Macrolane injections for breast enhancement in undiagnosed breast malignancy: a case report.

We report a case of cosmetic breast enhancement with Macrolane injections in an un-diagnosed breast cancer. This delayed cancer diagnosis and complicated surgical resection and reconstruction. It should therefore be mandatory for clinicians to exclude breast malignancy with imaging prior to Macrolane injection.

The outcome of drug smuggling by 'body packers'--the British experience.

Body packing or internal concealment used by drug dealers to smuggle illicit substances, puts the body packer at risk of both imprisonment and death. We report our experience over a 4 year period from January 1996 to December 1999 of suspects presenting to our hospital (the largest series in Europe). A total of 572 cases were assessed radiographically and 180 were shown to be carrying foreign bodies. The commonest reasons for admission were suspected overdose or gastrointestinal obstruction. Thirty-six cases were admitted, of whom 7 required surgical intervention. No deaths occurred. Of all people detained for smuggling by internal concealment into Britain during this period, 27% were seen in our hospital. These cases may present alone or escorted by Her Majesty's Customs and Excise personnel, and one must be aware of this possibility even when situated away from a port of entry.

Breast mass removal made easy by the lump extractor: introducing a new instrument in breast surgery.

The difficulty encountered in the removal of breast lumps has been addressed by the use of a new instrument. The lump extractor described in this paper allows minimal scar surgery and prevents crushing of the breast mass.

The peri-areolar incision--gateway to the breast!

BACKGROUND: In breast surgery the challenge for good cosmesis needs to be met in the management of benign or malignant disease. With tumours this must be balanced against good clearance with safe and adequate margins. For excision of benign lesions obvious deforming scars are unacceptable while with breast preserving cancer surgery a badly placed scar reduces reconstructive choices. The peri-areolar incision has a role in skin sparing mastectomy (SSM) and in breast conserving surgery. This paper describes the application of this incision in breast surgery. METHODS: Patients undergoing breast surgery for benign and malignant disease have undergone operations using a peri-areolar incision. Examples of use of this incision are shown. CONCLUSION: The peri-areolar incision provides good cosmesis while allowing for future or immediate reconstruction and without reducing the range of options.

Techniques for improving the cosmetic outcome of breast conservation surgery.

This paper presents techniques to enhance the aesthetic results of conservative breast surgery. A number of methods are described to improve results of conservative surgery by limiting deformity, reducing scars and by immediate replacement of tissue. By application of the appropriate technique breast tumours may be excised from any quadrant in a large or small breast with a good cosmetic outcome. Attention to detail with pre-operative planning of the estimated tissue loss, placement of incisions, fish-tailing of quadrantectomy scars, utilization of reduction mammoplasty incisions and immediate replacement of defects after wide excision are useful in obtaining good aesthetic results.

Single axillary incision for quadrantectomy, axillary clearance and immediate reconstruction with latissimus dorsi.

This paper describes a method of immediate breast reconstruction following conservative breast surgery. The technique is innovative in that axillary clearance, quadrantectomy and the harvest of the latissimus dorsi muscle are carried out through a small transverse axillary incision with no incision in the breast.

Breast volume assessment: comparing five different techniques.

Breast volume assessment is not routinely performed pre-operatively because as yet there is no accepted technique. There have been a variety of methods published, but this is the first study to compare these techniques. We compared volume measurements obtained from mammograms (previously compared to mastectomy specimens) with estimates of volume obtained from four other techniques: thermoplastic moulding, magnetic resonance imaging, Archimedes principle and anatomical measurements. We also assessed the acceptability of each method to the patient. Measurements were performed on 10 women, which produced results for 20 breasts. We were able to calculate regression lines between volume measurements obtained from mammography to the other four methods: (1) magnetic resonance imaging (MRI), 379+(0.75 MRI) [r=0.48], (2) Thermoplastic moulding, 132+(1.46 Thermoplastic moulding) [r=0.82], (3) Anatomical measurements, 168+(1.55 Anatomical measurements) [r=0.83]. (4) Archimedes principle, 359+(0.6 Archimedes principle) [r=0.61] all units in cc. The regression curves for the different techniques are variable and it is difficult to reliably compare results. A standard method of volume measurement should be used when comparing volumes before and after intervention or between individual patients, and it is unreliable to compare volume measurements using different methods. Calculating the breast volume from mammography has previously been compared to mastectomy samples and shown to be reasonably accurate. However we feel thermoplastic moulding shows promise and should be further investigated as it gives not only a volume assessment but a three-dimensional impression of the breast shape, which may be valuable in assessing cosmesis following breast-conserving-surgery.

Prediction of cosmetic outcome following conservative breast surgery using breast volume measurements.

This study was undertaken to examine the feasibility of breast volume estimation as a predictor of cosmetic outcome. We looked at the cosmetic result of conservative surgery related to the percentage of breast tissue removed. The breast tissue excised was calculated by comparing the breast volume, calculated from the mammogram, and the specimen volume. A total of 24 patients were recalled to a special clinic and were assessed for their cosmetic result by the clinician, independent observer and the patient. The assessment was based on a scale of 1 to 4 (poor to excellent). Our results show that if less than 20% of the breast was removed, all assessors felt that the cosmetic result was at least fair. If more than 20% of the breast was removed, the cosmetic score was poor as assessed by the clinician and independent observer. When excision of greater than 20% of breast tissue is anticipated, then a breast reconstruction procedure should be considered, if cosmetic outcome is to be enhanced.

Breast haematomas: same appearance, different diagnosis.

We report two cases of patients presenting as breast haematomas but with uncommon underlying pathology. One patient had a bilateral breast augmentation by a peculiar method of inserting shredded cellophane packing. A haematoma developed after a fall and subsequently became infected. The second patient was on long-term anticoagulant therapy and developed a haematoma through bleeding from an occult malignant lesion. Both cases demonstrate the need to obtain histology--especially in the elderly, where history and clinical examination may confound diagnosis.

Complications of rectus abdominis myocutaneous flaps in breast surgery.

One-hundred-and-twenty-two rectus abdominis myocutaneous flaps used for reconstruction, post mastectomy (106) and after salvage surgery (16), were reviewed. The minimum period of follow up was 24 months. Simple vertical flaps were raised in 88 patients; in addition seven Drevers, four trans-umbilical, 19 lower transverse and four combined (vertical and transverse flaps) were raised. Early complications (within 2 weeks of surgery) were seen in 30% (37/122) patients. Late complications occurred in 5% of patients (6/122) and 8% had both early and late complications. Flap necrosis was seen in 25% (21/122) of patients. This comprised complete flap loss in two patients. Partial skin and fat necrosis was observed in 14 patients and partial skin loss only in 15. In the group with simple vertical flaps the incidence of partial flap necrosis was 12.5%. Late complications included incisional hernia in 5% of patients. Reoperation for complications were required in 18% of patients. We conclude that while minor morbidity is common with rectus flaps, major complications are few. The more important considerations relate to cigarette smoking and overuse of the peripheral segment of the transverse rectus abdominis flap. While the transverse flaps have now largely replaced other breast flaps, in our practice vertical and higher transverse flaps were useful alternatives. Lessons learned during the development of these flaps have led to greatly improved results in the latter part of the series and it is regarded as a versatile and useful flap in this situation.

Role of Doppler ultrasound flowmetry in the diagnosis of breast lumps.

One hundred and five patients with discrete breast lumps were examined with a 10 MHz Doppler ultrasonic flowmeter. Doppler flow signals were analysed on an Angioscan spectrum analyser. Recordings from the opposite normal breast were taken as controls and signals from the two sides compared. In 23 patients signals from the normal breast could not be recorded and therefore results of the remaining 82 patients are reported. These included 39 patients with carcinoma, 20 with fibroadenoma, 12 with cyclical nodularity and 11 with cysts. Malignant lumps exhibited significantly higher peak systolic (S) and minimum diastolic frequencies (D) in comparison to the control breast. Fibroadenoma also had a higher S and D than those of the opposite normal breast. Signals over cysts and cyclical nodularity showed no significant difference from the recordings over the control side. Despite significantly higher systolic and diastolic frequencies in the cancer group in comparison to benign lumps and normal breast, considerable overlap in the values was seen between cancer and other groups. Therefore the patterns on 10 MHz Doppler sonography are not sufficiently specific to discriminate benign from malignant breast lumps.

Cosmetic results of immediate breast reconstruction post-mastectomy: a follow-up study.

We reviewed 95 patients who underwent immediate breast reconstruction at the time of mastectomy at least one year after operation for assessment of cosmetic results and complications. There were 45 rectus abdominis and 38 latissimus dorsi myocutaneous flaps used for reconstruction. Twelve patients had subpectoral implants without a flap. The results show a remarkable concordance of assessment by patient and surgeon: both found simple subpectoral prosthesis insertion to be inferior to flap reconstruction. Flap reconstruction gave satisfactory results in the majority of patients; latissimus dorsi and rectus abdominis flaps gave similar cosmetic results. However rectus abdominis flaps showed a higher complication rate of flap necrosis and incisional hernia of the abdominal wound. Psychological assessment showed no differences between the three types of reconstruction. We conclude that immediate breast reconstruction can give excellent cosmetic results, and provides an acceptable and safe means of ameliorating the effects of mastectomy. The number of grossly unsatisfactory results decreased notably as the series progressed. Experience and meticulous attention to detail are necessary, since many patients are unwilling to have revisionary procedures if the initial result is unsatisfactory.