Breast reconstruction in the high risk patient with systemic connective tissue disease: a case series.

INTRODUCTION: The presence of severe underlying connective tissue disease may restrict the reconstructive options offered to a woman in the event of mastectomy. Putative concerns about reconstructive surgery include the effects of connective tissue disease and immunosuppression on wound healing and donor site morbidity, and increased risks of deranged clotting and thrombophilia after free tissue transfer. There is also the possibility of an unpredictable tissue reaction after oncological resection surgery and adjuvant radiotherapy. METHODOLOGY: Here we present a review of the current sparse evidence regarding reconstructive breast surgery in this challenging group of patients. In addition we present a series of six consecutive patients with a spectrum of connective tissue disorders including combinations of longstanding Systemic Lupus Erythematosis (SLE), Rheumatoid arthritis and Raynaud's Disease who underwent successful post-mastectomy reconstruction with an extended autologous latissimus dorsi flap, along with subsequent successful correction of asymmetry and/or nipple reconstruction. RESULTS: There is a paucity of literature on this subject perhaps suggesting that surgeons are reluctant to offer reconstruction or that uptake is poor in this group. Complications related to radiotherapy and free tissue transfer in patients with severe CTD is less than may be expected. The most common complications experienced by our patients with CTD after extended ALD breast reconstruction were persistent donor site seroma, wound dehiscence and delayed haematoma formation, reflecting the abnormal inflammatory response and deranged haemostatic cascade common to connective tissue disease. However, all six patients made a full recovery from surgery without residual donor site morbidity and with an acceptable aesthetic breast reconstruction. CONCLUSION: Careful peri-operative management is crucial in this group of patients, but good outcomes are possible using a variety of reconstructive techniques. This is the first reported series of patients with severe connective tissue disease who have been managed with extended ALD breast reconstruction. The majority of complications relate to the donor site but the favourable outcomes demonstrate that the extended ALD flap remains a reliable reconstructive option for this group.

Prospective trial of adipose-derived regenerative cell (ADRC)-enriched fat grafting for partial mastectomy defects: the RESTORE-2 trial.

AIMS: Women undergoing breast conservation therapy (BCT) for breast cancer are often left with contour defects and few acceptable reconstructive options. RESTORE-2 is the first prospective clinical trial using autologous adipose-derived regenerative cell (ADRC)-enriched fat grafting for reconstruction of such defects. This single-arm, prospective, multi-center clinical trial enrolled 71 patients post-BCT with defects ≤150 mL. METHODS: Adipose tissue was collected via syringe lipoharvest and then processed during the same surgical procedure using a closed automated system that isolates ADRCs and prepares an ADRC-enriched fat graft for immediate re-implantation. ADRC-enriched fat graft injections were performed in a fan-shaped pattern to prevent pooling of the injected fat. Overall procedure times were less than 4 h. The RESTORE-2 protocol allowed for up to two treatment sessions and 24 patients elected to undergo a second procedure following the six month follow-up visit. RESULTS: Of the 67 patients treated, 50 reported satisfaction with treatment results through 12 months. Using the same metric, investigators reported satisfaction with 57 out of 67 patients. Independent radiographic core laboratory assessment reported improvement in the breast contour of 54 out of 65 patients based on blinded assessment of MRI sequence. There were no serious adverse events associated with the ADRC-enriched fat graft injection procedure. There were no reported local cancer recurrences. Injection site cysts were reported as adverse events in ten patients. CONCLUSION: This prospective trial demonstrates the safety and efficacy of the treatment of BCT defects utilizing ADRC-enriched fat grafts.

The timing of autologous latissimus dorsi breast reconstruction and effect of radiotherapy on outcome.

INTRODUCTION: The optimal timing of breast reconstruction is controversial. Immediate breast reconstruction (IBR) has been gaining in popularity due to the aesthetic and psychological benefits, although its role is less certain when postoperative radiotherapy may be required. There is some evidence that long term cosmetic outcome of IBR using the autologous latissimus dorsi (ALD) flap may be impaired if the reconstruction is subjected to postoperative radiotherapy. We compared the long term cosmetic outcome and patient satisfaction between a group of patients who underwent IBR with postoperative radiotherapy and a group who underwent delayed ALD reconstruction. METHODS: Patients who underwent ALD breast reconstruction between 1997 and 2000 were invited to attend a research clinic. At the clinic up-to-date photographs were obtained and a quality of life questionnaire was completed. Cosmetic outcome was assessed by a panel of judges including surgeons, nurses and lay people. RESULTS: Thirteen patients who had IBR and postoperative radiotherapy and 11 patients who had delayed reconstruction attended for follow up. In the long term both groups fell within an acceptable cosmetic outcome range. However, there was a trend towards a better outcome in patients undergoing delayed reconstruction, with the volume and contour of the upper pole being most affected in the irradiated reconstructions. Patient satisfaction was similar between the two groups, however most patients in retrospect would have preferred an immediate reconstruction. CONCLUSIONS: Immediate ALD breast reconstruction, even in the setting of postoperative radiotherapy, yields satisfactory results. We continue to offer it to patients undergoing mastectomy operations, even when postoperative radiotherapy is likely to be required.

The use of Munsell colour charts in nipple-areola tattooing.

Tattooing is an excellent, simple and quick option in nipple-areola reconstruction. Colour mismatch is one of the commonest problems with this procedure. Use of Munsell colour charts allows the premixing of common colours for different patient populations using pigments from various manufacturers. There are significant correlations between nipple colour and Fitzpatrick skin type and between nipple colour and parity. Three nipple-areola colours were more common than others and were found in 50% of patients; these can be premixed ready for use. Adjustment of premixed colours for individual patients can be performed prior to tattooing, speeding up the procedure. Accurate recording of colours also facilitates audit.

How many procedures to make a breast?

The construction of a new breast after mastectomy involves fashioning the breast mound and creating a projecting nipple and a coloured areola. This should involve three episodes for a patient, but is this the experience of patients embarking on breast reconstruction? We identified 177 patients who had undergone breast reconstruction between 1 September 1997 and 31 March 1999. The clinical records for 164 of these patients were found and the data summarised. The techniques, complications and other ancillary procedures experienced by this group of patients are presented. Multiple procedures are likely to be required to complete breast reconstruction, and the patient should be so counselled from the outset. Particular problems may be encountered with each technique and this should be borne in mind when selecting a procedure for each patient, especially in the context of immediate reconstruction where avoiding any delay to adjuvant treatment is a consideration.

Expanding silicone granuloma.

Complications of breast augmentation using silicone implants have been the subject of much discussion. We report a single case of a silicone granuloma, which has exhibited unusual behaviour in that it has grown rapidly and significantly. Whilst silicone granulomata have been reported on many occasions in the past, to our knowledge this is the first report of a rapidly growing example.

Avulsion of vascular anastomosis in free-flap breast reconstruction.

We report a case of anastomotic avulsion following a free deep inferior epigastric perforator (DIEP) flap reconstruction immediately after mastectomy for carcinoma of the breast. This occurred on the 5th postoperative day when the patient was allowed a shower and abducted her shoulders to wash her hair. The aim of this report is to make readers aware of such a possibility, and we suggest exercising caution in early mobilisation of the upper limb after free-flap breast reconstruction.

Cross-leg pedicled free scapular flap for neuropathic foot ulcer: case report.

A case is reported of the treatment of a chronic neuropathic ulcer on the lateral aspect of the foot with osteomyelitis. Extensive debridement and free scapular flap transfer were performed. Because the leg had only one patent vessel, the anterior tibial artery, which was unsuitable for anastomosis, the vascular anastomosis of the flap was performed to the posterior tibial vessel of the contralateral leg, which was used as a termporary carrier. The vascular pedicle was divided after 3 weeks, and the flap survived completely. This case report extends the indications of the cross-leg free flap for complex defects on a single-vessel foot.

Deep inferior epigastric perforator flap in breast reconstruction: experience with the first 50 flaps.

Abdominal wall function is a major concern for plastic surgeons performing breast reconstruction with TRAM flaps. The deep inferior epigastric perforator (DIEP) free flap spares the whole rectus abdominis muscle, includes skin and fat only, and therefore, preserves adequate abdominal wall competence. Between January of 1995 and May of 1997, a total of 50 breast reconstructions in 42 patients were performed by using the DIEP flap. Eight patients had bilateral procedures. Five breast reconstructions were immediate and 45 were delayed. All patients were collected prospectively and no patients were excluded from this study. The average age of patients was 47 years (range, 22 to 59 years) and the average weight was 65 kg (range, 51 to 103 kg). Seventy percent of patients had one or more risk factors for TRAM flap reconstruction. The mean postoperative follow-up period was 13 months (range, 3 to 30 months). Twenty consecutive patients (17 single and 3 bilateral DIEP flap breast reconstructions) within this group underwent evaluation of their abdominal wall function preoperatively and then 3 and 6 months postoperatively by using Lacote's muscle grading system. Average flap harvesting time was 120 minutes and average blood loss was 420 cc. Total flap loss and partial necrosis occurred in one (2 percent) and three flaps (6 percent), respectively. Abdominal wound infection occurred in seven patients (17 percent). Unfortunately, one patient died of adult respiratory distress syndrome on the seventh postoperative day. Fat necrosis was found in three flaps (6 percent). Postoperative abdominal wall examination did not reveal any hernia, but bulging was found in two patients (5 percent). All patients were able to resume their daily activities. Abdominal wall function tests in the series of 20 patients showed that all patients had reached or even improved their preoperative level of upper and lower rectus muscle function 6 months after the operation. The external oblique muscles were the most affected by the procedure of flap harvesting, but only two patients (10 percent) were found to have a measurable impairment after 6 months. Patient satisfaction with the reconstructed breast and the donor site was rated high. The free DIEP flap is, therefore, a reliable and valuable method of breast reconstruction. The donor site morbidity was decreased, and the more tedious flap dissection did not affect the overall outcome.

Burns of the female genitalia and perineum.

Burns of the female genitalia and perineum mostly occur in connection with more extensive thermal injuries to the trunk and lower extremities. Isolated burns to the vulva are very unusual because this area is anatomically well-protected. A few reports in the literature describe injuries due to bizarre accidents and now obsolete techniques. The management of these injuries, possible complications, prognosis and long-term results are discussed following a case report of a 28-year-old woman who sustained extensive deep dermal burns to her external and internal genitalia in a suicide attempt involving a firework.

[Increase of oxygen partial pressure and acceleration of wound healing by tetrachlorodecaoxide]. / Steigerung des Sauerstoffpartialdruckes und Akzeleration der Wundheilung durch Tetrachlordecaoxid.

63 transcutaneous measurements of oxygen pressure and 36 series of infrared thermograms in 9 hypoxic wounds showed that topical administration of tetrachlorine decaoxide (TCDO) results in increased oxygen supply of the wound. This effect is associated with improvement of the skin temperature and decrease of the pathological temperature difference between the wound and the surrounding tissue. TCDO can induce physiological wound healing, since it improves the mechanisms of the immune defence system, wound cleansing, granulation, and epithelialization in slow-healing wounds.