, which occurred in 57.1%. Results of postoperative ultrasound examination were evaluated. Incidence and the size of oil cysts and fat necroses were significantly lower in muscular layer in comparison with the subcutaneous layer of the reconstructed breast. CONCLUSIONS: Immediate fat transfer into the pectoralis and latissimus dorsi muscle increases the breast volume during the reconstruction with extended latissimus dorsi flap avoiding implant-related complications when abdominal tissue is not available. Pectoralis and latissimus dorsi muscles were shown as reliable and safe recipients for fat grafting.

TRIDIMENSIONAL DOPPLER ASSESSMENT: A RELIABLE, NON-INVASIVE AND COST-EFFECTIVE METHOD FOR PREOPERATIVE PERFORATOR ASSESSMENT IN DIEP FLAP.

BACKGROUND: The preoperative perforator mapping is an important step in autologous breast reconstruction, making the flap raising safer, more predictable and time-saving. Although the Doppler exam has proven to be less accurate in locating perforators compared with colour duplex sonography and CTA, it will probably remain of importance in clinical practice. The aim of this paper is to share some advices on how to perform a Doppler exam in preoperative evaluation of a DIEAp flap, increasing its reliability in location of the perforators. METHODS: The study was carried-out preoperatively on 26 consecutive patients. For the evaluation of the matching between Doppler Dot and operative finding was used a Cartesian coordinate systemResults: We have marked preoperatively 145 perforators in 26 patients for a total of 52 semi-abdomens. An average of 5.6 vessels per patient were marked. Of these, 80 (55.17%) were found between 0-1 cm, 36 (24.82%) between 1-2 cm and 5 (3.4%) of these more than 2 cm from each other. We had 24 (16.55%) false positives in which there was no correspondence between the signal and the intraoperative finding. CONCLUSION: Although the Doppler exam may not provide the same anatomic details as the other newer modalities, such as CTA and MRA, the HHD remains a very useful and important tool for autologous reconstruction. We recommend performing this exam in our standardized and reproducible method to improve the reliability..

Lipomodelling - advanced technique for the correction of Congenital hypoplastic breast malformations and deformities.

A variety of surgical techniques has been used to correct hypoplastic breast malformations and deformities, including tissue expanders, breast implants, custom chest wall implants, mammary gland remodelling, as well as locoregional or free flap. Case series of successful breast reconstruction using lipomodelling technique in one patient with severe Polands syndrome and two patients with tuberous breasts are reported together with literature review. No surgical complications were observed and ultrasound examination did not reveal any pathology in breast tissue other than oil pseudocysts postoperatively. In both malformations, submammary fold was moved downwards. Moreover, the lower part of the breast and areolar herniation was corrected in tuberous breast, and in Polands syndrome, the areolar complex was significantly shifted downwards and laterally. In comparison with other reconstructive techniques, lipomodelling allows for the breast correction to begin in early adolescence. Further growth of the unaffected breast may be effectively corrected by subsequent lipomodelling session. This technique appears to change the overall approach to the management of hypoplastic breast and chest wall malformations.

Reconstruction of large facial and orbital defects by combining free flap transfer with craniofacial prosthesis.

The reconstruction of complex craniofacial and orbital defects should satisfactorily restore functional and aesthetic integrity. Autologous reconstruction of nasal, periorbital and auricular facial subunits as a whole using a locoregional or a free flap is very challenging and the results are not sometimes ideal. With advanced technologies that are currently available it is possible to plan and produce authentic facial prosthesis that can satisfactory substitute these facial subunits. We demonstrate an alternative reconstructive concept for complex craniofacial defects based on a free flap combined with a facial prosthesis for the replacement of periorbital or auricular facial subunits. This approach was used in two patients with very satisfactory results. Combination of a free flap with a facial prosthesis may become a preferable approach for the reconstruction of complex craniofacial defects. Clinical outcomes of the reconstructions may be enhanced respecting the principle of aesthetic facial subunits.

[The effect of prophylactic mastectomy with recontruction on quality of life in BRCA positive women]. / Vliv profylaktické mastektomie s rekonstrukcí na kvalitu zivota zen s BRCA pozitivitou.

UNLABELLED: It is presumed that bilateral mastectomy is so far the most efficient way how to prevent development of breast carcinoma among BRCA positive patients. This mutilating intervention might be unacceptable for cosmetic reasons for most women. The purpose of this study was to determine the influence of prophylactic mastectomy on the quality of life of BRCA positive patients by comparing results of psychodiagnostic questionnaire methods before surgical intervention and after it. Our data set consisted of 25 BRCA positive healthy women and 19 BRCA positive women in remission. All these patients underwent a reconstructive surgical intervention after mastectomy. Age of patients was 38-55 years. The following questionnaires were used: Life Satisfaction Questionnaire by J. Fahrenberg, M. Myrtek and E. Brähler, Clinical analysis questionnaire by S. E. Kruge and R. B. Cattel, Impact of Event Scale - Revised by D. S. Weiss and C. R. Marmar. RESULTS: Women in remission showed most significant decrease in Financial position category and minor decrease in Work and Employment category and Friends, Acquaintances and Relatives category. Improvement of quality of life was recorded especially in category of Health, Sexuality, Own person, Partnership and in Relationship with own children and there was also a significant improvement to overall life satisfaction. Among healthy patients, there was a significant improvement in category of Health and Own person. Most significant decrease was in dimension of Financial position and Work and employment. Prophylactic mastectomy with reconstruction might be the way of prevention of breast carcinoma because from psychological point of view there is the unambiguously significant fact that there was improvement of perception of own health and own person in both groups of women. These are the quality of life aspects that are considered to be basal and long term stabilizing from the perspective of dynamics of own self and they also systematically influence other aspects of quality of life which are derived from them.

[Surgical prevention of breast carcinoma in patients with hereditary risk]. / Chirurgická prevence karcinomu prsu u pacientek s dedicným rizikem.

BACKGROUND: Women with BRCA1 gene mutation have 85% risk of breast cancer; the risk for BRCA2 carriers is 45%. The aim of the study was to verify if prophylactic mastectomy with immediate breast reconstruction can prevent breast cancer in BRCA positive patients. MATERIAL: There were 100 BRCA positive women in which prophylactic mastectomy with immediate reconstruction, 75 dieps, 25 with implants, performed in period 2000-2011. Group A was composed of healthy, non-affected 41 patients, group B of 59 patients in remission after breast cancer treatment. These groups were compared to group C that consisted of 219 healthy carriers of BRCA1/2, non-operated, from registry of genetic department of the Masaryk Memorial Cancer in Brno, from 2000-2011. METHOD: Follow-up for oncology status was done in September 2011 for all 3 groups. RESULTS: Average follow-up of 21 months revealed that in group A there was no breast cancer, in group B 4 patients died and 2 had treatment for metastases. In group C, there were 16 new cases of breast cancer. CONCLUSION: Bilateral prophylactic mastectomy with immediate reconstruction can be an effective way in breast cancer prevention in healthy carriers of BRCA1/2 mutation. In BRCA positive patients treated for breast cancer, the effect of prophylactic mastectomy is unclear. Their survival is more influenced by their previous disease than by a new tumor in the breast.

Genetic testing and prevention of hereditary cancer at the MMCI--over 10 years of experience.

Hereditary cancer syndromes are frequently seen in young cancer patients and patients with a positive family history. Genetic testing is important for the identification of high-risk individuals, and for the early introduction of specialized preventive care or prophylactic surgeries. High-risk tumour suppressor genes (BRCA1 and BRCA2) and DNA repair genes (MLH1, MSH2 and MSH6) are responsible for a substantial part of hereditary breast, ovarian and colorectal cancer. Other hereditary cancers are seen less frequently, but genetic testing has increased for many other site-specific cancers and complex syndromes. Genetic centres and molecular genetic laboratories are located mostly within university or regional hospitals. Some genetic centres are private. It is highly recommended (Czech Society for Medical Genetics) that all laboratories are accredited according to ISO 15,189 and that genetic testing of hereditary cancer syndromes is indicated by medical geneticists. The indication criteria and prevention strategies were published in Supplement 22 of Clinical Oncology 2009 (in Czech). Preventive care for high-risk individuals is organized by thirteen Oncology Centres, which provide most of the oncology care in the Czech Republic. Genetic testing and preventive care for high-risk individuals and mutation carriers is covered by health insurance. The molecular genetic laboratory at the MMCI provides molecular genetic testing of BRCA1, BRCA2, CHEK2 for hereditary breast/ovarian cancer, MLH1, MSH2, MSH6 for Lynch syndrome,TP53 for Li-Fraumeni syndrome, CDKN2A for familial malignant melanoma syndrome and CDH1 gene for hereditary diffuse gastric cancer. Other syndromes are tested in specialized laboratories elsewhere.The use of genetic testing is increasing because of more frequent referrals from oncologists and other specialists and the increasing variety of genes tested. However, in some patients the testing is not recommended and other family members are dying because of the late diagnosis of hereditary syndrome. Greater awareness of the importance of genetic testing in oncology is needed.

Immediate TRAM flap breast reconstruction: 128 consecutive cases.

The purpose of this article is to determine whether or not the transverse rectus abdominis musculocutaneous (TRAM) flap procedure is a practical operation for immediate breast reconstruction. Our series reports 128 consecutive patients who underwent immediate breast reconstruction with the TRAM flap from 1985 to 1990. Of these patients, 86 underwent conventional TRAM, while 40 underwent free TRAM breast reconstruction. Two-thirds of the patients underwent bilateral breast reconstruction. Comparison within this series of the free TRAM versus the conventional TRAM flap revealed improved statistics with regard to the free TRAM flap in a shorter hospitalization time and a decreased incidence of fat necrosis. There is no evidence to date that there is an increased chance of local recurrence with immediate breast reconstruction in this series, and chemotherapy was delayed in a single patient because of healing problems after immediate reconstruction. Operative times and the complication rate seem to be improving as compared with other series previously reported. The TRAM procedure, particularly the free TRAM procedure, is a primary choice for immediate breast reconstruction after mastectomy.

Ruben's fat pad for breast reconstruction: a peri-iliac soft-tissue free flap.

We present a single patient with a successful breast reconstruction using the peri-iliac fat pad as a free flap based on the deep circumflex iliac artery and vein. Although the follow-up is short, in this patient the donor site has been acceptable, and we believe that this flap will have a place in the selection of donor sites for autogenous tissue breast reconstruction.

Bilateral breast reconstruction after mastectomy.

The authors discuss the development of breast reconstruction following mastectomy in Czechoslovakia and present their first case of bilateral reconstruction employing the technique of the TRAM flap. In addition, they explore the possibility of eliminating high-risk parenchyma during with contralateral reconstruction.

Functional and aesthetic consequences in the forearm after harvesting the Chinese flap.

We have evaluated the donor site after harvesting the chinese flap in 40 patients operated at the Clinic of Plastic and Aesthetic Surgery of Brno between 1989 and 1994. We conclude that: 1--The hand function is not oustandly altered after harvesting the flap, but in our study 11 patients (27.5%) indicated that they have some limitation or impairment of their hand function. 2--Tolerance to forearm deformity is considerable, but it depends on degree of the defect for which the flap is transferred: 25 patients (62.5%) would like to elect a different flap. 3--It is necessary to think about cosmetic consequences of the chinese flap and consider other possibilities of the flap choice. Secondary defect may be for the patient a problem even several years after operation.

Microsurgery in the diabetic foot.

The treatment of serious tissue defects on the diabetic foot is complicated and tedious because of a combination of pathogenetic mechanisms that influence healing. Diabetic neuropathies (sensory, motor, vegetative), ischaemia and microangiopathies contribute in varying degrees to the adverse healing. The submitted three-year prospective study was focused on an analysis of the pathogenetic factors with the objective of defining the indications for one of three types of microsurgical transfer: 1. a free flap sutured directly to the vessels at the site of the defect (in predominantly neuropathic defects); 2. a free flap sutured to a politeopedal bypass (in predominantly ischaemic defects); 3. a "nourishing" flap sutured by means of a long venous graft to vessels of the medial and upper leg (in patients in whom an inadequate outflow tract does not make revascularisation possible). In the first year of the investigation, thirteen patients were operated on by means of a free muscle flap incl. three "nourishing" and ten sutured at the site of the defect. Twelve flaps were flaped healed; one patient died from myocardial infarction on the second day after surgery.

DIEP flap breast reconstruction--new experience.

One of the important microsurgical procedures in our department is breast reconstruction after ablations. For many years, the standard method was reconstruction with autologous tissues--a free TRAM flap with a recipient vessels vasa mammaria. We are convinced that this give very satisfactory results with microsurgical safety of operations. We use this method of reconstruction in 17-20 patients per year. The standard time of unilateral reconstruction is 2.5-4 hours, of bilateral reconstruction 4-6 hours. Postoperative morbidity in the abdominal region is, as a rule, associated with a weakening of the abdominal wall and the development of hemias (Galli et al., 1992); a perforator flap in which neither muscle nor fasciae are used creates the prerequisite condition for markedly reduced the morbidity associated with the site of flap collection. Although we used a perforator flap three times for reconstructions of the extremities as early as three years ago, we began to use it for breast reconstruction from the beginning of 2000. No doubt this late use of a large skin flap supplied by 1-2 perforators was due to a lack of trust in the provision of adequate blood perfusion for the large amount of tissue of the flap. From the beginning of 2000, in the course of five months, nine DIEP flaps were used for breast reconstructions, in two cases for bilateral reconstruction. In two instances sensory nerves of the flap were sutured to the branch of the intercostal nerves at the site of insertion. Seven flaps healed p.p.i; in two instances we were faced with the complication of postoperative venostasis, calling for revision and connection of the superficial venous system of the flap to the circulation. Subsequent healing was without complications. Preparation of the flap appears to be relatively easy, and the only pitfall is the selection of a suitable perforator. The operation is longer by half an hour than the classical free TRAM; when the sensory nerve of the flap is sutured, it is ca 1 hour longer. We like to use the DIEP flap for breast reconstruction, and it is a reliable method even for the reconstruction of large pendulous breasts. The donor site morbidity is significantly lower.

Microsurgical reconstruction during treatment of oncological diseases of head and neck.

In 37 oncological patients where extensive resections of the face, maxilla, mandible or calva were necessary, microsurgical reconstructions were used in 27 cases as primary operations at the time of resection, and in 10 cases delayed or secondary operations were made. 49 flaps were used. In five cases two flaps were used in a single stage reconstruction, i.e. one flap for reconstruction of the mandible or buccal and on the other for facial side of the face. During operations a multidisciplinary approach of the surgical team comprising a maxillofacial surgeon, ENT and plastic surgeon is preferred.

Woven vascular microsurgical prostheses in our experimental practice.

The authors have been concerned for six years with the development of woven microsurgical prostheses in experiments on laboratory rats, beagle dogs and domestic white pigs. In rats, in 224 experiments employing 38 types of prostheses with an inner diameter of 2 mm, a reliable prosthesis was selected, described as No. 36, with a 100% patency after insertion of a 1 cm long portion into a defect in the abdominal aorta in 40 experiments. The follow-up of this type of prosthesis lasted 12 months. In large animals this type of prosthesis was implanted into a defect of the radial artery and cephalic vein in dogs and into the femoral artery and the artery of a vascular pedicle of groin and lateral thigh flap. These experiments on large animals are not yet complete and will be the subject of a separate paper.

[Reconstruction of the breast after mastectomy]. / Rekonstrukce prsu po mastektomii.

The author analyzes some causes preventing the development of reconstruction of the breast after mastectomy, mentions the reasons for reconstruction and reflects on contraindications of this operation. He demonstrates a case of bilateral reconstruction of the breasts by means of a TRAM flap.

[The V-Y surgical flap vascularized by the musculoaponeurotic layer for covering scalp defects]. / V-Y plastika vyzivovaná musculoaponeurotickou vrstvou ke krytí defektu skalpu.

The author describes a method for covering skin defects of the scalp combining the principles of V-Y plasty and vascularization by means of the musculoaponeurotic layer. It is a simple operation, using the hairy skin in the vicinity of the defect with direct closure of the defect after transposition of the flap. With regard to the satisfactory cosmetic results, the method is suitable not only for primary defects after excision of tumours but also for medium-sized alopecias.

[Replantation of traumatically amputated parts of extremities-- indications and nomenclature]. / Replantace traumaticky amputovaných cástí koncetin--indikace a nomenklatura.

The authors submit a brief report on replantation activities during the past five years and discuss the problem of indications and terminology of traumatic amputations. The paper contains instruction regarding communication by telephone between the attending surgeon and a specialized microsurgical department. There are also instruction how to handle the amputated portion of the limb and how to transport the patient and the amputated portion of the limb. The authors discusses traditional procedures in replantation surgery on the basis of his own experience with 292 replantations or revascularizations.

The proximal first dorsal metacarpal artery free flap for reconstruction of complex digital defects.

We describe our experience and outcome with the 'Proximal first dorsal metacarpal artery free flap'. Ten consecutive cases utilizing the proximal first dorsal metacarpal artery free flap for complex digital defects were studied. Surgical technique, patient demographics, and flap outcome data were collected. Patient satisfaction was analysed using a questionnaire. All defects healed successfully with no loss of free flaps. The short-pedicle proximal first dorsal metacarpal artery free flap enables primary closure of the donor site up to 2 cm of width (in nine of the ten donor sites). The flap is a reliable and versatile alternative in selected cases of complex digital injuries.