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.

Skin and nipple-areola complex sparing mastectomy in breast cancer patients: 15-year experience.

Skin and nipple-areola complex sparing mastectomy (SNSM) and primary reconstruction have been popular for breast cancer treatment in the last decade. An advantage of the SNSM technique is the removal of all breast tissue as a radical surgical procedure while preserving native breast integrity, nipple-areola complex (NAC), and submammary fold. This retrospective 15-year clinical study analyzes medical records from our breast surgery database collected at our department between 1997 and 2012. A total number of 3757 patients were treated for breast cancer; 411 (10.9%) patients had a skin-sparing mastectomy with the median (range) length follow-up of 63 months. This is the longest follow-up for SNSM in breast cancer patients; 3.7% of patients who underwent SNSM developed disease local recurrence, whereas occult NAC involvement with cancer occurred in 7.7% and local recurrence in the NAC in 1.2%. Partial necrosis of the NAC developed in 9.4% and total necrosis in 0.7% of operated breasts. All disease recurrences occurred in the first 10 years of the follow-up period. Local recurrence developed as first recurrence event has longer median cancer-specific survival time of 70 months than those with only distant metastases with 50 months and locoregional plus distant metastases with 35.5 months. The "Omega" pattern incision combines an oncological radical procedure with a lower incidence of skin flap necrosis. Patients reconstructed with autologous tissue were the group most satisfied. SNSM is an oncological safe procedure for breast cancer treatment with low recurrence in properly selected patients.

Misleading presentations of malignant breast diseases--role of clinical cytology.

We described two examples with misleading presentations to draw attention to the role of clinical cytology as apart of multidisciplinary approach to breast lesions. In the first case--Paget's disease of the nipple, there was no obvious clinical and radiological evidence of breast cancer, while the second case--primary non-Hodgkin lymphoma of the breast imitated advanced breast carcinoma. The question is whether accurate and fast diagnoses can be made without cytological examinations. It must be kept in mind that first-hand clinical information and contact with the patient is necessary in rendering accurate cytological diagnoses.

[Necrotizing fasciitis of the upper leg--case report and review of the literature]. / Nekrotizirajuci fascitis natkoljenice--prikaz bolesnika i pregled literature.

Necrotizing fasciitis is an uncommon but serious infection of skin, subcutaneous fat and fascia, characterised by rapidly spreading inflammation and associated with considerable morbidity and mortality. A 42-year-old man, with necrotizing fasciitis of the right upper leg, was hospitalized and treated by surgical debridement, along with intravenous administration of antibiotics, fluid resuscitation, correction of acidosis and electrolyte abnormalities. Four debridements were performed over four days. The patient developed septic shock with early stage of multiple organ failure, requiring one week in intensive care unit (ICU). Split-thickness skin grafts were placed on the fourth day after admission to the hospital. The patient was released to home care on the 21st day after admission, fully recovered. Necrotizing fasciitis is a life threatening infectious entity that requires rapid diagnosis, urgent extensive surgical debridement and tissue coverage as soon as possible to prevent secondary infections. ICU measures including intravenous antibiotics are often necessary, along with surgical treatment.

Melanoma sentinel lymph node biopsy: analysis of cases operated on from 1999 to 2008 in The University Hospital Dubrava, Zagreb, Croatia.

TITLE: Melanoma Sentinel Lymph Node Biopsy: analysis of cases operated on from 1999-2008 in the University Hospital Dubrava, Zagreb, Croatia. AIM: To determine how well tumor thickness, ulceration, location and patient age and sex predict a positive sentinel lymph node in the analyzed population. PATIENTS AND METHODS: 321 patients were included in the study. 53% (169) were male and 47% (152) were females. 291 underwent sentinel lymph node biopsy. The median age was 56 years (age range 20-89). Sentinel lymph node biopsy was performed by lymphoscintigraphy using technetium-99m (99mTc)-labeled sulfur colloid and vital dye. RESULTS: Melanomas were similarly distributed on the trunk (154, 48%) and the extremities (145, 45%), a small number was located on the head and neck (12, 4%) and for 10 (3%) there was no record of the location. Positive lymph nodes were detected in 76 (26%) out of 291 patients who underwent sentinel lymph node biopsy. Micrometastases were found in 50 basins (60%), macrometastases were found in 15 basin (18%), one basin contained a metastasis that was spreading beyond the capsule (1%) and in the remaining 18 (21%) positive basins in the identified sentinel lymph nodes contained only isolated tumor cells. The average melanoma thickness of 3.41mm for sentinel lymph node biopsy positive melanomas was significantly greater than 2.47mm for negative melanomas (p=0.006). Proportionally more positive sentinel lymph nodes were found with increasing tumor thickness, (p=0.061). Ulceration was found to be a good predictor of positive sentinel lymph nodes (p<0.001). When comparing upper and lower extremities, sentinel lymph nodes were significantly more positive when the primary melanoma was on the legs (p=0.04). An ulcerated primary melanoma on the extremities was found more likely to have a positive sentinel lymph node (p=0.04). A significantly higher proportion of those older than 50 years old had positive lymph nodes (p<0.001). CONCLUSION: Tumor thickness, ulceration, location (upper vs. lower extremities, on the extremities with ulceration) as well as the age of the patient (>50) were found to be predictors of sentinel lymph node positivity. Clinically negative patients with any of these factors should be considered candidates for sentinel lymph node positivity.

Heel reconstruction with an iliac osteocutaneous free flap: 10-year follow-up.

During the Homeland War in Croatia, many civilians suffered from war wounds of the extremities. Explosive war wounds create composite and devastating injuries mainly by high-energy transfer to the tissue. We present an early reconstruction of explosive heel wound with an iliac osteocutaneous free flap with late follow-up result.

Lesion of the common peroneal nerve during arthroscopy.

Arthroscopic knee surgery has been well accepted worldwide and has become an important part of orthopaedic surgery. The use of arthroscopy has reduced the duration of hospitalization, overall costs, and time required for the patient to return to sports activities or work. However, because of the closed nature of the procedure and proximity of neurovascular structures to instruments, substantial risk of injuries exists. Significant anatomic variability in the nerve course has not been reported in previous literature as a cause of a knee arthroscopy complication. We present a case of complete transection of an unusually located common peroneal nerve during a knee arthroscopy for lateral meniscal repair in a 22-year-old football player.

Deep inferior epigastric perforator flap: a modification that simplifies elevation.

The deep inferior epigastric perforator flap is accepted worldwide as a reliable and relatively safe technique for autologous breast reconstruction. Preserving the continuity of the rectus muscle, it reduces donor site morbidity, allowing less postoperative pain, a faster recovery, and a reduced hospital stay. Nevertheless, the more complex nature of this type of surgery leads to increased operating time and a demand for more tedious microsurgical dissection. The authors present a modification of the deep inferior epigastric perforator flap harvesting technique that allows a more safe, simple, and faster elevation of the flap. They have used it successfully for breast reconstruction in 3 patients.

Incidence of the superficial fascia and its relevance in skin-sparing mastectomy.

BACKGROUND: With the move away from classical radical mastectomy to ever more skin-sparing procedures, there has been an ongoing discussion about how much skin and subcutaneous tissue should be resected to perform an adequate mastectomy while leaving viable skin flaps. One of the common recommendations is to dissect just superficial to the superficial layer (SL) of the superficial fascia of the breast. This, in turn, has revived the old, unsolved controversy about the existence or absence of the SL, a fascia that reportedly encloses the mammary gland ventrally. In skin-sparing mastectomies (SSM), which combine tumor resection with immediate breast reconstruction, the ideal would be to create skin flaps that are thin enough to remove all breast tissue but at the same time are thick enough to preserve flap circulation. The feasibility of meeting these two goals simultaneously and the possible role and relevance of the SL as a guide to dissection in SSM was examined in this study. METHODS: Sixty-two breast resection specimens from 31 women who underwent breast reduction were examined histologically to determine whether the SL was present, whether breast tissue could be detected within or beyond this SL, the measured distance between the caudal border of the dermis and the SL or the breast tissue, and whether the thickness of the subcutaneous fat layer was correlated with the patients' physical data, such as body weight or body mass index (BMI). RESULTS: The SL was absent in 44% of resection specimens. When the SL was present, 42% of specimens contained several islands of breast tissue within the SL. No breast tissue was found beyond the SL. The minimal distance between the SL and the dermis varied from 0.2 mm to 4.0 mm; the minimal distance between the breast tissue and the dermis was 0.4 mm. In 50% of specimens, the minimal distance between the dermis and the SL or breast tissue was < 1.1 mm. A distance of > or = 5 mm was encountered in only 17% of specimens, and a distance of > or = 10 mm was encountered in only 5% of specimens. No significant correlation between the right and left breast was found with any of the parameters examined. A weak negative correlation was seen between the BMI and the mean thickness of the subcutaneous fat (P = 0.049; correlation coefficient [r] = -0.39; Spearman rank correlation). CONCLUSIONS: Histologic evaluation revealed that the SL is not present in all breasts and, thus, cannot serve as a reliable plane of dissection. Furthermore, if the SL is present microscopically, then it often is too thin and delicate to be detectable macroscopically. Finally, even if the SL is present and visible macroscopically, the distance to the overlying skin is so small in the majority of patients that a dissection superficial to the SL would not leave viable skin flaps in skin-sparing mastectomies.