Immediate nipple reconstruction utilizing the DIEP flap in areola-sparing mastectomy.

The surgical treatment of breast cancer has dramatically evolved over the past decade toward an approach combining oncologic safety with aesthetic outcomes. The skin-sparing mastectomy initiated this paradigm shift amongst breast surgeons and can be oncologically safe, in some cases sparing both the areola and the nipple. In accordance with the emphasis on aesthetics, some general surgeons have adopted new methods of resecting only the nipple, sparing the areola in select patients. The superior aesthetic results, durability, and decreased donor site morbidity of perforator flaps have brought autologous reconstruction back to the forefront of breast reconstruction with the deep inferior epigastric artery perforator (DIEP) flap as the gold standard. We describe a technique utilizing the DIEP flap skin paddle for immediate nipple reconstruction at the time of mastectomy and reconstruction, eliminating the need for delayed reconstruction and limiting donor site morbidity by concealing the donor site below the mastectomy skin flaps. In the six cases described performed between 2010 and 2012 (mean with 53 years; range 46-59 years), there have been no complications to the flap or the nipple postoperatively, nor has there been a need for further nipple revisions for 6 months. The nipple position relative to the flap breast mound has remained unchanged for up to 6 months. The immediate nipple reconstruction does not significantly lengthen operative time, requiring approximately 30 additional operative minutes per nipple. Immediate nipple reconstruction utilizing the DIEP flap can be a cost-effective and feasible technique for recreating a natural-appearing and aesthetic nipple in select patients.

A loop technique for the safe, secure, and convenient fixation of subclavian central venous catheters to the chest wall.

Central venous catheters are placed frequently at our institution. Residents are taught the technique of subclavian line placement starting in their first year of training. Frequently the teaching stops once the line is in the vein. We have developed a method of fixation for subclavian central venous catheters that provides a safe, secure, and convenient means of fixation to the chest wall. The central venous catheter can be inserted by that technique with which the physician is the most comfortable and familiar.

The perichondrium in auricular melanomas: implications for surgical management.

OBJECTIVE: Auricular melanomas are now considered less aggressive than originally thought, but those located on the conchal bowl and posterior ear can create particular challenges for reconstruction. Given the paucity of cases, no standardized recommendations exist for tumor resection. In this study, we provide a pathologic basis in support of conservative tumor resection along the perichondrial plane. STUDY DESIGN: Case series with review of pathology and medical records. SETTING: Academic tertiary referral center. SUBJECTS AND METHODS: We retrospectively reviewed all ear melanomas from the archives of Yale Dermatopathology and Surgical Pathology laboratories between 1987 and 2009. Cases of melanoma in situ or malignant melanoma of the earlobe were excluded. RESULTS: Fifty-one cases were included in the study. Patients' age ranged from 26 to 94 years, with a mean (SD) of 58.9 (17.5) years. The male to female ratio was of 5.4:1. Melanomas were distributed similarly between right and left ears, at 52% and 48%, respectively. The most common location was the helix (74.5%). The Breslow depth ranged from 0.19 to 11 mm, with a mean (SD) of 1.64 (1.6) mm. The lesion-perichondrium distance ranged from 0 to 8.12 mm, with a mean (SD) of 1.11 (1.1) mm. Notably, the perichondrium was not invaded in any of the cases. CONCLUSION: Based on the histopathologic characteristics of our cases, the perichondrium can be considered an effective barrier and therefore a biological plane for wide local resection in some cases of auricular melanomas, allowing surgeons to achieve negative margins without necessarily sacrificing underlying cartilage.

Breast reduction: safe in the morbidly obese?

BACKGROUND: With an increasing obese population, plastic surgeons are consulted by women requesting larger breast reductions, with body mass indices in the obese to morbidly obese range (30 to >or=40 kg/m) and breasts considered gigantomastic (>2000 g resected from each breast). There have been few descriptions of outcomes in the morbidly obese population. Previous literature reports high complication rates in obese women and large-volume breast reductions. METHODS: Retrospective investigation of 179 reduction mammaplasty patients was performed out to determine whether reduction mass, age, body mass index, smoking, method used (i.e., vertical pedicle, inferior pedicle/central mound, or free nipple graft), and comorbidities influenced complication rates. The patients were categorized by size of reduction, age, and body mass index. RESULTS: The overall complication rate was 50 percent. There was no statistical difference in the incidence of complications attributable to size of reduction, age, or body mass index (p = 0.37, p = 0.13, and p = 0.38, respectively). Also, smoking status, method used (p = 0.65 and p = 0.17, and p = 0.48 and p = 0.1, respectively) and comorbidities had no effect on complication rates (reduction size, p = 0.054; age, p = 0.12; and body mass index, p = 0.072). There was no significant increase in the rate of complications for each body mass index group based on the reduction mass (p = 0.75, p = 0.89, p = 0.23, and p = 0.07). CONCLUSION: It is as safe to perform large-volume breast reductions in the morbidly obese patient with comorbidities as in anyone else.