Maximizing breast projection after free-nipple-graft reduction mammaplasty.

In 1922, Thorek described standard free-nipple reduction mammaplasty for gigantomastia. This technique provided a simple and effective way to perform reduction mammaplasty. However, the technique is frequently criticized for producing a breast and nipple with poor projection. Even with the standard modification of the original technique, the resultant breast and nipple may be wide and flat, with unpredictable nipple-areola pigmentation. To create a breast mound and nipple with projection and even pigmentation, the free-nipple-graft breast reduction technique is presented. The Wise pattern skin reduction markings and the superiorly based parenchymal reduction technique are used. After the nipple-areola complex is removed, as a free graft, the inferior pole of the breast is then amputated along the Wise pattern skin markings, leaving lateral and medial pillars of breast tissue, with the apex of the resection corresponding to the new nipple location. The lateral and medial pillars of the superiorly based breast mound are then sutured together. Key interrupted sutures are placed, beginning at the most inferior and posterior point of the pillars, while recruiting tissue centrally to increase the projection. The intersecting point of the inverted T, at 7 cm from the new nipple position, is then sutured to the fasciae of the pectoralis major muscle. If more central projection is desired, the vertical limb design can be lengthened. The tissue inferior to the 7-cm mark is de-epithelialized and tucked under the central breast, if needed, contributing further to the final breast parenchyma projection. The skin of the vertical limb of the Wise pattern is then closed with a dog-ear at the apex to further contribute to nipple projection. The nipple is replaced as a free, thick, split-thickness skin graft. The breast is temporarily closed, and the medial and lateral breast tissue excess is liposuctioned to create a more conical breast. Excessive medial and lateral skin is then resected, keeping the inframammary crease incision under the breast mound. Twenty-five patients underwent free-nipple-graft reduction mammaplasty using this technique between 1992 and 2000. An average of 1600 g of breast tissue per breast was removed. The average follow-up period was 36 months. Patient satisfaction has been very high.

Differences in wound healing between ultrasound-assisted lipoplasty and suction-assisted lipoplasty in inverted T-pattern breast reduction surgery and chest wall contouring.

BACKGROUND: Inverted T-pattern breast reduction does not directly address axillary or lateral chest wall fullness. Lipoplasty of this tissue has been advocated by some surgeons to reduce additional scarring. OBJECTIVE: A prospective study was designed to examine the differences in wound healing of the breast reduction skin flaps when ultrasound-assisted lipoplasty (UAL) and suction-assisted lipoplasty (SAL) were each used as an adjunct to inverted T-pattern breast reduction surgery. METHODS: The prospective study involved 15 consecutive nonsmoking female patients undergoing a standard inferior pedicle, central mound breast reduction and contouring of the lateral chest wall. Contouring of the left lateral chest wall and axilla was done with UAL and contouring of the right lateral chest wall with SAL. Lipoplasty was not used elsewhere in the breast tissue. The height and length of skin ischemia or necrosis at the inverted T incision was measured at postoperative day 2 or 3. Patients were placed on dressing changes and followed frequently until fully healed. RESULTS: The amount of breast tissue removed and the amount of UAL/SAL axillary aspirate were not significantly different from side to side (for the mean UAL side, tissue 828 +/- 190 g and aspirate 195 +/- 102 mL; for the mean SAL side, tissue 780 +/- 187 g and aspirate 194 +/- 94 mL; P > .05). The mean area of lateral skin flap ischemia at the inverted T incision was significantly less on the UAL side than on the SAL side (UAL, 47 +/- 128 mm(2); SAL, 361 +/- 500 mm(2); P = 0.02). The time to complete skin wound healing of the lateral flap was significantly less in the UAL-treated flaps than in the SAL-treated flaps (UAL, 9.6 +/- 8.6 days; SAL, 22.1 +/- 22 days; P = .02). The study was terminated once these resounding differences in lateral skin flap necrosis and time of wound healing became obvious. CONCLUSIONS: UAL offers significant benefits in comparison with SAL as an adjunct to standard breast reduction surgery for contouring of lateral chest wall fullness.

Long-term predictable nipple projection following reconstruction.

The creation of the nipple-areola complex is often the final step in the surgical treatment of breast cancer patients, and it consequently has important symbolic and aesthetic implications. Patient expectations and the need for symmetry make nipple projection a crucial aesthetic determinant of nipple reconstruction. We hypothesize that long-term nipple projection and shape can be achieved in a predictable fashion using the modified star dermal fat flap technique. Prospectively, 93 nipples were reconstructed by a single surgeon using a modified star dermal fat flap technique in 44 implant and 49 TRAM flap breast reconstructions. Flap dimensions (base diameter and flap length) were designed according to patient desire or to the base diameter and projection of the opposite breast nipple. A standardized, 3-month postoperative care regimen was observed in all patients. Nipple projection was assessed by the same observer at each follow-up examination. The average length of follow-up was 730 days (745 for TRAM reconstructions and 713 for implants). Consistently, an average of 41 percent of the intraoperative projection remained intact in both groups at final evaluation (SD 12 percent). The total flap length was strongly predictive of intraoperative and long-term projection (r = 0.64 and 0.86, p < 0.0001). Flap lengths ranged from 5.5 to 9.0 cm, and in a linear correlation, resulted in intraoperative projection of 1.0 to 2.1 cm, respectively, and long-term projection of 0.4 to 0.83 cm, respectively. Based on the linear relationship, every 1-cm increase in flap length could be expected to result in a 0.16-cm increase in projection. When controlled for flap length and intraoperative projection, there was no difference between TRAM and implant nipple reconstruction in predicting postoperative nipple projection. Intraoperative planning and execution are critical to achieve predictable nipple shape, size, and projection. The dimensions of the star dermal fat flap can be strategically modified to allow the surgeon predictable projection with a consistent 41-percent preservation of intraoperative nipple projection in both TRAM and implant patients at 2 years.

A systematic, one-stage approach in the treatment of tuberous breast deformity.

During a 2-year period, we performed a single-stage procedure on 7 patients with unilateral "tuberous" breasts after thorough analysis of the deformity and the contralateral breast. Deficient breast envelope skin was replaced by use of a laterally based random inframammary cutaneous flap. Breast tissue rearrangement with or without augmentation was required to address the parenchymal maldistribution and volume abnormalities. Associated tuberous breast ptosis was adequately corrected by tissue rearrangement, augmentation, and circumareolar mastopexy. Areola herniation and size were adjusted by performing a circumareolar mastopexy. Relocation of the inframammary crease was necessary to achieve symmetry. There were two complications in two patients: In one patient a staphylococcal infection developed in the breast pocket after a traumatic hematoma that occurred 2 weeks after surgery. Another patient required implant exchange for a smaller one to achieve better symmetry. Nipple sensation was not affected adversely by the surgery. Ultimately, all patients achieved acceptable symmetry and were satisfied with the results.

Buried inferiorly based gluteus maximus musculocutaneous flap for reconstruction of large, recurrent ischiopubic pressure sores.

The ischium is the most common site for recurrence of pressure sores in the paraplegic population. Successful reconstruction of these wounds depends on the total excision of ulcer, soft tissue debris, bony prominence, and the durability of the soft tissue repair. The V-Y gluteus maximum musculocutaneous flap based on the inferior gluteal vessels can be advanced medially, deepithelialized, and buried to fill large, deep soft tissue ischial wounds. Local rotational flaps close the superficial wound. This buried flap, although not previously described, is useful for the reconstruction of large ischiopubic pressure sores initially or at the time of recurrence.

A reliable approach to the closure of large acquired midline defects of the back.

A systematic regionalized approach for the reconstruction of acquired thoracic and lumbar midline defects of the back is described. Twenty-three patients with wounds resulting from pressure necrosis, radiation injury, and postoperative wound infection and dehiscence were successfully reconstructed. The latissimus dorsi, trapezius, gluteus maximus, and paraspinous muscles are utilized individually or in combination as advancement, rotation, island, unipedicle, turnover, or bipedicle flaps. All flaps are designed so that their vascular pedicles are out of the field of injury. After thorough debridement, large, deep wounds are closed with two layers of muscle, while smaller, more superficial wounds are reconstructed with one layer. The trapezius muscle is utilized in the high thoracic area for the deep wound layer, while the paraspinous muscle is used for this layer in the thoracic and lumbar regions. Superficial layer and small wounds in the high thoracic area are reconstructed with either latissimus dorsi or trapezius muscle. Corresponding wounds in the thoracic and lumbar areas are closed with latissimus dorsi muscle alone or in combination with gluteus maximus muscle. The rationale for systematic regionalized reconstruction of acquired midline back wounds is described.

Management of fingertip injuries.

Fingertip injuries are a very common problem that require precise wound care for optimal results. The special sensory receptor sites in the glabrous skin of the fingertip are uniquely adapted for digital proprioception and should be preserved whenever possible. The etiology of injury; the patient's age; the level, angle, and type of tip amputation; and the patient's anticipated hand use must all be considered when choosing the type of wound closure. The hand surgeon should select the method of repair that provides optimal hand function for each patient on an individual basis.

Monomorphic adenoma of the parotid in a premature neonate.

We report the case of a monomorphic adenoma of the parotid in a neonate. Although solid tumors of the parotid are rare in the pediatric population, these lesions may develop in utero and present at any time after birth. A solid mass in the parotid must be considered malignant until proved otherwise regardless of the age of the patient.

[Community practice in units of primary care at the rural level: an experience with medical students]. / Práctica comunitaria en unidades de atención primaria a nivel rural: una experiencia con estudiantes de medicina.

During the three weeks of vacation from the sixth semester of medical school in May 1982, a group of six students and a professor in the Department of Social Medicine of Valle University, Colombia, conducted a voluntary experimental exercise in some of the rural primary care units of Tuluá Regional Hospital in Valle del Cauca department, using the hospital's Administration as their operational center. The purpose of the exercise, called "Ruralito," was to compile a health census of the general characteristics of the rural communities constituting the primary health care service area. The teaching process employed was designed to encourage the students to act on their own initiative and in their own way and to exchange experiences and plan measures even after completion of the three years of the exercise. The article describes the salient features of the relationship between teaching practice and public health practice in this first exercise, in which a new instructional framework was introduced for the area of medicine; the students' highly favorable reaction to this exercise and the substantial gains made justify the expectation that it will serve as an example for future student exercises in similar processes.

Práctica comunitaria en unidades de atención primaria a nivel rural: una experiencia con estudiantes de medicina / Community practice in units of primary care at the rural level: an experience with medical students

During the three weeks of vacation from the sixth semester of medical school in May 1982, a group of six students and a professor in the Department of Social Medicine of Valle University, Colombia, conducted a voluntary experimental exercise in some of the rural primary care units of Tuluá Regional Hospital in Valle del Cauca department, using the hospital's Administration as their operational center. The purpose of the exercise, called «Ruralito,» was to compile a health census of the general characteristics of the rural communities constituting the primary health care service area. The teaching process employed was designed to encourage the students to act on their own initiative and in their own way and to exchange experiences and plan measures even after completion of the three years of the exercise. The article describes the salient features of the relationship between teaching practice and public health practice in this first exercise, in which a new instructional framework was introduced for the area of medicine; the students' highly favorable reaction to this exercise and the substantial gains made justify the expectation that it will serve as an example for future student exercises in similar processes (Au)