Importance of breast biopsy incision in final outcome of breast reconstruction.

Currently, breast cancer is one of the most common malignant lesions among women in North America--it occurs in one in every nine such women. Approximately 180,000 cases will be diagnosed this year. During the past 3 years at the Mayo Clinic, approximately 4,000 breast biopsies were performed. In approximately 20% of such biopsy specimens, a malignant lesion will be identified. Surgeons should be aware of the current possibilities in breast reconstruction and should consider the cosmetic result in the placement of breast biopsy incisions. Even lesions in the superior or inferior portions of the breast are accessible through generous periareolar incisions. The biopsy incision should be within the confines of a possible skin excision for mastectomy to avoid creating two scars if the specimen proves cancerous. The choice of site for the biopsy incision, however, should never jeopardize the treatment of the cancer. Appropriate preoperative planning will ensure optimal cosmetic and therapeutic results in the management of breast lesions.

Autologous breast reconstruction with use of transverse rectus abdominis musculocutaneous flap: Mayo clinic experience with 147 cases.

OBJECTIVE: To assess the results of transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions of the breast. DESIGN: We retrospectively reviewed 147 consecutive cases of TRAM reconstructions of the breast performed at the Mayo Clinic between 1981 and 1992. MATERIAL AND METHODS: The median patient age was 47 years, and the median duration of follow-up was 29 months. In 25 patients, both rectus pedicles were used, 15 of those for bilateral reconstruction. The other 122 patients had unipedicled unilateral reconstruction. Only 9% of the breast reconstructions were immediate. Analysis of risk factors in the patient population revealed smoking in 16%, preoperative irradiation of the chest wall in 20%, preoperative chemotherapy in 27%, and both radiotherapy and chemotherapy in 12%. RESULTS: The mean overall operative time was 4 hours and 43 minutes (4 hours and 20 minutes for unipedicled flaps and 5 hours and 46 minutes for bipedicled reconstructions). No blood transfusion was needed in 47% of patients; of those who received transfusions, 78% required 2 units or less. In 58 of the 147 patients (39%), an operation was performed on the contralateral breast. Follow-up operations were necessary in 71% of patients. The overall frequency of complications was as follows: hernia that necessitated surgical repair, 7.5%; full TRAM ischemic loss, 3.7%; partial TRAM loss, 9.9%; and fat necrosis, 11.7%. No pattern of increased complications was noted in subgroups of patients who smoked or who had received preoperative irradiation, chemotherapy, or both. In comparison with our early cases, the last 50 TRAM procedures were generally associated with fewer complications. The rates of occurrence of complications in our series of patients were similar to those reported in the literature. CONCLUSION: The TRAM flap provides satisfactory results for reconstruction of the breast.

Tumor-ablative surgery, microvascular free tissue transfer reconstruction, and postoperative radiation therapy for advanced head and neck cancer.

OBJECTIVE: The objectives of this study were to determine whether the combination of complex tumor-ablative surgery and microvascular free tissue transfer reconstruction delays the onset of postoperative radiation therapy, whether free tissue transfers are lost after a course of radiation therapy, and what patterns of tumor recurrence and survival rates are present in patients who undergo this type of multidisciplinary treatment. DESIGN: A retrospective review was conducted in 37 patients who underwent tumor-ablative surgery and reconstruction between November 1987 and August 1991. MATERIAL AND METHODS: Of the 30 men and 7 women who underwent tumor-ablative surgery, microvascular free tissue transfer reconstruction, and postoperative radiation therapy, recurrent or T4 primary tumors were treated in 84%. Sixty-two percent of the patients had nodal metastatic disease. The median dose of postoperative irradiation was 60 Gy (range, 32.4 to 76.8). Follow-up in all patients was until death (21 patients) or for a median of 17.5 months (range, 4.1 to 43.2). RESULTS: The median duration of overall survival and the 2-year overall survival rate were 17 months and 46%, respectively. For cause-specific survival, the median duration and 2-year rate were 17 months and 50%, respectively. Local recurrence developed in 8 patients, neck recurrence in 10, and distant metastatic disease in 11. No microvascular free tissue transfers failed. CONCLUSION: Radiation therapy can begin in most patients within 8 weeks postoperatively, microvascular free tissue transfers seem to tolerate postoperative radiation therapy well at the doses administered, and the rates of local and neck control are reasonable relative to the advanced stage of the cancers treated.

Postpneumonectomy empyema. The role of intrathoracic muscle transposition.

Forty-five patients (36 male and nine female) were treated for postpneumonectomy empyema. All were initially managed with the first stage of the Clagett procedure (open pleural drainage). In 28 patients with associated bronchopleural fistula the fistula was closed and reinforced with muscle transposition at the time of open drainage. Seven patients had multiple flaps. The serratus anterior muscle was transposed in 28 patients, latissimus dorsi in 11, pectoralis major in four, pectoralis minor in one, and rectus abdominis in one patient. After the fistula was closed and the pleural cavity was clean, the second stage of the Clagett procedure (obliteration of the pleural cavity with antibiotic solution and closure of the open pleural window) was done. The number of operative procedures ranged from 1 to 19 (median 5.0). Length of hospitalization ranged from 4 to 137 days (median 34.0 days). There were six operative deaths (mortality rate 13.3%), none in the patients who had both stages of the Clagett procedure. Follow-up of the 39 operative survivors ranged from 2.1 to 90.2 months (median 21.8 months). Eighty-four percent of patients in whom the Clagett procedure was completed (26/31) had a healed chest wall with no evidence of recurrent infection. The bronchopleural fistula remained closed in 85.7% of patients (24/28). There were 19 late deaths, none related to postpneumonectomy empyema. We conclude that the Clagett procedure remains safe and effective in the management of postpneumonectomy empyema in the absence of bronchopleural fistula and that intrathoracic muscle transposition to reinforce the bronchial stump is an effective procedure in the control of postpneumonectomy-associated bronchopleural fistula.

Klippel-Trenaunay syndrome: the risks and benefits of vascular interventions.

Our experience with Klippel-Trenaunay syndrome (KTS), a rare congenital malformation, has increased considerably in recent years and now includes 144 patients (65 male and 79 female patients). Hemangioma was present in 137 patients (95.1%), varicosity in 110 (76.4%), and hypertrophy of the soft tissues or bones in 134 (93.1%). In most patients (71.5%) the disease involved one lower extremity. Diagnostic workup included roentgenogram to document limb length discrepancy, noninvasive arterial and venous evaluation, contrast venography, and nuclear magnetic resonance imaging. Most patients did well without treatment or with elastic compression only. Surgical treatment for the vascular malformation in KTS is rarely needed and it continues to be controversial. To evaluate the risks and benefits of vascular interventions, we examined in detail the clinical histories of nine patients who in the last decade underwent operation for a vascular malformation of the lower extremity. In seven patients we removed varicose veins or resected hemangioma of the lower extremity. Although none was cured, all five who underwent resection of varicose veins and one of the two patients who underwent resection of a hemangioma improved. Two additional patients, however, who underwent resection of varicose veins in another institution had worsening of the symptoms. In one patient we performed deep venous reconstruction for atresia of the superficial femoral vein, using the contralateral saphenous vein. Such operation in KTS has not been reported previously. The patient has a patent graft with a competent valve and clinical improvement 6 months after the operation. Although patients with severe chronic venous insufficiency, disturbing cosmetic appearance, or complications of hemangioma may benefit from surgical treatment, detailed preoperative imaging of the extremity and pelvis with magnetic resonance imaging and contrast venography is needed to decrease complications. Rarely, reconstruction for atresia or hypoplasia of the deep veins may be needed.

An algorithm for maxillectomy defect reconstruction.

A maxillectomy defect creates a communication from oral cavity to nasal cavity that may extend to the orbit. Functional deglutition and speech problems with a significant soft tissue deficit ensue. This paper defines the reconstruction options for the spectrum of inferior partial maxillectomy defects to midface-orbital exonerations. Treatment protocols from maxillectomy patients treated in January 1991 to February 1996 at a major tertiary care institution were reviewed (n = 108). An ascension of care from dental obturator, nonvascularized graft, local flap, regional flap, and free tissue grafts (n = 28) is described. These data and experience were organized to provide a treatment algorithm to assist in presurgical planning for maxillectomy reconstruction.

Extensive defects of the sino-orbital region. Results with microvascular reconstruction.

We performed microvascular free-tissue reconstruction of extensive defects in the sino-orbital region in 11 patients. Reconstructions were immediate in 10 patients and delayed in one patient. There was loss of orbit in eight patients, maxilla in eight patients, cranial base in two patients, and skin and soft tissue of the face in six patients. Nine rectus abdominis flaps, one radial forearm flap, and one lateral arm flap were used. Palatal reconstruction with autologous tissue was successful in all patients. Cranial base repairs healed without sequelae or evidence of meningitis. Cosmetically, soft-tissue repair of facial skin was only satisfactory. For large defects, it was difficult to reconstruct the palate and facial soft tissue and to maintain nasal airway patency with a single microvascular procedure. Free-tissue transfers remain the safest and most versatile reconstructive procedure for massive sino-orbital defects after ablation of a tumor.

Refinements in intrathoracic use of muscle flaps.

Intrathoracic infections associated with infection, leakage, or bleeding of the airway, lung parenchyma, esophagus, heart or great vessels is a life-threatening situation that luckily is infrequently seen. Failure to control these infections with the usual techniques can often be attributed to the presence of persistent pleural space, continuing empyema or bronchopleural fistula. Intrathoracic transposition of extrathoracic skeletal muscle in these situations offers an effective of management. Our experience has been possible because of the continued integrated effort with our thoracic surgical colleagues. We have found the team approach to work best and will continue to use it.

The rigid transparent dome protector: a new dressing for free-tissue transfers and skin grafts.

We have presented a transparent, inexpensive, rigid dome that allows a window to the wound, humidity chamber effect to continuously observe difficult skin-grafted wounds or free-tissue transfers allowing constant monitoring by visualization. The dome is inexpensive because it is simply a discarded breast implant package.

Merkel cell tumor: diagnosis, prognosis, and management.

The histologic features of the Merkel cell and the pathologic characteristics of the Merkel cell tumor are described. From a literature review, 68 cases are examined; 23 cases that have been followed up accurately are presented from the Mayo Clinic. A representative case is used to demonstrate the problems of diagnosis and suggested treatment. The latter should be wide local resection with removal of nodal metastases if present. When indicated, this should be followed up with radiation therapy. Chemotherapy is of little or no value. Survival rates are presented.

Conservative management in full-thickness nipple-areolar necrosis after subcutaneous mastectomy.

Nipple-areolar necrosis is a known and expected complication in a small percentage of patients undergoing subcutaneous mastectomy, especially with concomitant mastopexy or in smokers. Impending ischemia or congestion of the areola can often be ameliorated by simple maneuvers such as suture release. When full-thickness necrosis occurs, conservative management with essential debridement, dressings, and careful wound hygiene alone will often yield a surprisingly good result, requiring little or no revisional surgery.

Angioleiomyomas of the extremities: report of a case and review of the Mayo Clinic experience.

Angioleiomyomas are rare smooth-muscle tumors that occur anywhere in the body. We present the case of a 46-year-old woman with a 3-year history of a painless angioleiomyoma in the right-hand fourth web space with the typical histologic features of tortuous vascular channels and thick muscular walls. In the 39 cases of angioleiomyoma of an extremity treated at the Mayo Clinic, we found a male-to-female ratio of 1:2.2, a mean age of 52 years, and pain as the presenting symptom in 67 percent of the patients. The lesions usually were less than 1 cm in diameter, and they decreased significantly in size with increasing patient age. Simple excision was curative. Angioleiomyoma should be considered in all patients with nodular lesions of an extremity.

Intrathoracic free flaps.

The utility of pedicled muscle flaps transposed into the thoracic cavity to reconstruct complex intrathoracic defects has been well documented. However, in some patients, local chest-wall muscles have already been either sacrificed or transected by previous thoracotomies and are not available for reconstruction. In these patients, we have successfully employed microvascular techniques to transfer distant muscle flaps into the thoracic cavity. Seven patients with complex intrathoracic defects were reconstructed with three latissimus dorsi, one omental, and three rectus abdominis free flaps. In each case, the microvascular anastomosis was extrathoracic, with the flap transposed into the thoracic cavity. Each of the flaps was revascularized successfully. Four of the five bronchopleural fistulas were sealed, with the remaining patient continuing to demonstrate a reduced but persistent air leak. No infections were encountered, and each flap transfer resulted in a healed wound. When local muscle flaps are not available to reconstruct complex intrathoracic wounds, microvascular transfer of distant muscle flaps can provide abundant well-vascularized tissue for reconstruction of any portion of the thoracic cavity. Versatility is afforded in flap selection and recipient vessel site location, making this technique an important option in the treatment of these difficult wounds.

The radial forearm flap: a biomechanical study of donor-site morbidity utilizing sheep tibia.

The use of vascularized bone grafts to reconstruct extremity and mandibular defects is now commonplace in reconstructive surgery. Fibula, scapula, iliac crest, rib, and metatarsal as well as the radial forearm osseocutaneous flaps have all been utilized for this purpose. Troublesome spiral fractures of the distal radius are the most common fractures associated with the use of the distal radius as a vascularized bone-graft donor site. This study was proposed to investigate the effect of donor-site bone loss on the strength of the radius under torsional (rotational) loading. Previous clinical series and experimental studies have not examined this aspect of distal radius loading after harvesting the bone graft. Fifty pairs of sheep tibiae were utilized in the experiment. Five pairs were used in a pilot study and 45 pairs were used in the main experiment. Five pairs of human radii were used for the control in the pilot study. The pilot study attempted to make a comparison between the human radius and the sheep tibia for experimental purposes. For the biomechanical study of donor-site defects, four study groups were examined with random assignment and matched pairs. The control group (group 1) had no alteration to the bone. Each test condition included five matched pairs of sheep tibiae. Experiment 1 compared the difference in the depth of the osteotomy defect. In doing this, one-third of the total length of the bone was removed in each of the following specimens to include (1a) 30 percent of the cross-sectional area of the total bone, (1b) 37 percent of the cross-sectional area of the total bone, and (1c) 50 percent of the cross-sectional area of the total bone. In experiment 2, the osteotomy shape was varied. Instead of the ends of the cuts being squared, the ends were beveled or rounded. Experiment 3 compared different lengths of bone removed in the osteotomy defect and included the following: In experiment 3a the diameter of the sheep tibia was measured at the incisura fibularis. This dimension was one diameter of bone, and a one-diameter length of bone was removed. In experiment 3b, a two-diameter length of bone was removed. In experiment 3c, a three-diameter length of bone was removed. In experiment 3d, a four-diameter length of bone was removed.(ABSTRACT TRUNCATED AT 400 WORDS)

Management of the recalcitrant total-hip arthroplasty wound.

The infection rate for total-hip arthroplasty is around 1 percent. This small group is usually managed by complete removal of the prosthesis and the cement and closure over suction catheters to "collapse" the wound and eventually achieve a girdlestone arthroplasty. Occasionally, there are patients who have a persistent draining wound after this treatment and repeated efforts at wound closure. We present 27 patients who had recalcitrant, noncollapsible wounds of the hip that were present for many months to years. Twenty-eight cases of infected total-hip arthroplasties that did not respond to removal of the prosthesis and cement and closure were seen by the authors between January of 1977 and December of 1988. One patient had bilateral involvement. Average age was 64 years (range 33 to 79 years). There was an average of 4.2 previous surgical attempts at closure (range 1 to 21). Staphylococcus aureus was the most common organism, but the infections were virtually all multiple. Thirty-three muscles were utilized in 27 patients. The rectus femoris was used in 23 cases, the vastus lateralis in 8, tensor fasciae latae in 1, and combined latissimus dorsi-serratus anterior free-tissue transfers were carried out in 2. Multiple combinations of transpositions and free flaps were utilized. Follow-up ranged from 1 to 10 years, with an average of 6.4 years. Eighteen patients were ambulatory with minor degrees of pain, five ambulated with a cane, seven ambulated with a walker, six ambulated with crutches, and four ambulated unassisted, all of whom had reimplantation of their hip arthroplasty at least 12 months following the muscle flap procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

The radial forearm flap donor site: should we vein graft the artery? A comparative study.

Controversy exists in the literature regarding reconstruction of the radial artery after elevation of the radial forearm flap. The literature suggests that reconstructing the radial artery with a vein graft is an important aspect in the use of this flap. In our experience, this has never been performed with no sequela. We examined 13 consecutive patients who underwent radial forearm flaps for head and neck reconstruction over a 28-month period. The patients were examined and questioned about the function of their upper extremities in hope of evaluating the postoperative vascular status in each. Median follow-up was 6 months, with a range of 1 month to 24 months. No patient had preexisting trauma or congenital abnormality of either arm, so that the nondonor arm could be considered as a control for each patient. Evaluation consisted of history and physical examination. The following parameters in each patient were carefully accumulated: grip strength, cutaneous blood flow measured by using a laser Doppler flowmeter, transcutaneous oxygen levels, digital/brachial blood pressure ratios, cutaneous temperature from thumb/index and thumb/small pinch, and rapid rewarming at 1-minute and 5-minute intervals after cold immersion for 2 minutes. The radial forearm flap was elevated in each patient in the nondominant extremity. Grip strengths ranged from 19 to 77 kg, with a median of 30 kg. Early rewarming of the thumb/index was also an average of 1.5 degrees less than the temperature in the control arm and was statistically significant to (p = .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Experience with 80 rectus abdominis free-tissue transfers.

Eighty patients receiving rectus abdominis free-tissue transfers are discussed. The operations were performed between July of 1983 and December of 1986. Specifically, the patients were followed in the clinic to determine the extent and degree of donor-site morbidity. Sixty-two flaps were transferred to the lower extremities, 15 to the head and neck, 2 to the arm, and 1 was placed intrathoracically. Osteomyelitis was the most common indication for free-muscle transfer in 33 patients, soft-tissue defects in 26, and facial soft-tissue augmentation in 14 patients. In the 80 rectus abdominis free-muscle transfers, there were 9 local complications. A seroma occurred in 4 patients, wound infection in 3, and an abdominal wall hernia occurred in 1 patient. The success rate for muscle transfer was 93 percent with six flap losses. Because there is a low incidence of donor-site complications, the surgical dissection is relatively easy, and the relative consistency and size of the deep inferior epigastric pedicle are good, the rectus abdominis muscular unit is now one of the most frequently used free-tissue transfers at our institution.

Muscle-flap coverage for infected peripheral vascular prostheses.

Infection in a peripheral vascular prosthesis continues to be a serious complication in arterial reconstructive surgery and threatens the patient with loss of either limb or life. Infection rates at major centers are now low, ranging from 1 to 6 percent; however, limb loss and mortality rates for this complication range from 25 to 75 percent depending on the location of the graft and the extent of the infection. The use of muscle flaps in the management of acute wounds, infection-prone wounds, exposed orthopedic hardware, and osteomyelitis is now commonplace. Transposed muscle has been shown to be well-vascularized tissue that improves healing time and decreases local wound bacterial counts. After considering the preceding facts, we used muscle flaps for coverage of infected peripheral vascular prostheses in a highly select group of patients. These patients were "end of the line," and last-ditch efforts were made to salvage life or limb. Twenty-four infected vascular grafts in 20 patients have been analyzed. Ages ranged from 52 to 87 years. All patients had grade 3, stage I, II, or III peripheral graft infections, as previously defined by Szilagyi and modified by vonDongen. Aortofemoral reconstruction was the most common initial bypass procedure (14), followed by femoral popliteal (6), axillofemoral (2), iliofemoral (1), and subclavian/subclavian bypass (1). Staphylococcus aureus was the most common infecting organism. Muscles used for coverage were the rectus femoris (13), the sartorius (9), the rectus abdominis (1), and the pectoralis major (1). The graft material was composed of Dacron in 16 instances and polytetrafluoroethylene in 8.(ABSTRACT TRUNCATED AT 250 WORDS)

Chylous fistula: an unusual occurrence after mastectomy with immediate breast reconstruction.

Postoperative lymphatic complications of mastectomy and immediate reconstruction are well documented, consisting predominantly of lymphorrhea, lymphocele, and chronic lymphoedema. Chylous fistula is a hitherto undescribed entity complicating breast surgery. It was managed successfully by cessation of oral intake and the use of intravenous fluids, as is recommended in the treatment of chylous fistulas occurring elsewhere in the body. Although these are exceedingly rare, all plastic surgeons doing breast reconstruction should be aware of chylous fistulas and their treatment.

Surgical correction of the acromegalic face. A one stage procedure with a team approach.

The features of acromegaly are presented with special reference to facial deformity. A one-stage procedure with careful pre-operative planning is advocated. The operating team is composed of a plastic surgeon and an oral surgeon. The frontal protrusion is corrected by osteotomy, the vertical and anteroposterior facial disproportion by bimaxillary procedures, the nasal deformity by rhinoplasty or skull bone grafting, and the macroglossia by tongue resection. This results in an improvement of the patient's psyche and frequently improvement in speech.