Prediction of Skin Necrosis after Mastectomy for Breast Cancer Using Indocyanine Green Angiography Imaging.

BACKGROUND: In immediate tissue expander reconstruction following total mastectomy for breast cancer, indocyanine green angiography (ICGA)-guided skin trimming is useful for the prevention of complications. However, instances of unclear ICGA contrast can occur with this method, which are difficult to judge as to whether preventive trimming is warranted. To further improve the mastectomy flap necrosis rate, more accurate objective parameters are necessary. METHODS: The degree of clinical improvement was compared between 81 patients trimmed according to the surgeon's judgment (non-ICGA group) and 100 patients with ICGA-guided trimming (ICGA group). We then retrospectively measured 3 parameters [relative perfusion (RP); time (T) to reach RPmax; and slope (S = RP/T) reflecting the rate of increase to RPmax] by using region of interest analysis software and examined their relationships with skin necrosis. RESULTS: The rate of grade III necrosis (reaching the subcutaneous fat layer) was significantly lower in the ICGA group (4.8%) than in the non-ICGA group (17.8%; P < 0.05). The specificity of RP for the diagnosis of skin necrosis was high (98.5%; cutoff value, 34). However, the sensitivities of slope parameters were higher than RP. CONCLUSIONS: ICGA-guided trimming decreased the rate of deep skin necrosis requiring additional surgical treatment. Region of interest analysis indicated that a relatively low percentage luminescence (RP < 34) was indicative of the need for skin trimming, combined with a slow increase in the perfusion of the mastectomy skin flaps.

Vascularized rib support for chest wall reconstruction using Gore-Tex dual mesh after wide sternochondral resection.

Only a few reports describe chest wall reconstruction after sternal resection using Gore-Tex dual mesh, and very few reports describe the use of a vascularized rib to support the thoracic cage. We present a case of a breast cancer patient who underwent anterior chest wall resection for recurrent sternal cancer. Her sternoclavicular joints bilaterally and lower sternum were divided using an electric saw. The bony chest wall was reconstructed using Gore-Tex dual mesh, and a vascularized rib was used to bridge the space between the clavicular heads to support the thoracic cage. The patient's postoperative course was uneventful, without complications, such as paradoxical respiration or pneumonia.

Retrospective comparison of non-skin-sparing mastectomy and skin-sparing mastectomy with immediate breast reconstruction.

Background. We compared Skin-sparing mastectomy (SSM) with immediate breast reconstruction and Non-skin-sparing mastectomy (NSSM), various types of incision in SSM. Method. Records of 202 consecutive breast cancer patients were reviewed retrospectively. Also in the SSM, three types of skin incision were used. Type A was a periareolar incision with a lateral extension, type B was a periareolar incision and axillary incision, and type C included straight incisions, a small elliptical incision (base line of nipple) within areolar complex and axillary incision. Results. Seventy-three SSMs and 129 NSSMs were performed. The mean follow-up was 30.0 (SSM) and 41.1 (NSSM) months. Respective values for the two groups were: mean age 47.0 and 57; seven-year cumulative local disease-free survival 92.1% and 95.2%; post operative skin necrosis 4.1% and 3.1%. In the SSM, average areolar diameter in type A & B was 35.4 mm, 43.0 mm in type C and postoperative nipple-areolar plasty was performed 61% in type A & B, 17% in type C, respectively. Conclusion. SSM for early breast cancer is associated with low morbidity and oncological safety that are as good as those of NSSM. Also in SSM, Type C is far superior as regards cost and cosmetic outcomes.

The thoracodorsal vascular tree-based combined fascial flaps.

In this study, combined fascial flaps pedicled on the thoracodorsal artery and vein were raised and used for thin coverage of dorsal surfaces of the fingers and the dorsum of hand and foot with favorable results. The combined fascial flaps consist of the serratus anterior fascia and the axillary fascia at the entrance of the latissimus dorsi. These flaps were used for reconstruction of the hand, fingers, or foot in nine patients. Reconstruction was performed for burn or burn scar contracture, after resection of malignant tumors, posttraumatic skin defects, and chronic regional pain syndrome. The sites of reconstruction were dorsal surfaces of fingers, dorsum of hand, wrist and palm, forearm, lower leg, and foot. The flaps were used in various configurations including two independent fascial flaps, two-lobed fascial flap with separate feeding vessels, and composite fascial and thoracodorsal artery perforator flap. The fascial and skin flaps survived in all nine patients, with favorable results both functionally and esthetically. Good coverage of soft tissue defects and good recovery of range of motion in resurfaced joints were achieved. There were no complications. The scars at the sites of harvest were not noticeable. The advantage of this method is that not only a single flap but flaps of a variety of configurations can be harvested for different purposes. The thoracodorsal vascular tree-based combined fascial flaps are useful for the reconstruction of soft tissue defects in the extremities.

Muscle sparing-2 transverse rectus abdominis musculocutaneous flap for breast reconstruction: a comparison with deep inferior epigastric perforator flap.

Breast reconstruction using free transverse rectus abdominis musculocutaneous (TRAM) flap can be divided into 4 muscle-sparing (MS) types: conventional TRAM flap containing full width muscle as MS-0, while deep inferior epigastric perforator (DIEP) flap containing absolutely no muscle as MS-3. We include only the muscle portion between the medial row and lateral row perforator vessels in TRAM flap, which is designated as MS-2. Between October 1999 and April 2006, the same surgeon performed 82 breast constructions using MS-2 free TRAM flaps in 79 patients. All the flaps survived. Postoperative complications included partial fat necrosis in 8 cases, all corresponding to zone IV or zone II. Bulging of donor site occurred in 5 patients, 4 of whom were obese and 1 had bilateral flap harvest. Compared with our own reconstructions using DIEP flap (30 cases), there were no significant differences in operative time and blood loss between the two techniques. In conclusion, MS-2 free TRAM flap is a useful technique for breast construction considering the easy surgical techniques, length of the vascular pedicle that can be harvested, and the degree of freedom of the flap.

Kimura disease: diagnostic imaging findings and surgical treatment.

We have encountered 11 cases of Kimura disease, comprising 10 males and 1 female. The ages at presentation ranged from 16 to 48 years, with a mean of 31.5 years. The sites of the subcutaneous masses were bilateral posterior auricular regions in two cases, frontal region in two cases, temporal region in two cases, head region in one case, parotid region in two cases, parotid and temporal regions in one case, and left earlobe in one case. The interval from onset to surgery ranged from 1 to 10 years, with a mean of 4.7 years. For diagnostic imaging, a combination of magnetic resonance imaging (MRI) and ultrasonography had a high diagnostic value. MRI depicted abnormalities at sites in contact with bone, such as posterior auricular regions, and sites with abundant soft tissue, such as parotid and cheek regions. Diffuse atrophy of subcutaneous fat was observed at the sites of the masses. On ultrasonography, the interior of lymph nodes was homogeneous and hyperechoic, whereas the periphery was hyperechoic, and blood vessels entering lymph nodes were clearly depicted. Surgery was performed in all cases. Postoperative adjuvant radiotherapy was conducted in one patient and radiotherapy and steroid therapy in one other patient. There were two relapses, and both were excised by repeated surgery. Surgical excision of the subcutaneous mass in Kimura disease has the advantages that the treatment period is short and precise histopathologic diagnosis can be obtained.

Free dorsal middle phalangeal finger flap.

Three patients underwent finger reconstruction using free dorsal middle phalangeal finger flaps (DMF flaps). All flaps survived. The free DMF flap relies on blood flow from the dorsal branches of the digital artery and is harvested from the skin on the dorsum of the middle phalanx. The digital artery gives rise to four dorsal branches; two in the middle and two in the proximal phalangeal regions. The flap is based on the dorsal branch of the digital artery that passes near the center of the phalanx. The characteristic feature of the free DMF flap is that the dorsal cutaneous veins are used as drainage vessels. Unlike island flaps, blood congestion does not occur after free DMF flap surgery. Sensibility of the free flap may be obtained by inclusion of the dorsal branches of the digital nerves in the flap pedicle. Loss of the digital artery at the donor site can be circumvented with venous grafting. Surgery under brachial plexus block is an advantage of this flap. The free DMF flap is a useful technique for skin and soft-tissue defects.

Innervated reverse dorsal digital island flap for fingertip reconstruction.

PURPOSE: Various methods of fingertip reconstruction with a sensory flap have been reported. Digital island flaps or cross-finger flaps have to be used for large defects; however, the digital artery is sacrificed when creating conventional homodigital island flaps and 2 surgeries are required for the cross-finger flap. We describe our experience with an innervated reverse dorsal digital island flap that does not require sacrifice of the digital artery. METHODS: We used innervated reverse dorsal digital flaps for fingertip reconstruction in 8 patients. The flap was supplied by the vascular network between the dorsal digital artery (the terminal branch of the dorsal metacarpal artery) and the dorsal branch of the digital artery. Venous drainage was through the cutaneous veins and the venous network associated with the dorsal arterial network. The flap was designed on either the dorsal proximal or the dorsal middle phalangeal region. The flap was harvested with the dorsal branch of the digital nerve (for the dorsal middle phalanx), the dorsal digital nerve (for the dorsal proximal phalanx), or the superficial branch of the radial nerve (for the thumb), which was anastomosed to the distal end of the digital nerve. After flap transfer the donor site was covered with a full-thickness skin graft. RESULTS: Of the 8 flaps, 6 survived completely, 1 had partial epithelial skin necrosis, and 1 showed central compression skin necrosis. Three flaps showed congestive changes from the first to the fifth day after surgery, which resolved by massage. All patients achieved satisfactory recovery of sensation; the static 2-point discrimination ranged from 3 mm to 5 mm and the Semmes-Weinstein test results ranged from 0.036 g to 0.745 g. CONCLUSIONS: The innervated reverse dorsal digital island flap provides another option for homodigital tip coverage. The advantages are that the digital artery is not sacrificed and only 1 surgery is needed. A disadvantage is the potential for venous congestion for the first 4 or 5 days after surgery.

Primary intrapelvic lymphaticovenular anastomosis following lymph node dissection.

Lymphedema of lower extremities occurs following surgical resection of malignant tumors and intrapelvic lymph node dissection and is a long-term problem for patients. We performed primary intrapelvic lymphaticovenular anastomosis to prevent postoperative leg lymphedema. The procedures were conducted in 7 patients (aged 35-61 years) with cancer of the uterine body. After completion of hystero-oophorectomy and intrapelvic lymph node dissection, the afferent lymphatics entering internal and external iliac lymph nodes were end-to-end anastomosed with branches of the deep inferior epigastric veins. The time taken for constructing 4 anastomoses was 100 to 120 minutes. The follow-up period ranged from 10 to 18 months (mean, 14 months). All patients were discharged and are independent in daily living. Apart from mild leg lymphedema in 1 patient, no lymphedema was observed in other patients up to the last follow-up. This surgical modality is effective in preventing lymphedema in lower extremities after intrapelvic para-aortic lymph node dissection.

Huge cavernous hemangioma arising in a male breast.

We report a rare case of a huge cavernous hemangioma arising in a male breast. A 60-year-old man first noticed 1 x 2 cm elastic hard nodule just below his right nipple ten years previously. It enlarged 5 x 5 cm over six years. When he came to our clinic, it was size of child head (510 mm in circumference),was an elastic hard with a rather smooth surface, and firmly fixed to the chest wall. Magnetic resonance imaging (MRI) and multidetectocomputed tomography (MDCT)showed a large mass infiltrating into the chest wall. Fine needle aspiration cytology (FNA) and core needle biopsy (CNB) failed to obtain proper material except for old bloody fluid or necrotic connective tissue, precluding a correct diagnosis preoperatively. Mastectomy with partial resection of the chest wall was subsequently performed. Histologically, it was found to be a cavernous hemangioma without cellular atypia. In such a case, complete excision is recommended to exclude the possibility of an underlying malignant lesion.