Inverted Nipple With Nipple-Sparing Mastectomy.

BACKGROUND: The inverted nipple is a relatively common aesthetic problem seen by plastic surgeons. The etiologies of an inverted nipple include insufficiency of supporting tissues, hypoplasia of the lactiferous ducts, and retraction caused by fibrous bands at the base of the nipple. Many different surgical techniques have been described, either individually or in combination, but none represents a landmark strategy. In our present study, we report our experience of spontaneous improvement immediately after nipple-sparing mastectomy with simple buried interrupted sutures to maintain nipple base in inverted nipple patients. METHODS: We describe our 10 years' experience in using a simple approach to correct inverted nipples after nipple-sparing mastectomy with pedicled transverse rectus abdominis myocutaneous flap reconstruction. Between January 2001 and August 2010, we observed 23 inverted nipples after nipple-sparing mastectomy by using only a buried baseline suture to tighten the base of the nipple. The follow-up period ranged from 3 to 13 years. RESULTS: After nipple-sparing mastectomy with tightening of the base of the nipple, improvements were seen in 18 of the 23 patients. No complications associated with surgery occurred, such as infection, depigmentation, sensory disturbance, or nipple necrosis. CONCLUSIONS: The simple method of baseline suturing that only tightens the nipple base with nipple-sparing mastectomy has been used in our center over a 10-year period in patients with breast cancer and an inverted nipple. The retractile duct or fibrous cord was completely cut with nipple-sparing mastectomy, and over 70% of inverted nipples in the patients were improved and maintained with only the tightening of the base of the nipple. Our results show that inverted nipple is caused by tight fibrous band or short duct rather than a lack of subareolar tissue.

Simplified Designing and Insetting of the Free Flap in Reconstructing Oral and/or Oropharyngeal Defect.

Reconstructing oral and/or oropharyngeal defect after tumor ablation requires anatomic restoration of the complex structures to maximize functional outcomes. This study introduces a simple and adjustable way of designing and insetting of a free flap in such reconstruction. Patients who received free flap reconstruction of oral and/or oropharyngeal defect with 33% to 66% of the native tongue left intact after resection of the tumor were enrolled and reviewed. Flap was designed as an oval shape according to the maximum width and length of the defect, and sutured from the most posterior part. Natural imbrication of the flap formed by anterior pulling of the tongue was marked and de-epithelized to create a three-dimensional shape. A total of 30 patients met the inclusion criteria of this study and the median follow-up was 32 months. All flaps survived after 1 case of venous reanastomosis. The average hospital stay was 23.7 days. All patients were decannulated. Twenty (66.7%) patients could eat a normal or soft diet, and 19 (63.3%) patients had normal or intelligible speech. Simplified designing of the flap with adjustable tailoring allowed for easy and effective way of free flap oral and/or oropharyngeal reconstruction. De-epithelization (or trimming) of the naturally imbricated area during the procedure of insetting created a bilobed shape in effect to conform to the three-dimensional defect.

The Low DIEP Flap for Breast Reconstruction.

Supplemental Digital Content is available in the text.

Modified lumbar artery perforator flaps for gluteal pressure sore reconstruction.

BACKGROUND: Gluteal perforator flaps (GPFs) are the most useful for gluteal region pressure sore reconstruction. However, application is difficult if the surrounding area has scar tissue from previous operations or trauma, especially with recurrent sores. We describe the use of modified lumbar artery perforator flaps when GPFs cannot be used. METHODS: Between May 2009 and April 2014, 51 patients underwent gluteal pressure sore reconstructions with gluteal (n = 39) or modified lumbar artery (n = 12) perforator flaps. Patients in the modified lumbar artery perforator group had scar tissue from trauma or previous surgery. In this retrospective review, we analyzed patient age and sex, defect size and location, operative time, follow-up duration, immediate postoperative issues, flap necrosis, dehiscence, re-operation, donor-site morbidity and recurrence. Complications and clinical outcomes were compared between groups. RESULTS: We found no significant differences in patient demographics, surgical complications or clinical outcomes. There were eight cases of temporary congestion (20.51%) and four of partial flap necrosis (10.25%) in the gluteal perforator group. In the modified lumbar artery perforator group, there were three cases of temporary congestion (25%) and one of partial flap necrosis (8.33%). No pressure sores recurred during follow-up in either group. CONCLUSION: GPFs are the gold standards for gluteal pressure sores, but modified lumbar artery perforator flaps are relatively easy and useful when GPFs cannot be used due to scar tissue.

Nipple reconstruction with combination of modified CV flap and contralateral nipple composite graft.

BACKGROUND: Numerous nipple reconstruction methods have been proposed including the use of local flaps and composite grafts, but most methods have shown a significant loss of projection. We combined a modified CV flap with a composite graft (nipple sharing) to maximize the projection and volume of the new nipple and reduce the size of the contralateral nipple. METHODS: In total, 30 patients underwent nipple reconstruction using a combined method between January 2013 and November 2015. This technique was selected if the diameter of the contralateral nipple was large and the thickness of the skin was less than 2 mm. After the modified CV flap was created, a composite graft from the contralateral nipple was placed between the V flaps and the C flap. The loss of projection and the ratio of the new nipple to the contralateral nipple were evaluated 12 months after surgery. RESULTS: Nipple reconstruction was successful in all cases. The projection at 12 months after reconstruction was 68% of the initial projection, and the mean projection ratio of the new nipple to the contralateral nipple was 0.81. There was no complication in the donor nipple; in fact, the shape was improved with nipple reduction, and the scar was inconspicuous. CONCLUSIONS: Nipple reconstruction that combines a modified CV flap and composite graft can maximize the nipple projection and provide a chance for nipple symmetry as the two components will act synergistically.

Outcomes of Take-Back Operations in Breast Reconstruction with Free Lower Abdominal Flaps.

BACKGROUND: Microvascular complications after free-flap breast reconstructions are potentially devastating problems that can increase patient morbidity and lead to flap loss. To date, no comprehensive study has examined the rates of salvage and the methods of microvascular revision in breast reconstruction. We reviewed the treatment of microvascular complications of free-flap breast reconstruction procedures over a seven-year period. METHODS: A retrospective review of all patients who underwent microvascular breast reconstruction at our institution between April 2006 and December 2013 was conducted. Based on their surgical records, all patients who required emergency re-exploration were identified, the rate of flap salvage was determined, the factors associated with flap salvage were evaluated, and the causes and methods of revision were reviewed. RESULTS: During the review period, 605 breast reconstruction procedures with a free lower abdominal flap were performed. Seventeen of these flaps were compromised by microvascular complications, and three flaps were lost. The overall salvage rate was 82.35%. No significant differences between the salvaged group and the failed group were observed with regard to age, BMI, axillary dissection, number of anastomotic arteries and veins, recipient vessel types, or use of the superficial inferior epigastric vein in the revision operation. Successful salvage of the flap was associated with a shorter time period between recognizing the signs of flap compromise and the take-back operation. CONCLUSIONS: The salvage rate of compromised lower abdominal flaps was high enough to warrant attempting re-exploration. Immediate intervention after the onset of flap compromise signs is as important as vigilant postoperative monitoring.

The thin gluteal artery perforator free flap to resurface the posterior aspect of the leg and foot.

BACKGROUND: The authors evaluated the clinical application of the gluteal artery perforator free flap harvested above the superficial fascia as a new approach to reconstruct soft-tissue defects of the posterior aspect of the lower limb. METHODS: Between September of 2010 and August of 2013, 27 thin flaps were used to reconstruct lower extremity defects in 27 patients. All flaps were elevated on the superficial fascia plane and based on a single perforator from either the superior or inferior gluteal artery. RESULTS: With the exception of two flaps that healed secondarily after partial loss, all flaps survived completely. Average flap thickness was 8.5 mm (range, 5 to 11 mm). The average flap size was 125 cm (range, 9 × 4 cm to 25 × 12 cm). The average pedicle length was 5.5 cm (range, 3 to 8 cm.). The average artery diameter was 0.65 mm (range, 0.4 to 1.3 mm). During the average follow-up of 13 months (range, 2 to 35 months), all flaps showed good contour and did not require any secondary revisions. CONCLUSIONS: The gluteal artery perforator free flap provides a thin flap for ideal contour, minimizes the operative risks of changing the patient's position intraoperatively, and conceals the donor site with minimal morbidity. However, the pedicle can be short and supermicrosurgery skills may be needed to accommodate the short pedicle. Overall, this new approach of using a thin gluteal artery perforator free flap to reconstruct the posterior aspect of the leg and foot can be considered a feasible option. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.