Oblique lateral incision and subpectoral dissection in modified Nuss procedure minimize future breast deformity.

BACKGROUND: We experienced the occurrence of breast deformity in some young female patients who underwent a modified Nuss procedure before breast development. We studied the causes of and preventive measures for this complication. METHODS: We classified 13 prepubescent female patients who underwent our modified Nuss procedure into three groups according to the direction of the skin incision and the dissection layer for bar insertion. Four patients who underwent transverse lateral thoracic skin incision and bar insertion through a subpectoral dissection were assigned to the T/SP group, five who underwent oblique skin incision along the rib and bar insertion through a suprapectoral dissection were assigned to the O/IP group, and four who underwent oblique skin incision and subpectoral dissection were assigned to the O/SP group. Each patient in the T/SP group underwent the operation by a different surgeon, two of whom were the authors, including the first author; the first author performed all operations in the O/IP and O/SP groups. The first author evaluated the shape of the developed breasts using the frontal- and oblique-view photographs. We also investigated the location of the lateral border of the mammary gland in seven other adolescent and adult female patients using three-dimensional computed tomography images. RESULTS: Lateral depression of the breast occurred in four of eight breasts with a transverse incision, and flattening of the lowermost portion of the inframammary fold occurred in six of 10 breasts with suprapectoral dissection. None of the eight breasts with an oblique incision and subpectoral dissection exhibited deformities. The lateral border of the mammary gland was on the fifth rib in five patients and on the fifth intercostal space in two patients. CONCLUSION: An oblique lateral thoracic skin incision along the sixth rib and subpectoral dissection may reduce the occurrence of breast deformity.

Orbicularis oris myomucosal island flap transfer to the nose.

We developed the orbicularis oris myomucosal island flap (OOMMIF) to reconstruct the nasal lining in one stage. The OOMMIF blood supply derives from the intramuscular vascular network which communicates with the submucosal vascular plexus via the vascular network formed by the deep ascending branches of the superior labial artery. An oral mucosal flap of approximately 2 x 3cm can be harvested from the upper lip pedicled solely on the orbicularis oris muscle. We transferred this flap to a nasal lining defect located in the ala in four patients, the nasal floor in two patients, and the columella in two patients. The flap donor site was closed primarily. All flaps took completely with satisfactory results. Minor complications included slight asymmetry of the vermilion height due to donor site contracture in one patient and flap drooping in two patients corrected by secondary debulking. Upper lip functional loss was not observed, although upper lip hypoaesthesia occurred in one patient, which disappeared within 6 months. An OOMMIF can be easily elevated with minimal donor site morbidity. Thus, the OOMMIF is a good candidate for one-stage reconstruction of small nasal lining defects.

Efficacy of distraction osteogenesis for mandibular reconstruction in previously irradiated areas: clinical experiences.

The efficacy of distraction osteogenesis in an irradiated area is controversial, although this procedure is now widely used in the field of craniomaxillofacial surgery. We report the clinical results from 4 patients with mandibular defects treated by lengthening of the irradiated mandibles. All patients had a mandibular defect caused by ablation of a malignant tumor. They had undergone radiotherapy at a total dose of 30 to 50 Gy to the surgical site after tumorectomy. Distraction osteogenesis was used as the secondary reconstruction method in 6 sites of the remaining irradiated mandibles and in 1 site of the transferred vascularized scapula after radiotherapy. The transported segment was obtained by corticotomy with an initial gap of 0 to 2 mm, and internal extension plates were used. Distraction was commenced after a latency period of 7 to 10 days and performed at the rate of 0.25 to 1.0 mm/d. The total amount of distraction and consolidation periods ranged from 15 to 25 mm and 120 to 193 days, respectively. In 5 of the 6 sites in the remaining irradiated mandibles, satisfactory bone formation in the distraction gap was observed, although a fracture after new bone formation was observed in 1 site. Fibrous callus formation was observed in 1 irradiated site only, and satisfactory results were obtained in another site of transferred vascularized scapula in the same patient. From these experiences, we believe that distraction may provide a reconstruction option for mandibular defects even under irradiated conditions because the procedure is simple and less invasive.