Reconstruction of the Meatus Urethrae After Oncologic Vulvectomy: Outcome of 42 Vaginal Flap Advancements in 41 Women.

BACKGROUND AND AIM: Resection of the distal part of the urethra is performed in 15% to 55% of women with vulvar cancer to achieve radicality of vulvectomy. Urinary reconstruction in these women may be complicated by urethral stenosis resulting from circular inset of the meatus. We report on our experience with 2 surgical techniques of noncircular inset to prevent such stenosis. METHODS: From January 2005 to January 2020, 42 urethral meatus reconstructions were performed in 41 women after vulvectomy for (pre)malignant skin disorders by a "limited" (n = 17) or "extended" (n = 25) anterior vaginal wall advancement technique, including V-Y insertion of part of the vaginal flap in a posterior longitudinal urethrotomy. Preoperative characteristics, procedural details, and surgical outcomes were reviewed. RESULTS: We observed 1 neomeatal stenosis and 1 case of partial vaginal wall flap necrosis as major complications following the "limited" technique and 1 circumferential neomeatal dehiscence and occlusion as major complication after the "extended" technique. Both the neomeatal stenosis and the dehiscence/occlusion are felt to have been preventable and not caused by a flaw of design of the advancement technique. CONCLUSIONS: We advocate applying these vaginal wall advancement techniques to prevent circular inset of the neomeatus. The "extended" technique offers a solution in cases where the periurethral vulvar defect cannot be closed by transpositioning of labial skin.

Surgical Complications of Skin-Sparing Mastectomy and Immediate Implant-Based Breast Reconstruction in Women Concurrently Treated With Adjuvant Chemotherapy for Breast Cancer.

BACKGROUND AND AIM: To date, studies on adjuvant chemotherapy as a risk factor for the surgical outcome of combined mastectomy and breast reconstruction were hampered by the inclusion of mixed reconstructive cohorts of both delayed and immediate timing and of both autologous and implant-based techniques. Consequently, there is a paucity of data on the impact of adjuvant chemotherapy on surgical complication rates after combined skin-sparing mastectomy and immediate implant-based breast reconstruction. METHODOLOGY: We compared the postoperative complications that occurred within 16 weeks after this combined procedure in 131 women (139 breasts) treated with adjuvant chemotherapy with those in a control group of 491 women (517 breasts) not receiving any adjuvant therapy within 16 weeks. RESULTS: In line with the clinically indicated selection of women to undergo adjuvant chemotherapy, the interventional group differed significantly from the control group in 7 of the 12 patient- and procedure-related characteristics. The prevalence of minor complications (13.7% and 12.4%, respectively, P = 0.68) and major complications (31.7% and 29.4%, respectively, P = 0.60) did not differ significantly between the interventional group and the controls. The fraction of breasts that needed unscheduled surgery (0.29 and 0.24, respectively, P = 0.20), the fraction of total number of interventions (0.34 and 0.33, respectively, P = 0.24), and the fraction of implants lost (0.72 and 0.67, respectively, P = 0.86) did not differ significantly between both groups. The onset of chemotherapy, furthermore, seemed not to influence the occurrence or severity of complications. CONCLUSIONS: Like other women who have to undergo mastectomy, women who need to undergo adjuvant chemotherapy can potentially benefit from combined skin-sparing mastectomy and immediate implant-based breast reconstruction.

Rembrandt's Aging Face in Plastic Surgical Perspective.

BACKGROUND AND AIM: When the painter Rembrandt van Rijn (1607-1669) died 350 years ago, he left us some 90 self-portraits showing his aging face. Recognizing aging characteristics of the male face is fundamental to the planning of a surgical procedure and a prerequisite when communicating to the male patient. Rembrandt's recordings through the years might offer an optimal aid to train such recognition, provided that they are truthful. In this article, we present an inventory of age-related changes observed in these self-portraits to assess whether they are truthful. METHODS: High-quality photographs of 25 self-portraits that are generally accepted as works by Rembrandt were independently assessed in a standardized fashion for the presence of 25 aging characteristics, by 2 plastic surgeons and a physician-portraitist. RESULTS: The observed proportion of agreement between assessments reached 0.87 (κ = 0.68, indicating good agreement). We found Rembrandt's self-portraits to reflect his facial aging as a chronologically increasing process. Observed characteristics set in as of 1642, the year that he lost his beloved first wife, Saskia. His face appears to have particularly aged from 1652 to 1659, in which period Rembrandt's second great love Hendrickje was summoned because of her living in sin with Rembrandt, and Rembrandt himself faced financial problems. As of 1660, Rembrandt seems to have been less intended to depict his facial aging characteristics. CONCLUSIONS: We conclude that Rembrandt truthfully reflected his ongoing age in the self-portraits, up to 1660. These self-portraits therefore may allow for training the art of observation of such characteristics.

Peptide mimetics of immunoglobulin A (IgA) and FcαRI block IgA-induced human neutrophil activation and migration.

The cross-linking of the IgA Fc receptor (FcαRI) by IgA induces release of the chemoattractant LTB4, thereby recruiting neutrophils in a positive feedback loop. IgA autoantibodies of patients with autoimmune blistering skin diseases therefore induce massive recruitment of neutrophils, resulting in severe tissue damage. To interfere with neutrophil mobilization and reduce disease morbidity, we developed a panel of specific peptides mimicking either IgA or FcαRI sequences. CLIPS technology was used to stabilize three-dimensional structures and to increase peptides' half-life. IgA and FcαRI peptides reduced phagocytosis of IgA-coated beads, as well as IgA-induced ROS production and neutrophil migration in in vitro and ex vivo (human skin) experiments. Since topical application would be the preferential route of administration, Cetomacrogol cream containing an IgA CLIPS peptide was developed. In the presence of a skin permeation enhancer, peptides in this cream were shown to penetrate the skin, while not diffusing systemically. Finally, epitope mapping was used to discover sequences important for binding between IgA and FcαRI. In conclusion, a cream containing IgA or FcαRI peptide mimetics, which block IgA-induced neutrophil activation and migration in the skin may have therapeutic potential for patients with IgA-mediated blistering skin diseases.

Repeated Use of Gluteal Fold Flaps for Post-Oncologic Vulvoperineal Reconstruction.

BACKGROUND AND AIM: Because of the associated high recurrence rate, future reconstructive options should be reckoned with during surgical treatment of primary or recurrent (pre)malignant vulvoperineal lesions. One of the claimed advantages of the gluteal fold flap is the possibility of repeated use of the flap in case of recurrence. We present our experience with such reuse of gluteal fold flaps to illustrate this possibility. METHODS: A mean of 27 months after initial use, 10 subcutaneously pedicled or perforator-based V-Y advancement or propeller-rotation flaps were elevated from previously used gluteal fold flaps in 9 women presenting with recurrent vulvoperineal (pre)malignancy. Five of these women had undergone radiotherapy prior to flap reuse. RESULTS: Although short-term complications were observed in 3 women, all flaps survived and healed completely. CONCLUSIONS: We showed the feasibility of successful reuse of subcutaneous pedicled or perforator-based gluteal fold flaps for repeated vulvoperineal reconstruction, both in nonirradiated and irradiated women. This concept of reuse of the gluteal fold flap is useful for recurring (pre)malignant vulvoperineal defects, and reconstructive surgeons and patients may benefit from this potential option.

A Prospective Assessment of Surgical Risk Factors in 114 Gluteal Fold Flap Reconstructions After Oncological Vulvoperineal Resection.

BACKGROUND AND AIM: To date, clinically relevant selection criteria have not been established for the use of the gluteal fold flap after oncological vulvoperineal resection. We prospectively assessed the surgical risk factors of this reconstructive technique in a large series. METHODOLOGY: From April of 2000 through December of 2015, 114 gluteal fold flaps were used for vulvoperineal reconstruction after excision of (pre)malignant skin disorders in 75 women. The possible influence of 10 patient-related and 6 procedure-related risk factors on flap-related postoperative complications was statistically analyzed. RESULTS: We observed a major complication in 13 flaps (11%) and a minor complication in 19 flaps (17%). Previous radiotherapy (P = 0.01) was associated with significantly more complications, and a rotation flap design rather than VY advancement (P = 0.02) was associated with major complications. Recurrent disease, multifocal tumor localization, incomplete removal of tumor, and bilateral flap procedure were found to be clinically relevant risk factors, but not significantly so. The same applied to recurrence of disease during postoperative follow-up. CONCLUSIONS: We identified surgical risk factors for gluteal fold flap use after oncological vulvoperineal resection. These observations may potentially allow for more favorable future surgical outcomes by adaption of selection of patients or procedure.

Andreas Vesalius' 500th Anniversary: First Description of the Mammary Suspensory Ligaments.

Sir Astley Paston Cooper has, to date, been acknowledged to be the first to describe the suspensory ligaments of the breast, or Cooper's ligaments, in 1840. We found these ligaments to be recorded in the first edition of 'De Humani Corporis Fabrica Libri Septem' by Andreas Vesalius, published in 1543. To commemorate Vesalius' 500th birthday, we quote and discuss this earlier record. Vesalius' record of the nature and function of the fleshy membrane between mammary gland and pectoral muscle, the hard fat intervening the mammary glands, and the fibers running from the fleshy membrane to the skin are a clear representation of posterior layer of the superficial fascial system, the fibro-adipose stroma surrounding and linking the mammary glandular elements, and the suspensory ligaments as we know them. Vesalius recorded the anatomy and function of the latter structures nearly 300 years before Sir Astley Paston Cooper did.

Andreas Vesalius' 500th Anniversary: Initiation of the Superficial Facial System and Superficial Musculoaponeurotic System Concepts.

Because of their relevance for liposuction and rhytidectomies, respectively, the superficial fascial system (SFS) and superficial musculoaponeurotic system (SMAS) have been thoroughly studied over the past decennia. Although it is well known that the SMAS concept was introduced by Tessier in 1974, it remains unknown who first properly described the stratum membranosum of the SFS. In light of the 500th birthday of Andreas Vesalius (1515-1564), we searched his 1543 masterwork De Humani Corporis Fabrica Libri Septem and related work for references to these structures. We found ample reference to both structures as the membrana carnosa (or fleshy membrane) in his works and concluded that Vesalius recognized the extension, nature, and functions of the stratum membranosum of the SFS, as well as its more musculous differentiation as the SMAS in the head and neck area, and the dartos in the perineogenital area. In doing so, Vesalius recorded most details of the SFS and SMAS concepts avant la lettre.

Malignant differential diagnosis in children referred for infantile hemangioma.

BACKGROUND AND AIM: Early age malignant tumors can mimic benign infantile hemangioma (IH). The purpose of this study was to determine the percentage of patients referred with a diagnosis of IH that were misdiagnosed, including that of those who in fact had malignant lesions and to assess how the misdiagnosis was reached. METHODS: From April 2003 through December 2009, all records of children, referred with a diagnosis of IH, were studied to determine the definitive diagnosis. Characteristics of the children with malignant diagnoses and of their diagnostic process were retrospectively analyzed. RESULTS: The referral diagnosis "hemangioma" was recorded in 423 children and confirmed in 89%. Thirty-nine children were rediagnosed with a vascular malformation (7%) or other benign anomalies (2%). The 7 (2%) remaining children were diagnosed with a malignancy. CONCLUSIONS: In cases where the diagnosis of IH is equivocal, biopsy has to be performed in a specialized center to prevent delay.

Partially Plexiform Neurofibroma of the Labia Minora and Clitoral Hood-A Prognostic Dilemma.

BACKGROUND: Unlike solitary neurofibromas, neurofibromatosis type 1 (NF1 or von Recklinghausen disease) has been associated with an increased risk of malignancies. Differentiation between these 2 entities may not be straightforward. CASE REPORT: We present the exceptional case of a girl with one congenital plexiform neurofibroma of the labia minora and clitoral hood in whom the diagnosis NF1 could not been made. Although this presented a prognostic dilemma, we advised against a screening program for any of the malignancies associated with NF1. Still, long-term follow-up seems indicated for recurrence of the partially plexiform neurofibroma and a possible occurrence of malignant peripheral nerve sheath tumor.

Andreas Vesalius' five hundreth anniversary: initiation of the rotator cuff concept.

PURPOSE: The rotator cuff concept refers to the four scapulohumeral muscles that stabilize and rotate the humerus relative to the scapula. To date, the first description of the rotator cuff remained unidentified. METHOD: In light of the 500th birthday of Andreas Vesalius (1515-1564) we searched his 1543 masterwork "Fabrica Corporis Humani Libri Septem" for references to the morphology and function of the rotator cuff muscles. RESULT: Even though he distinguished three rather than four scapulohumeral muscles, Vesalius recognized the need for structures that prevent dislocation of the shoulder inherent to the morphology of the humeral caput and scapular socket. He recorded "three strong ligaments" and the "three muscles that rotate the arm" of which the tendons completely "embrace the ligaments of the joint" as such structures. CONCLUSION: Vesalius defined the rotator cuff concept avant la lettre.

Blocking Fcα receptor I on granulocytes prevents tissue damage induced by IgA autoantibodies.

IgA represents the most prominent Ab class at mucosal surfaces and the second most prevalent Ab in human blood after IgG. We recently demonstrated that cross-linking of the granulocyte IgA FcR (FcαRI) by IgA induces a chemotactic-driven positive-feedback migration loop, hereby amplifying recruitment of granulocytes to IgA deposits. Therefore, we postulated that aberrant IgA-Ag complexes, which can be found in tissues in IgA-mediated diseases, are responsible for tissue damage by inducing continuous granulocyte migration and activation. Using an IgA-dependent skin-blistering disease as a model system, we demonstrated colocalization of FcαRI-positive granulocyte infiltrates with IgA in cryosections of lesional skin of patients suffering from this disease. Furthermore, we showed granulocyte migration to IgA deposits injected in human skin explants and in murine skin of FcαRI transgenic mice in vivo. Importantly, ex vivo migration and tissue damage were inhibited by blocking FcαRI, indicating that these events are dependent on the interaction of IgA autoantibodies with FcαRI. Thus, interrupting the granulocyte migration loop by blocking FcαRI reduces tissue damage in diseases with aberrant IgA-immune complexes. As such, our results may lead to development of new therapies for IgA-mediated chronic inflammatory diseases, hereby decreasing severe morbidity and improving quality of life for these patients.

Can previous diagnostic examinations prevent preoperative angiographic assessment of the internal mammary perforators for (micro)surgical use?

BACKGROUND AND AIM: Preoperative assessment of the internal mammary artery perforating (IMAP) branches enhances IMAP-based reconstructive procedures. Conventionally, color-flow Doppler, selective catheter arteriography, or CT angiography is used for such assessment. We studied how often these examinations may be rendered superfluous by assessment of previously performed diagnostic examinations. METHODS: A radiologist and a plastic surgeon jointly assessed whether information on the dominant IMAP could sufficiently be obtained from the thoracic CT scans of 12 head and neck cancer patients and 12 breast cancer patients, and from the mammary MRI of 12 breast cancer patients. Secondly, we retrospectively assessed in how many of the 10 patients who underwent an IMAP-flap head and neck reconstruction, and in how many of the 10 women who consecutively underwent a deep inferior epigastric perforator (DIEP) flap mammary reconstruction such previous diagnostic examinations were available and informative regarding the level of the dominant perforator. RESULTS: All 24 CT scans and 11 of the 12 MRI scans sufficiently allowed assessment of the level of the dominant IMAP. Previous information had already been available in all 10 DIEP flap patients and 6 of the 10 IMAP-flap patients. The distribution of IMAP dominance over the intercostal levels on the scans differed from that found by cadaveric or intraoperative assessment. CONCLUSIONS: Previously performed diagnostic CT scans and MRI scans that included the parasternal region usually allow sufficient preoperative assessment of the internal mammary perforators for reconstructive procedures. We advocate re-assessment of such previous examinations before ordering additional angiography. Additionally, we suggest to include the parasternal region in diagnostic scans.

Impact of combined skin sparing mastectomy and immediate subpectoral prosthetic reconstruction on the pectoralis major muscle function: a preoperative and postoperative comparative study.

BACKGROUND: We assessed the subjective and objective functional loss induced by detachment of the pectoralis major muscle and whether synergistic function of adjacent muscles compensates for such loss. METHODS: A preoperative to postoperative comparison of the Disability of the Arm, Shoulder and Hand score, 3-dimensional video-analysis of the range of motion, and dynamometric force assessment with electromyography registration were prospectively conducted in 22 women who underwent bilateral preventive breast surgery. RESULTS: Although the statistically significant postoperative increase of the Disability of the Arm, Shoulder and Hand score (P = < 0.01) was indicative of more subjective disability, this difference is irrelevant for activities of daily life. This is in line with the observed postoperative lack of restrictions of range of motion of the shoulder. The mean postoperative maximum force measured in 4 directions reflective of the pectoralis major muscle function was 7.13 N, or 3.8%, lower than the preoperative force (P = 0.079). The mean postoperative maximum force in the 2 contramovement directions was 15.5 N, or 14%, higher than the preoperative force (P = 0.04). Electromyographically, both parts of the deltoid muscle preoperatively and postoperatively showed the same peaks in the 6 directions. Contrastingly, the clavicular part of the pectoralis major muscle postoperatively showed a statistically significant increase of peak of muscle activity in 3 of 4 directions reflective of pectoralis major function and in both contramovement directions, indicating compensatory activity. CONCLUSIONS: Daily life consequences of partial detachment of the pectoralis major muscle were acceptable in our patients.

An Algorithm for Labia Minora Reduction Based on a Review of Anatomical, Configurational, and Individual Considerations.

A variety of reduction labiaplasty techniques have been introduced to date, but no single technique will offer the optimal solution for every patient. Rather, the technique should be chosen based on anatomical, configurational, and technical considerations, as well as on patients' personal preferences regarded maintenance of the labial rim, maintenance of labial sensitivity, and prevention of iatrogenic thickening of the labium. We reviewed, defined, and assessed labial configurational variety, neurovascular supply, reduction techniques, and patient's preferences as the considerations relevant to the choice of labiaplasty technique. Based on this review, an algorithm was constructed that leads to a choice of reduction technique through five decisions to be made regarding (1) resection or (partial) retention of the labial free rim, (2) the measure of required labial width reduction, (3) labial vascular status, (4) prevention of iatrogenic labial thickening, and (5) preservation of labial sensibility. The choice of techniques includes edge trimming, central spindle form de-epithelialization or full-thickness resection, and three modifications of the wedge resection or de-epithelialization technique. These three modifications comprised a modified anterior resection or de-epithelialization combined with posterior flap transposition, a custom flask resection or de-epithelialization, and a modified posterior wedge resection or de-epithelialization combined with anterior flap transposition. Use of the five decisional steps and the inclusion of modifications of all three conventional reduction techniques offer an improved algorithm for the choice of labioplasty technique.

Surgical flap delay to allow primary transabdominal transplantation of extended rectus abdominis myocutaneous flaps in increasingly complex pelvic wound reconstructions.

Primary intra- or transabdominal transplantation of an extended rectus abdominis myocutaneous (ERAM) flap may help prevent surgical complications of pelvic resections. Surgical delay of the ERAM flap may help prevent intra-abdominal (partial) flap loss after transplantation in highly complex situations including previous irradiation. We report on the outcome of this approach and the risk-factors associated with an eventful outcome. From 2012 to 2020, 105 delayed ERAM flaps were consecutively applied immediately following extended pelvic resections after chemoradiation or hyperthermic intraperitoneal chemotherapy. We addressed the increased reconstructive demands by designing the flap in line with the 10th rib and delaying the flap's skin island. All post-operative complications were assessed in light of patient-related or procedure-related potential risk-factors. Major complications occurred in 39 patients. These were correlated with surgery for residual or recurrent malignancy (p < 0.01), with tip necrosis after flap delay (p = 0.02), and with the use of a mesh to close the abdominal donor site (p < 0.01). (Partial) flap loss occurred in 4 cases. We observed a comparably high rate of major complications after ERAM transplantations for increasingly extending indications of perineal-pelvic resections. We consider this to be attributable to poorer patients' conditions and disease processes, rather than to flap viability. Delay of the flap allowed for the use of large and voluminous flaps with comparably little (partial) flap loss.

Oncological status is not a determinant of refraining from breast reconstruction among 490 candidates for mastectomy and post-mastectomy radiotherapy.

BACKGROUND: Although breast reconstruction in the setting of post-mastectomy radiotherapy (PMRT) is controversial, we offer nipple-sparing mastectomy and immediate implant-based breast reconstruction ([N]SSM/IIBR) to women needing primary mastectomy regardless of PMRT. Nevertheless, some of these women have no reconstruction. PURPOSE: To assess the uptake of breast reconstruction in women who undergo PMRT and the patient characteristics associated with such uptake. Additionally, we assessed the determinants of forgoing breast reconstruction. METHODOLOGY: Demographic, physical and oncological characteristics of women who underwent mastectomy, PMRT and breast reconstruction were compared to the characteristics of those who did not undergo breast reconstruction from 2013 through 2018. As determinants of delaying or refraining from breast reconstruction, we distinguished between an oncological reason, patient's preference, patient's co-morbidity, combined tobacco abuse and obesity and the need for PMRT. RESULTS: 490 women received PMRT. Of these, 396 women (81%) underwent combined [N]SSM/IIBR and PMRT or mastectomy and PMRT with delayed breast reconstruction. Ninety-four additional women (19%) did not undergo breast reconstruction. The latter group differed significantly from those who did in demographic and physical characteristics but not in terms of oncological diagnosis and history. Patient's preference was the single most frequent determinant of not performing either immediate or delayed breast reconstruction among these 94 women. Oncological status was not a major determinant in refraining from reconstruction. CONCLUSION: The significant difference in non-oncological characteristics between the reconstructed and non-reconstructed women confirms the importance of these characteristics in the preference for either reconstruction or non-reconstruction.

Combined skin-sparing mastectomy and immediate implant-based breast reconstruction: Outcome following mantle field irradiation versus outcome following whole-breast irradiation.

BACKGROUND: Mastectomy may be needed in the context of previous radiotherapy in cases of breast carcinoma following mantle field radiotherapy for Hodgkin lymphoma or in cases of local relapse or second primary tumours after breast conserving therapy including whole-breast irradiation (BCT). The outcome of combined skin-sparing mastectomy and immediate implant-based breast reconstruction (SSM-IIBR) has been reported to be unfavourable in these cases. PURPOSE: To compare the outcome of SSM-IIBR after mantle field radiotherapy to that after BCT and to compare both to the outcome observed in non-irradiated breasts. METHODOLOGY: The prevalences of short-term events, device loss, long-term corrections and secondary reconstructions, and reversion to autologous tissue techniques of 42 SSM-IIBRs performed after mantle field irradiation were compared to those of 47 salvage SSM-IIBRs following BCT. Both outcomes were compared to the outcome in the contralateral, non-irradiated breast of the subgroup of 23 women in the BCT group. RESULTS: The groups were comparable in terms of patient- and procedure-related risk factors, except for time lapse after previous therapy, intraoperative device weight, and the fraction of immediate use of a definitive implant. The outcome of SSM-IIBR after mantle field irradiation significantly differs favourably from that after BCT. It matches the outcome observed in non-irradiated breasts. CONCLUSION: Skin-sparing mastectomy combined with immediate implant-based breast reconstruction is a fully justifiable option for women who previously underwent mantle field irradiation for Hodgkin lymphoma. We feel that the unfavourable outcome observed in women who previously underwent BCT necessitates an alternative reconstructive modality.

Short-Term Surgical Complications of Skin-Sparing Mastectomy and Direct-to-Implant Immediate Breast Reconstruction in Women Concurrently Treated with Adjuvant Radiotherapy for Breast Cancer.

Background Postmastectomy radiotherapy (PMRT) is allegedly associated with a higher risk of complications of combined nipple-sparing or skin-sparing mastectomy and subpectoral direct-to-implant immediate breast reconstruction ([N]SSM/SDTI-IBR). For this reason, this combination is usually advised against or, even, refused in women who need to undergo PMRT. Because this advice has never been justified, we assessed the short-term complications that may potentially be associated with PMRT after [N]SSM/SDTI-IBR. Methods We compared the complications requiring reintervention and implant loss occurring after 273 [N]SSM/SDTI-IBR that were exposed to PMRT within the first 16 postoperative weeks (interventional group) to those occurring in 739 similarly operated breasts that were not (control group). Additionally, we compared the fraction of complications requiring reintervention occurring after the onset of radiotherapy in the interventional group to that occurring after a comparable postoperative period in the control group. Results The fraction of breasts requiring unscheduled surgical reinterventions for complications and the loss of implants did not differ significantly between both groups but significantly more reinterventions were needed among the controls ( p = 0.00). The fraction of events after the onset of radiotherapy in the interventional group was higher than the fraction of events after 6.2 weeks in the control group, but not significantly so. Conclusion We found no prove for the alleged increase of short-term complications of adjuvant radiotherapy. Therefore, we advise that these should not be considered valid arguments to advice against [N]SSM/SDTI-IBR.

A cadaver study of the vascular territories of dominant and nondominant internal mammary artery perforators.

The perfusion territory of the pedicled internal mammary artery perforator flap has been described, but the number of perforators to be included in the flap's pedicle is controversial. We studied the vascular territory of the dominant perforator and the contribution of additional nondominant perforators to it. Therefore, the dominant perforators in 9 fresh cadavers and the nondominant perforators in 4 of these, were injected with water-based ink. The dominant perforator vascularized a territory extending from the superior border of the clavicle to the xiphoid, and from midsternal to the anterior axial fold, with a mean craniocaudal length of 19.4 cm (range, 17.0-24.0) and a mean mediolateral width of 18.6 cm (range, 16.0-22.5). Additional injection of nondominant perforators did not lead to any substantial enlargement of this territory. One single dominant perforator vascularizes a large part of the hemithorax, allowing for various flap designs. Nondominant perforators do not have to be included in the vascular pedicle of the internal mammary artery perforator flap, which leads to less donor-site morbidity.