Congenital breast deformity reconstruction using perforator flaps.

BACKGROUND: Congenital breast deformities such as Poland syndrome, unilateral congenital hypoplasia, tuberous breast anomaly, and amastia pose a challenging plastic surgical dilemma. The majority of patients are young, healthy individuals who seek esthetic restoration of their breast deformities. Currently, both implant and autologous reconstructive techniques are used. This study focuses on our experience with congenital breast deformity patients who underwent reconstruction using a perforator flap. METHODS: From 1994 to 2005, a retrospective chart review was performed on women who underwent breast reconstruction using perforator flaps to correct congenital breast deformities and asymmetry. Patient age, breast deformity type, perforator flap type, flap volume, recipient vessels, postoperative complications, revisions, and esthetic results were determined. RESULTS: Over an 11-year period, 12 perforator flaps were performed. All cases were for unilateral breast deformities. The patients ranged from 16 to 43 years of age. Six patients had undergone previous correctional surgeries. Eight (n = 8) flaps were used for correction of Poland syndrome and its associated chest wall deformities. Four (n = 4) flaps were used for correction of unilateral breast hypoplasia. In all cases, the internal mammary vessels were the recipient vessels of choice. No flaps were lost. No vein grafts were used. All patients were discharged on the fourth postoperative day. Complications encountered included seroma, hematoma, and nipple malposition. Revisional surgery was performed in 30% of the cases. Esthetic results varied from poor to excellent. CONCLUSIONS: Perforator flaps are an acceptable choice for patients with congenital breast deformities seeking autologous breast reconstruction. Deep inferior epigastric artery (DIEP) or superficial inferior epigastric artery (SIEA) flaps are performed when adequate abdominal tissue is available; however, many young patients have inadequate abdominal tissue, thus a GAP flap can be used. Perforator flaps are a safe, reliable surgical technique. In the properly selected patient, donor-site morbidity and functional compromise are minimized, improved self-esteem is noted, postoperative pain is decreased, and excellent long-term esthetic results can be achieved.

Cytoreductive surgery in patients with advanced-stage carcinoid tumors.

The role of aggressive surgical resections as well as criteria for resectability in patients with advanced carcinoid tumors is not clearly defined. Thirty patients (17 male and 13 female) who were previously diagnosed to have "unresectable carcinoid disease" were treated using a multimodality approach over a period of 2 years. Extensive liver involvement was present in 28 of 30 (93%) of the cases. Small bowel involvement was noted in 22 of 30 (73%), and peritoneal/retroperitoneal/mesenteric invasion was observed in 15 of 30 (50%) of the cases. Three patients had remote metastases (brain, bone, and eye). Twenty of 30 (66%) patients had carcinoid syndrome with severely disabling symptoms. Eight patients (26%) had small bowel obstruction. All patients underwent at least one surgical exploration/intervention. Radiofrequency ablation (RFA) of one or more liver lesions was performed as an adjunct in 22 of 30 (73%) patients. Six patients (20%) had a second surgical procedure. There were 11 complications in eight patients (27%) after the initial operation. Median hospital stay for patients who underwent RFA only, RFA/liver resection, and liver resection with abdominal tumor debulking were 2, 4, 8, and 16 days respectively. Twenty-five of 30 patients (83%) showed symptomatic improvement. Mean pre- and postoperative Karnofsky physical performance scores were 55 and 85 respectively (P < 0.02). Small bowel obstruction was due to adhesions in five patients. All patients with intestinal obstruction had complete relief of their symptoms postoperatively. 5-Hydroxyindolacetic acid levels decreased by 50 per cent in all patients with follow-up determinations available. Aggressive surgical exploration and tumor debulking could be performed with significantly improved symptomatic outcome and relatively minor complications. Longer follow-up is needed for assessment of effect on survival.