Immediate autogenous breast reconstruction in clinically advanced disease.

Breast reconstruction is pursued more aggressively today. We have offered primary autogenous reconstruction to patients with advanced disease and review herein our experience with these patients to define the benefits or problems of this practice. We carried out immediate autologous tissue breast reconstruction in 21 patients with disease in clinical stage IIb or higher, including 12 in stage III and 3 in stage IV. No patient experienced delay in the delivery of adjuvant chemotherapeutic or radiation treatment, and the reconstructed breasts tolerated these treatments well. Although 4 patients required biopsy of postoperative masses deep within the reconstructed breast, none proved to represent recurrence of disease. One patient developed cutaneous recurrence in a scar uniting mastectomy flap with reconstructive flap, and 2 had axillary recurrences. All were quickly detected and treated. Two patients with stage III disease and 2 with stage IV disease died from metastases, but with good local-regional control. Primary autogenous breast reconstruction may be offered to motivated patients regardless of disease stage.

The "circummuscular" free TRAM pedicle: a trap.

A variation of the deep inferior epigastric system is presented in which the vessels or their dominant branches do not enter the rectus muscle at any point on its deep surface. Full submuscular exploration of the deep inferior epigastric pedicle is proposed as a necessity (prior to muscle section) if flap loss is to be avoided during efforts to raise free TRAM flaps with minimal muscle harvest.

Restoring the breast to match the normal side.

Although breast symmetry is for most patients a reconstructive goal of the highest order, the alteration of a normal breast may, for many women, constitute another "branding." Our patients have chosen overwhelmingly to leave their normal breasts "untouched" since having been given the opportunity to do so. Treatment planning and surgical methods are described that have made possible symmetrical results without change in the normal breast. Representative patients are shown to document the usefulness of these plans in women of varied anatomy. Our ongoing experience shows us that it is an uncommon patient, indeed, for whom symmetrical breast restoration cannot be accomplished without resorting to surgery on the normal organ.

The teres major muscle flap in breast reconstruction.

We describe the teres major as a muscle flap. The results of anatomical and radiographic studies demonstrate the surgical anatomy. The details of 4 clinical cases illustrate its application in breast reconstruction. The teres major flap offers advantages over previously described muscle flaps in selected cases of breast and chest contour reconstruction.

An experimental model for soft-tissue coverage of the traumatized distal lower extremity: the distally-based gracilis flap.

A model for regional muscle-flap coverage of experimental soft tissue defects of complex injuries of the rabbit lower leg is presented. This technique has provided reliable and generous coverage without the difficulty or risk of a free flap procedure, nor the limitations of other local flaps.

A clinical evaluation of cricothyroidotomy.

Cricothyroidotomies were performed upon 147 patients at the New York University Medical Center and Booth Memorial Center from March 1976 through February 1978. Cricothyroidotomy was demonstrated to be a rapid and technically simple and precise procedure. The incidence of complications was 8.6 per cent. Catastrophic complications occurred in two patients who had severe laryngeal stenosis. Cricothyroidotomy was performed following prolonged endotracheal intubation in these two patients who had airway obstruction immediately following endotracheal extubation. In both patients, there was a glottic and subglottic component to the laryngeal stenosis suggesting that endotracheal intubation as well cricothyroidotomy played a critical part in the development of laryngeal stenosis. In view of these observations, we believe that cricothyroidotomy is useful, particularly in emergency situations and in patients with median sternotomy incisions but is contraindicated in patients having endotracheal intubation of more than seven days' duration or in patients having airway obstruction develop following removal of an endotracheal tube except as a temporary lifesaving procedure.