Chest and upper body morbidity following immediate postmastectomy breast reconstruction.

OBJECTIVE: The performance of a mastectomy for the treatment or prophylaxis of breast cancer may have long-term implications for both physical and mental well-being in women. The development of breast numbness and phantom breast sensations following mastectomy is well-known; however, relatively little is known about physical morbidity following postmastectomy breast reconstruction. The primary objective of this study was to evaluate the level of physical morbidity experienced following three surgical approaches: mastectomy alone, postmastectomy tissue expander/implant reconstruction, and postmastectomy autogenous tissue reconstruction. METHODS: We conducted a cross-sectional survey of a sample of women who had undergone mastectomy with or without reconstruction. Chest and upper body morbidity were evaluated using the BREAST-Q. Physical well-being was compared across three types of breast surgery. RESULTS: In total, 308 of 452 women who received a questionnaire booklet returned completed questionnaires. There was an overall difference in physical morbidity attributable to surgical treatment (P < 0.001). Patients who underwent autogenous tissue reconstruction had the highest (i.e., best) mean physical well-being score. Women who underwent expander/implant reconstruction also had less chronic physical morbidity than women who underwent mastectomy alone (P < 0.05). CONCLUSIONS: Our findings suggest that women who undergo immediate autogenous tissue reconstruction experience significantly less chest and upper body morbidity than those who undergo either mastectomy with implant-based reconstruction or mastectomy alone. This information can be used to facilitate clinical decision-making, to validate individual experiences of breast cancer survivors, and to inform future innovations to decrease the long-term physical morbidity associated with breast cancer surgery.

Can galactography-guided stereotactic, 11-gauge, vacuum-assisted breast biopsy of intraductal lesions serve as an alternative to surgical biopsy?

The purpose of this study was to determine the value of galactography-guided, stereotactic, vacuum-assisted breast biopsy (VABB) for the assessment of intraductal breast lesions and its potential as a therapeutic tool that could eliminate the need for surgical excision. Eighteen patients (median age 64 years, range 37-80) with nipple discharge and galactography-verified intraductal lesions underwent galactography-guided, stereotactic, 11-gauge VABB followed by surgery. Histopathology findings from VABB and subsequent surgery were compared. Underestimation and false-negative rates were assessed. After VABB, histopathology revealed invasive ductal carcinoma (IDC) in three (17%), ductal carcinoma in situ (DCIS) in six (33%), high-risk lesions in six (33%) and benign lesions in three (17%) cases. After surgical biopsy, histopathology confirmed the previously established diagnosis in 11 lesions (61%). The underestimation rate for high-risk lesions and DCIS was 50% (6/12). The false-negative rate was 7% (1/14). Histopathology examination after surgery showed that not a single lesion had been completely removed at VABB. Galactography-guided VABB is a feasible diagnostic tool. However, its value as a therapeutic procedure is limited because of the high number of underestimated and missed lesions and because of the histopathological detection of lesions' remnants in every case. Surgical excision should be the therapeutic gold standard in cases of pathological nipple discharge and galactography abnormalities.

The vertically oriented free myocutaneous gracilis flap in head and neck reconstruction.

Oncologic resections in the head and neck can result in a variety of complex defects. Many free tissue transfers have been described for soft-tissue reconstruction in this area. The pedicled, vertical gracilis myocutaneous flap has been well described for use in the perineum, but is rarely used as a free tissue transfer because of previously documented unreliability of the skin island. The objective of this study was thus to review a single author's experience with reconstruction of complex head and neck defects using the vertically oriented free myocutaneous gracilis flap. A retrospective review of all head and neck reconstructions at a major cancer center from 2003-2006 was performed. Demographic, oncologic and reconstructive data were retrieved from a prospectively maintained clinical database. Ten patients (mean age, 57 years; range, 33-84 years) with complex defects of the head and neck were reconstructed using a gracilis myocutaneous flap with a vertically oriented skin paddle. Seven patients had a malignant skin tumor; 3 patients had a parotid gland tumor. Mean surface area requirements were 88.6 cm. Composite resections were common and included skin, facial nerve, mandibular and/or temporal bone, partial glossectomy, parotidectomy, and/or orbital exenteration. Six patients had a history of prior irradiation; 6 patients received postoperative radiotherapy. Mean follow-up was 8 months (range, 2-20 months). Total flap survival was 100%. There were no partial flap losses. Primary wound healing occurred in all cases. The vertically oriented free myocutaneous gracilis flap is a reliable option for reconstruction of moderate volume and surface area defects in the head and neck. It represents an underutilized flap that should be more commonly considered for soft-tissue reconstruction of complex defects in the head and neck.

Dynamic reconstruction of eye closure by muscle transposition or functional muscle transplantation in facial palsy.

For patients with facial palsy, lagophthalmus is often a more serious problem than the inability to smile. Dynamic reconstruction of eye closure by muscle transposition or by free functional muscle transplantation offers a good solution for regaining near-normal eye protection without the need for implants. This is the first quantitative study of three-dimensional preoperative and postoperative lid movements in patients treated for facial paralysis. Between February of 1998 and April of 2002, 44 patients were treated for facial palsy, including reconstruction of eye closure. Temporalis muscle transposition to the eye was used in 34 cases, and a regionally differentiated part of a free gracilis muscle transplant after double cross-face nerve grafting was used in 10 cases. Patients' facial movements were documented by a three-dimensional video analysis system preoperatively and 6, 12, 18, and 24 months postoperatively. For this comparative study, only the data of patients with preoperative and 12-month postoperative measurements were included. In the 27 patients with a final result after temporalis muscle transposition for eye closure, the distance between the upper and lower eyelid points during eye closing (as for sleep) was reduced from 10.33 +/- 2.43 mm (mean +/- SD) preoperatively to 5.84 +/- 4.34 mm postoperatively on the paralyzed side, compared with 0.0 +/- 0.0 mm preoperatively and postoperatively on the contralateral healthy side. In the resting position, preoperative values for the paralyzed side changed from 15.11 +/- 1.92 mm preoperatively to 13.46 +/- 1.94 mm postoperatively, compared with 12.17 +/- 2.02 mm preoperatively and 12.05 +/- 1.95 mm postoperatively on the healthy side. In the nine patients with a final result after surgery using a part of the free gracilis muscle transplant reinnervated by a zygomatic branch of the contralateral healthy side through a cross-face nerve graft, eyelid closure changed from 10.21 +/- 2.72 mm to 1.68 +/- 1.35 mm, compared with 13.70 +/- 1.56 mm to 6.63 +/- 1.51 mm preoperatively. The average closure for the healthy side was from 11.20 +/- 3.11 mm to 0.0 +/- 0.0 mm preoperatively and from 12.70 +/- 1.95 mm to 0.0 +/- 0.0 mm postoperatively. In three cases, the resting tonus of the part of the gracilis muscle transplant around the eye had increased to an extent that muscle weakening became necessary. Temporalis muscle transposition and free functional muscle transplantation for reanimation of the eye and mouth at the same time are reliable methods for reconstructing eye closure, with clinically adequate results. Detailed analysis of the resulting facial movements led to an important improvement of the authors' operative techniques within the last few years. Thus, the number of secondary operative corrections could be significantly reduced. These qualitative and quantitative studies of the reconstructed lid movements by three-dimensional video analysis support the authors' clinical concept of temporalis muscle transposition being the first-choice method in adult patients with facial palsy. In children, free muscle transplantation is preferred for eye closure, so as not to interfere with the growth of the face by transposition of a masticatory muscle. In addition, a higher degree of central plasticity in children might be expected.

Simultaneous GDNF and BDNF application leads to increased motoneuron survival and improved functional outcome in an experimental model for obstetric brachial plexus lesions.

Motoneurons of the neonate rat respond to proximal axonal injury with morphologic and functional changes and ultimately with neuronal death. Recent studies showed that both glial cell-line-derived neurotrophic factor (GDNF) and brain-derived neurotrophic factor (BDNF) reduce induced degeneration of motoneurons after axotomy and avulsion. Whether rescued motoneurons are functionally intact has been argued. In the present investigation, the authors have used a proximal crush lesion of the brachial plexus in neonatal rats as the experimental model of neuronal injury. This allowed the authors to study the effects of trophic factor administration on injured motoneurons and the relationship between motoneuron survival and extremity function. Trophic factors were locally released by small polymer implants in a low-dose slow-release mode. Six groups of 10 animals were prepared: BDNF, GDNF, GDNF/BDNF, control, sham, and normals. The number of surviving motoneurons was determined by retrograde tracer techniques using Fluorogold and Fastblue. Extremity function was quantitatively evaluated with functional muscle testing at day 56. The results of this study demonstrate that trophic factors applied separately had no effect, whereas combined trophic factor application (GDNF/BDNF group) had a dramatic rescue effect on motoneuron survival as compared with the control groups, which also effected significantly greater strength. The authors conclude that a combination of trophic factors leads to enhanced motoneuron survival, with improved voluntary function as the animal enters adulthood so that exogenous trophic support of motoneurons might have a role in the treatment of all types of severe neonatal plexopathies, maintaining the viability of motoneurons until reconstructive surgery provides them with a pathway for regeneration and endogenous trophic support.

Two-photon confocal microscopy: a nondestructive method for studying wound healing.

Two-photon confocal microscopy is a new technology useful in nondestructive analysis of tissue. The pattern generated from laser-excited autofluorescence and second harmonic signals can be analyzed to construct a three-dimensional, microanatomical, structural image. The healing of full-thickness guinea pig skin wounds was studied over a period of 28 days using two-photon confocal microscopy. Three-dimensional data were rendered from two-dimensional images and compared with conventional, en face, histologic sections. Two-photon confocal microscopy images show resolution of muscle, fascia fibers, collagen fibers, inflammatory cells, blood vessels, and hair. Although these images do not currently have the resolution of standard histology, the ability to noninvasively acquire three-dimensional images of skin promises to be an important tool in wound-healing studies.

Demystifying trans-axillary augmentation/periareolar mastopexy: a novel, two-stage, single-operation approach to management of the contralateral breast in implant reconstruction.

BACKGROUND: Following unilateral tissue expander/implant reconstruction, combined augmentation/mastopexy of the contralateral breast may be performed in an attempt to improve breast symmetry. Combined augmentation/mastopexy can be a very difficult operation, even for the surgeon with substantial experience. To simplify the technical approach to this complex problem, the senior author (PGC) has developed a 'two-stage, single-operation' approach. The purpose of this study is to review the safety and efficacy of this approach to the contralateral breast in the setting of unilateral, implant-based reconstruction. METHODS: A retrospective review of all combined trans-axillary augmentation/periareolar mastopexies performed from 1998 to 2007 was undertaken. Only patients who had a history of prior unilateral mastectomy and immediate expander placement were included. Photographic documentation of long-term aesthetic results was evaluated by two independent observers. RESULTS: In total, 26 combined, trans-axillary augmentation/periareolar mastopexies were performed in patients, who had initiated unilateral, postmastectomy, tissue expander/implant reconstruction on the contralateral side. No patient desired revisional surgery for inadequate ptosis correction or malpositioning of the nipple. A total of 69% of patients had a 'very good to excellent' overall aesthetic result. Of those patients who were deemed to have a 'good' aesthetic result, the development of a capsular contracture in the reconstructed breast detracted from the overall aesthetics. CONCLUSION: The two-stage, single-operation approach to unilateral augmentation/mastopexy described here can produce a good aesthetic result and allow for adequate oncologic follow-up. In particular, excellent results are seen in patients with grade I or II ptosis and good-quality skin preoperatively. Monitoring of the breast for cancer, using mammography, is still possible with this technique.

Sciatic nerve injury model in the axolotl: functional, electrophysiological, and radiographic outcomes.

OBJECT: The 2 aims of this study were as follows: 1) to establish outcome measures of nerve regeneration in an axolotl model of peripheral nerve injury; and 2) to define the timing and completeness of reinnervation in the axolotl following different types of sciatic nerve injury. METHODS: The sciatic nerves in 36 axolotls were exposed bilaterally in 3 groups containing 12 animals each: Group 1, left side sham, right side crush; Group 2, left side sham, right side nerve resected and proximal stump buried; and Group 3 left side cut and sutured, right side cut and sutured with tibial and peroneal divisions reversed. Outcome measures included the following: 1) an axolotl sciatic functional index (ASFI) derived from video swim analysis; 2) motor latencies; and 3) MR imaging evaluation of nerve and muscle edema. RESULTS: For crush injuries, the ASFI returned to baseline by 2 weeks, as did MR imaging parameters and motor latencies. For buried nerves, the ASFI returned to 20% below baseline by 8 weeks, with motor evoked potentials present. On MR imaging, nerve edema peaked at 3 days postintervention and gradually normalized over 12 weeks, whereas muscle denervation was present until a gradual decrease was seen between 4 and 12 weeks. For cut nerves, the ASFI returned to 20% below baseline by Week 4, where it plateaued. Motor evoked potentials were observed at 2-4 weeks, but with an increased latency until Week 6, and MR imaging analysis revealed muscle denervation for 4 weeks. CONCLUSIONS: Multiple outcome measures in which an axolotl model of peripheral nerve injury is used have been established. Based on historical controls, recovery after nerve injury appears to occur earlier and is more complete than in rodents. Further investigation using this model as a successful "blueprint" for nerve regeneration in humans is warranted.

Influence of the recipient vessel on fat necrosis after breast reconstruction with a free transverse rectus abdominis myocutaneous flap.

The effect of the selection of recipient vessels on the rate of fat necrosis after microsurgical reconstruction of the breast remains largely unknown. Our aim was to evaluate the incidence of fat necrosis after unilateral breast reconstruction with a free transverse rectus abdominis myocutaneous (TRAM) flap after anastomosis with either the internal mammary vessels or the thoracodorsal artery and vein. Consecutive patients who had unilateral reconstruction with a free, muscle-sparing TRAM flap at two tertiary care centres over a 6-year period were identified. The incidence of fat necrosis, defined as postoperative firmness of 1 cm or more persisting for 3 months or more after anastomosis was calculated. To control for the effect of potentially confounding variables (body mass index (BMI), history of preoperative or postoperative radiation, previous abdominal operation, smoking, and hospital) we did a matched-cohort study. A total of 840 unilateral muscle-sparing TRAM flaps were done using either the internal mammary (n = 109) or the thoracodorsal (n = 731) vessels. Evaluation of the entire cohort showed that the incidence of fat necrosis after the two anastomoses was 13 (12%) compared with 130 (18%), respectively (p = 0.17). To control for the effect of confounding variables, 98 patients who had internal mammary anastomoses were matched 1:1 with 98 patients who had thoracodorsal anastomoses. Pair-wise comparisons showed that the incidence of fat necrosis was significantly higher when the thoracodorsal vessels were used (29; 30%) compared to when the internal mammary vessels were used (12; 12%; p = 0.002). Our results showed that a higher rate of fat necrosis may be seen after muscle-sparing TRAM flap reconstruction after anastomosis to the thoracodorsal vessels than with the internal mammary vessels. The exact mechanisms of this association are unknown and warrant additional investigation.

Salvage of tissue expander in the setting of mastectomy flap necrosis: a 13-year experience using timed excision with continued expansion.

BACKGROUND: Mastectomy flap necrosis after immediate tissue expander placement can have profound implications, resulting in prosthetic infection necessitating tissue expander removal. The purpose of this investigation was to evaluate the safety and efficacy of timed, surgical excision during continued serial expansion in the setting of mastectomy flap necrosis and to identify an algorithm for surgeons faced with the management of this difficult problem. METHODS: Consecutive patients in whom documented mastectomy flap necrosis developed following immediate tissue expander placement from 1995 to 2008 were identified. Patient demographic, reconstructive, and complication data were obtained from a prospectively maintained clinical database. Medical records were then retrospectively reviewed to further characterize the extent of mastectomy flap necrosis and its management. RESULTS: Over the 13-year study period, 178 patients with documented mastectomy flap necrosis following immediate tissue expander were identified. In 58 patients (33 percent), surgical excision of the mastectomy flap necrosis was performed. Surgical excision occurred a mean 36 days (range, 8 to 153 days) after tissue expander placement. Mean surface area of eschar excised was 42.5 cm (range, 2.5 to 240 cm). In nine (15.5 percent) of the 58 patients, resection of such an extensive area of mastectomy flap necrosis necessitated explantation of the tissue expander and subsequent flap closure (local advancement flaps, n = 8; latissimus flap, n = 1). Of the remaining patients, only three (6 percent) developed a subsequent infection necessitating the premature removal of a tissue expander. CONCLUSIONS: Timed excision with continued expansion is a straightforward procedure associated with a low incidence of failure. This approach allows for salvage of a significant percentage of threatened tissue expanders and may be coordinated with adjuvant oncologic therapy without excessive delays.