Trans-Oral Video-Assisted Neck Surgery (TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandible approach.

BACKGROUND: Endoscopic thyroidectomy is a well-established surgical technique. We have been utilizing precordial video-assisted neck surgery (VANS) with a gasless anterior neck skin lifting method. Recently, natural orifice transluminal endoscopic surgery (NOTES) has generated excitement among surgeons as potentially scar-free surgery. We developed an innovative gasless transoral technique for endoscopic thyroidectomy that incorporated the concept of NOTES in a VANS-technique. METHODS: Incision was made at the vestibulum under the inferior lip. From the vestibulum to the anterior cervical region, a subplatysmal tunnel in front of the mandible was created and cervical skin was lifted by Kirschner wires and a mechanical retracting system. This method without CO2 insufflation created an effective working space and provided an excellent cranio-caudal view so that we could perform thyroidectomy and central node dissection safely. RESULTS: Beginning with our first clinical application of TOVANS in September 2009, we have performed eight such procedures. Three of the eight patients had papillary microcarcinoma and received central node dissection after thyroidectomy. All patients began oral intake 1 day after surgery. The sensory disorder around the chin persisted more than 6 months after surgery in all patients. Recurrent laryngeal nerve palsy revealed in one patient. Nobody had mental nerve palsy, and no infection developed with use of preventive antibacterial tablets for 3 days. CONCLUSIONS: We developed a new method for gasless transoral endoscopic thyroidectomy with a premandible approach and anterior neck-skin lifting. TOVANS makes possible complete endoscopic radical lymphadenectomy for papillary thyroid cancer. We believe that this method is innovative and progressive and has not only a cosmetic advantage but also provides easy access to the central node compartment for dissection in endoscopic thyroid cancer surgery.

Immediate reconstruction using a modified inframammary adipofascial flap after partial mastectomy.

Breast conservative therapy (BCT) as treatment for early breast cancer usually ensures local control and acceptable cosmetic results. We describe a new technique of using an inframammary adipofascial flap to reconstruct defects caused by lower-pole partial mastectomy, which achieved excellent results (Kijima et al. in Am J Surg 193:789-91 (1); Sakai et al. in Ann Plast Surg 29(2):173-7, 2; Ogawa Am J Surg 193:514-8, 3). We developed this procedure as an oncoplastic technique for a Japanese woman with a similar defect without ptosis. After partial mastectomy, the superior half of the flap is harvested via an initial incision along the inframammary line, and the inferior half is harvested via an additional incision along the caudal edge of the flap, to produce a crescent of de-epithelialized skin. A tongue-shaped flap containing the crescent of de-epithelialized skin, subcutaneous fat, and the fascia of the vertical rectus abdominis muscle is then rotated upwards, gathered, and inserted into the breast defect.

Oncoplastic surgery combining partial mastectomy with breast reconstruction using a free nipple-areola graft for ductal carcinoma in situ in a ptotic breast: report of a case.

We report a case of early breast cancer, which was treated successfully by oncoplastic surgery. A 65-year-old Japanese woman was referred to us for investigation of a grouped calcification on mammography of her left breast, detected during mass screening for breast cancer. No mass lesion was palpated, but we suspected that the grouped calcification seen on the mammography was a malignant lesion in the lower area of the left breast. Ultrasonography and magnetic resonance imaging revealed ductal carcinoma in situ, restricted to the inner quadrant of the left breast. Achieving a good symmetrical outcome after partial mastectomy would have been made difficult by the degree of ptosis. Thus, we performed partial mastectomy followed by an amputation-type reduction operation with free nipple-areola complex grafting, which achieved good cosmetic and oncologic results.

Immediate breast reconstruction using autologous free dermal fat grafts provides better cosmetic results for patients with upper inner cancerous lesions.

PURPOSE: Although breast-conserving therapy (BCT) is the standard form of treatment for early-stage breast cancer, in patients with small breasts cosmetic results can be poor, especially when the lesion is located on the inner upper quadrant area. This study analyzes our use of autologous free dermal fat grafts (FDFGs) for immediate breast reconstruction. METHODS: A total of 23 patients who received a partial mastectomy for an inner upper quadrant lesion from 1992 to 2006 at Kagoshima University Hospital were retrospectively divided into three groups according to the reconstructive procedure that was used for the defect after partial mastectomy: immediate reconstruction using an autologous FDFG from the lower abdomen (group FDFG); patients receiving only rotation and fixation of the parenchymal adipose tissue or gland to repair the defect (group GL); and a third group who underwent immediate reconstruction using a miniflap of the latissimus dorsi (group LD). RESULTS: The total duration of surgery in group FDFG was significantly shorter than in group LD (P < 0.01). The mean volume of blood lost in group FDFG was significantly lower than in group LD (P < 0.01). The breast retraction assessment (BRA) of group FDFG was significantly better than for the patients in groups GL and LD (P < 0.01). The total score using the ABNSW system for cosmetic assessment was significantly better in group FDFG than in group GL (P < 0.01). Similarly, the total score in group FDFG using the assessment by the Japanese Breast Cancer Society was significantly higher than that in group GL (P < 0.01). CONCLUSION: Immediate breast reconstruction for a defect after a partial mastectomy of an upper inner quadrant malignant lesion using FDFG can be especially useful for patients with small breasts.

Oncoplastic surgery for Japanese patients with breast cancer of the lower pole.

This report presents the results of oncoplastic surgery in three Japanese patients with breast cancer lesions involving the lower pole of the breast. Their breasts were ptotic, and their lesions were considered to be suitable for breast conservation surgery. There were treated with partial mastectomy resection using vertical-scar mammaplasty, with reduction surgery and recentralization of the nipple-areola complex. Two patients underwent a mirror-image biopsy on the contralateral breasts to determine the symmetry. The remaining patient had periareolar incision mastopexy without reduction added for the contralateral breast. A large surgical margin was used to remove excessive skin and parenchymal tissue. Ideal symmetry was achieved by performing reduction and/or mastopexy on the contralateral breast.

Histological findings of an autologous dermal fat graft implanted onto the pectoralis major muscle of a rat model.

BACKGROUND: The aim of this study was to investigate the maintenance of volume as a spacer by comparing vascular supply and apoptosis in an implanted autologous-free dermal fat graft (FDFG) and free fat graft (FFG). An autologous FDFG is a material used in plastic surgery and oncoplastic breast surgery that is ideal for immediate volume replacement after partial mastectomy because of its easy availability and minimal invasion of the donor site; however, immunohistochemical findings and survival procedures have not yet been reported. METHODS: An experimental protocol using a unique animal model was designed for the present study. The expression of vascular endothelial growth factor (VEGF) was measured in FDFGs and FFGs implanted onto the pectoral major muscle of Wistar rats. Thirty Wistar rats were divided into two groups and postoperatively 1, 2, 4, 8, and 16 weeks (POW1, 2, 4, 8, 16). Six samples from three rats in each group were used as control samples (POW0). RESULTS: The thickness of the implanted FDFG was not significantly different from the control sample at POW1, 2, 4, 8, and 16 between FDFG and FFG group; however, the thickness at POW8 and 16 was significantly lesser in the FFG group than in the control samples. The average proportion of fatty tissue to whole tissue ranged from 34.2 to 48.6 % in the FDFG group and from 57.2 to 76.7 % in the FFG group during the observation period; however, there was no significant difference in the proportion of fatty tissue between these two groups. There were no significant differences between the average number of VEGF-positive cells in the FDFG group and the FFG group at POW1, 2, 4, 8, and 16. The average number of TUNEL-positive cells in the early period at POW1 was significantly lower in the FDFG group than in the FFG group. CONCLUSIONS: This rat model was useful for investigating the mechanisms of angiogenesis, apoptosis, structure maintenance, and fibromatous changes. From the present experimental study, we believe that FDFG is one of the most convenient materials currently available to repair small defects at the time of BCS even in the clinical field.

Oncoplastic surgery in a Japanese patient with breast cancer in the lower inner quadrant area: partial mastectomy using horizontal reduction mammoplasty.

We report the results of oncoplastic surgery in a Japanese patient with early breast cancer. Her breasts were ptotic, and her lesion was considered to be suitable for breast-conserving surgery. Oncoplastic surgery involving partial resection of the gland and a horizontal-type mammoplasty was performed. The technique was easy to perform, and the cosmetic outcome was excellent.

Clinical and pathologic evaluation of implanted free dermal fat grafts after breast cancer surgery: a retrospective analysis.

PURPOSE: The efficacy of immediate breast reconstruction using a free dermal fat graft (FDFG) was evaluated clinically. PATIENTS AND METHODS: A total of 22 breasts in 21 patients who underwent partial mastectomy for early breast cancer involving mainly the inner upper quadrant were enrolled in this study. The defect was reconstructed immediately by filling it with an autologous FDFG. At 6 months and 1, 2, 3, 4, and 5 years postoperatively, the width (horizontal length) and thickness (distance perpendicular to skin) of the FDFG on computed tomography (CT) scans were measured. Histologic samples from the implanted FDFG were collected by core needle biopsy (CNB). The correlations between clinical findings and volume of the FDFG on CT and the proportion of fatty tissue in the CNB were examined statistically. Cosmetic results were also evaluated. RESULTS: On CT, the mean width of the FDFG was 95%, 81%, 79%, 73%, 68%, and 47% and the mean thickness were 125%, 121%, 120%, 115%, 104%, and 103% at 6 months, and 1-5 years postoperatively, respectively. In the CNB samples, the mean fatty tissue distribution was 76%, 63%, and 54% at 1 year, 1-4 years, and >4 years postoperatively, respectively. The percent change in the width of the FDFG at 6 months after the operation displayed a significant negative correlation with the postmenopausal period and a significant positive correlation with the maximum surgical margin. On CT, thickness was negatively correlated with the size of the resected breast tissue, and thickness of the implanted FDFG. No clinicopathologic factors or technical factors were related to FDFG outcome and the proportion of fat tissue in the CNB sample, except for axillary dissection. Nineteen of 21 patients had good to excellent cosmesis. CONCLUSION: FDFG implanted into breast defects after partial mastectomy undergo mild resorption and degeneration to fibrous tissue, but most patients have good to excellent cosmesis.

Immediate reconstruction using a modified thoracodorsal adipofascial cutaneous flap after partial mastectomy.

The treatment of early breast cancer using breast conservation therapy (BCT) usually ensures local control and acceptable cosmetic results. We report a useful technique involving the use of a thoracodorsal adipofascial cutaneous flap for reconstructing defects in the upper-outer quadrant area after partial mastectomy that has achieved excellent results. We developed this procedure as an oncoplastic technique for treating a Japanese woman with a similar defect and a relatively slim body. In this procedure, partial mastectomy is followed by raising the anterior half of the flap via the same skin incision, and the posterior half is raised via an additional incision posterior to the axillary area to produce a crescent of de-epithelialized skin. A C-shaped flap containing a crescent of de-epithelialized skin composed of subcutaneous fat and the fascia of the latissimus dorsi muscle is then rotated, gathered, and inset into the breast defect.

Oncoplastic surgery in Japanese patients with breast cancer close to the areola: partial mastectomy using periareolar mammoplasty: a case report.

We report the results of oncoplastic surgery in two Japanese patients with early breast cancer. Their breasts were large and ptotic, and their lesions, which were close to the areola, were considered to be suitable for breast conservative surgery. Oncoplastic surgery involving partial resection of the gland and a periareolar mammoplasty were performed. The technique was easy to perform, and the cosmetic outcome was excellent.

Oncoplastic surgery for Japanese patients with ptotic breasts.

BACKGROUND: Oncoplastic techniques, which combine the concepts of oncologic and plastic surgery, are becoming more common, especially in Western countries, however, only a few case reports have been published in Japan. We report the results of oncoplastic surgery for Japanese patients with early breast cancer in the lateral quadrant area. METHODS: In eight patients, their breasts were ptotic, and each lesion was diagnosed to be suitable for breast-conservative surgery, we performed oncoplastic surgery combining reduction-type partial mastectomy with nipple-areola recentralization. RESULTS: The total operation period ranged from 112 to 290 min with the mean period being 189 min. For the six patients who received contralateral mirror image reduction surgery and recentralization of the nipple-areola complex, the reconstruction period ranged from 80 to 230 min with the mean period being 102 min. For two patients who underwent oncoplastic surgery to the treated breast only, the reconstruction periods were 40 and 60 min, respectively. The weights of the resected tissue of the treated breast ranged from 60 to 306 g whereas that of the contralateral breast ranged from 70 to 302 g. Postoperative seroma after axillary dissection was observed in one case. CONCLUSIONS: Oncoplastic surgery for patients with ptotic breasts was successfully performed and may become more popular in Japan in the near future.

Number of Axillary Lymph Node Metastases Determined by Preoperative Ultrasound is Related to Prognosis in Patients with Breast Cancer.

OBJECTIVE: To analyze the impact on prognosis of the number of axillary lymph node metastases (LNM) detected by ultrasound (US) in patients with breast cancer. METHODS: One-to-one comparison of LNM was performed between the ultrasound and histologic diagnosis in 380 patients. RESULTS: The accuracy of preoperative ultrasound diagnosis was 79.7%. According to the subdivision of number of LNM (0, 1-3, 4-9, 10+), the accuracy rates associated with LNM were 82%, 49%, 34%, and 86%, respectively. The disease-free-survival curves according to the number of LNM were similar in them. CONCLUSION: Preoperative ultrasound can determine axillary involvement and may be useful for predicting prognosis.