The "dermal cage": Inferiorly based dermal flap technique for breast reconstruction after mastectomy.

"Direct to implant," "one-stage," or "immediate" breast reconstruction procedures have become extremely popular in the last decade. The additional task of covering the lower pole of the prosthetic implant for stability can be achieved by one of two principal methods: either the use of acellular dermal matrix (ADM) or alternatively by the use of autologous dermis (inferiorly based dermal flap). In 2013, we published a modification of the inferior pedicle technique for reduction mammaplasty with the principal goal of making a strong, durable, and internalized ``dermal cage'' fixed to the chest wall to support the remaining breast tissue and to prevent the long-term descent of the breast tissue through the effects of gravity. At that time, we started to use the same technique in breast reconstruction for selected cases who required skin or nipple-sparing mastectomy with reduction of the skin envelope, not just to cover the lateroinferior pole of breast implants as an alternative to ADM but primarily for functional support and suspension with fixation of the implant on the chest wall, shaping the reconstructed breast with the aim of preventing lateral displacement. In this article, we present the method and rationale of our "dermal cage" technique explaining differences between previously published modifications by other authors of the inferior dermal pedicle.

The "dermal cage": a modification of the inferior pedicle breast reduction.

UNLABELLED: In spite of more recent techniques for breast reduction, the inferior pedicle technique has proven to be enduring and still a very popular option in the plastic surgeon's armamentarium despite certain shortcomings. This technique is especially important for treating large breasts with a long sternal notch-to-nipple distance. The modifications we describe in this article overcome some of the main drawbacks of the standard inferior pedicle technique and make the procedure particularly effective when used on appropriately selected patients. This is achieved principally by the creation of a strong, durable, and internalized "dermal cage" that remains fixed to the chest wall in the upper part, as well as on both sides, to support the majority of the remaining breast tissue. This serves several purposes, including narrowing the breast thereby giving good projection and reduction of the N-IMF length of the inferior pedicle. Through suspension and fixation of the inferior pedicle to the chest wall, one can mitigate the effects of gravity on the inferior pedicle. The benefits of this include reduced tension on the T junction, thereby reducing the incidence of wound dehiscence in the immediate postoperative period, while reduction of tension on the nipple-areola complex reduces "bottoming" out over the long term. This process has been the main shortcoming of the inferior pedicle technique to date. The technique was used on 26 patients over a 7-year period with a mean long-term follow-up of 41 months. The results demonstrate the short- and long-term effectiveness of our own particular combination of modifications to previously described techniques and modifications of the inferior pedicle breast reduction. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Angiogenesis and melanoma - from basic science to clinical trials.

The effective management of malignant melanoma has remained centred around the surgeon. The arrival of anti-angiogenic agents as the 'fourth' cancer treatment joining the ranks of surgery, chemotherapy and radiotherapy has been a source of renewed hope. This article provides an up-to-date review of the focus, state and rationale of clinical trials of anti-angiogenic therapies in metastatic malignant melanoma. Vascular Endothelial Growth Factor (VEGF) is by no means the only target, although perhaps the most extensively studied following the successful introduction of the anti-VEGF Antibody bevacizumab. This has been combined with other established therapies to try and improve outcomes in metastatic disease, and is being trialled in the UK to prevent metastasis in high-risk patients. We describe the encouraging preclinical work that lead to great enthusiasm for these agents, assess the key trials and their outcomes, discuss why these therapies have not revolutionised melanoma care and explore how they might be better targeted in the future.