The gluteal fold fascio-cutaneous flap for reconstruction after radical excision of primary vulvar cancers.

OBJECTIVES: Reconstructive surgery plays an important role in cosmetic and functional results of major excisional surgery performed as a treatment for invasive vulvar cancer. Traditional techniques -- gracilis myocutaneous o rectus abdominis flaps -- have several limits. We describe here a different surgical approach that we have used since 1998 in an effort to obtain better results in vulvar reconstruction. METHODS: From January 1998 to June 2007, thirty three patients who underwent excisional radical surgery for invasive vulvar tumors, were treated with vulvar reconstruction using the gluteal fold fascio-cutaneous local flap. Flaps were designed along the gluteal fold in adequate length and size. They were oval or triangular in shape depending on the defect they were supposed to cover. The flaps -- which always included the fascial layer -- were raised up to identify a perforator branch of the internal pudendal artery and then harvested as an island flap to achieve better mobility. RESULTS: We had no major complications, only two patients presented marginal necrosis and eight patients experienced significant seromas. Advantages over the alternative techniques included reduced dimensions of scars, absence of flap liponecrosis, no need of modifying patient's position on the surgical table, and very limited blood loss. CONCLUSIONS: We conclude that gluteal fold flap offers excellent cosmetic and functional results with a low complication rate. Therefore we support the gluteal fold flap as a valid surgical option whenever reconstruction is needed after radical excision of vulvar neoplasms.

Psychological evaluation of patients undergoing breast reconstruction using two different methods: autologous tissues versus prostheses.

Breast reconstruction has become an available option for most patients undergoing mastectomy. In fact, many authors agree that breast reconstruction does not interfere with possible therapies and improves the women's quality of life. The aim of this study was to evaluate the psychological adjustment of patients who had immediate or delayed reconstruction using two different methods: implants and autologous tissues. Specifically, it was explored whether the different methods of breast reconstruction have caused significant changes in psychological functioning. The study population (102 patients) was derived from patients who underwent breast reconstruction in the period January 1988 to December 1991 at the Department of Plastic and Reconstructive Surgery of the National Institute for Cancer Research in Genoa, Italy. Fifty-two patients underwent breast reconstruction using implants and 50 using the transverse rectus abdominis myocutaneous (TRAM) flap. Demographic information was gathered from each patient. The psychological instruments consisted of three standardized self-administered questionnaires: Psychological Distress Inventory, State Trait Anxiety Inventory, Form Y, and the Eysenck Personality Inventory. To better assess the changes in body image after breast reconstruction, three more specific questions about sexual desire, physical image, and social relationships were added. The 102 patients assessed in this study indicated a low incidence of psychological distress. Impairment was reported regarding body image by patients who underwent delayed reconstruction; these patients also showed higher distress scores. The type of breast reconstruction also seems to influence body image, showing in the patients with TRAM flap reconstruction more relevant psychological discomfort.(ABSTRACT TRUNCATED AT 250 WORDS)

Can the cost affect the choice of various methods of postmastectomy breast reconstruction?

AIM AND BACKGROUND: A wide range of methodologies for breast reconstruction is now available. For immediate breast reconstruction we prefer to use implants, whereas reconstruction using autologous tissues, such as transverse rectus abdominis musculocutaneous flaps (TRAMF) and muscular latissimus dorsi flaps, is applied only in selected cases. In contrast, for delayed reconstruction the choice between prostheses and autologous tissue depends on various conditions. The different reconstructive methods can be adopted as a single procedure or as a combination of surgical procedures. Following the issue of legislation defining the new structure of the Italian Health Service, the need to accurately assess the costs incurred for the execution of surgical operations has taken on paramount importance. The aim of the study was to evaluate not only the clinical limits of each surgical technique, but also its cost, in order to optimize the choice of the same procedures, conditions being equal. METHODS: The study population included 105 patients who underwent breast reconstruction in the period 1st January 1994-30th June 1995. The reconstructive procedures included 48 immediate implants, 7 immediate TRAMF, 17 delayed implants, 30 delayed TRAMF, and 3 delayed latissimus dorsi muscular flaps. RESULTS: After data evaluation, we concluded that reconstruction using permanent expandable implants is the most convenient among implant reconstructions for its low global treatment cost. In fact, reconstructive procedures using temporary expanders, which require two surgical operations, have a higher cost than breast reconstruction using permanent expandable implants. Breast reconstruction using TRAMF is the most convenient because it limits the cost of surgical materials and because flap versatility limits the number of modifications on the contralateral breast. In contrast, breast reconstruction using latissimus dorsi flaps has high costs. CONCLUSIONS: There is no balance between price list and effective cost of the different surgical reconstructive procedures, which may be a point of departure to see whether it is impossible to improve the efficiency of the Health Care System and in any case open a debate between the Regions and hospitals to improve the service, keeping it at a good level.

[Considerations in immediate and delayed breast reconstruction]. / Considerazioni sulle alternative chirurgiche nella ricostruzione mammaria immediata e differita.

The authors evaluate the different procedures for breast reconstruction in order to determinate the best indication of each technique. From January 1983 to June 1992, 196 reconstructions for breast cancer using implants, including 100 immediate and 96 delayed, were performed. Different types of breast implants were used in this period: in 1983-84 46 double lumen prostheses were performed, in 1985-86 34 Radovan temporary tissue expanders, from January 1986 to June 1991 115 Becker and Gibney permanent tissue expanders and 8 microstructured prostheses. Due to unavailability of silicon-gel implants, from January to June 1992 12 breast reconstructions with saline temporary tissue expanders were performed. In the patients with radical mastectomy 39 latissimus dorsi muscular flaps were carried out for implant coverage. In the same decade 204 breast reconstructions using Rectus abdominis myocutaneous (TRAM) flaps, including 201 delayed and 3 immediate were performed. It can be concluded that the implants are first choice for small or medium size breast, with light ptosis, in immediate reconstruction and when the patients refuse harder surgical procedures. On the contrary the autologous tissue, such as TRAM flap, can be used in patients with redundant abdomen, with controlateral large and ptotic breast and in delayed reconstruction.

[Evaluation of the tolerability of Hydrogel breast implants: a pilot study]. / Studio pilota per la valutazione della tollerabilità delle protesi tipo hydrogel.

BACKGROUND: During the 90s the widely publicised controversy regarding the use of silicone gel breast implants stimulated research into alternative alloplastic filling materials. In this context, a new type of breast implant, containing Carboxymethylcellulose at 3.7% in the form of Hydrogel, was introduced into the European market. METHODS: A preliminary pilot study was carried out to evaluate the tolerability and reliability of breast implants pre-filled with Hydrogel. A group of 12 consecutive patients was recruited for this purpose and underwent plastic surgery for breast augmentation or reconstruction (20 implants) at the Department of Plastic and Reconstructive Surgery at the University of Genoa between December 1996 and October 1997. All patients were then followed up for a minimum of 3.5 years. The mean age of patients was 50 years and ranged from 28 to 67 years old. After surgery the patients were examined at 4 weeks (evaluation of any immediate complications), 3 months, 6 months and 1 year (evaluation of any delayed complications). RESULTS: No immediate complications were reported in any patient. After 3.5 years of follow-up, the degree of capsular contraction according to Baker in these patients varies between 1 and 2. In general, the implants were very soft to touch even some time after surgery, above all in patients undergoing breast augmentation. Four implants (20%) were removed from 3 patients for reasons unconnected to the implants themselves (because of neoplasm in one case and due to inadequate volume in the other two patients). No case of rupture has been reported. CONCLUSIONS: This pilot study appears to confirm the validity of implants prefilled with Hydrogel in reconstructive or cosmetic breast surgery. A larger population and longer periods of minimum follow-up are obviously required to confirm these results over the long term.

[Permanent expanders in esthetic, corrective and reconstructive surgery of the breast]. / Gli espansori a permanenza nella chirurgia estetica, malformativa e ricostruttiva della mammella.

Since 1986 we used the permanent expandable implant (PEI) as the first choice of prosthesis in breast surgery. The possibilities offered by multiple over-expansions and deflations have been explored: 224 PEI were utilized in 162 patients for aesthetic (38 with bilateral hypoplasia), corrective (20 with asymmetry, tubular breasts or Poland's Syndrome) and reconstructive breast surgery (104 patients for immediate and delayed reconstruction following radical, modified radical, partial and subcutaneous mastectomy). All implants were positioned submuscularly; a latissimus dorsi flap was transposed when pectoralis major was absent or damaged. Either the Becker or the Gibney implant was used. All PEI were immediately or progressively overinflated by 25-80% and then deflated to the planned volume. Twenty-two patients developing capsular contracture were treated by overinflations and deflations with subjective and objective improvement. Many of augmentation mammaplasty patients refused implant deflation to the planned preoperative volume. The over-expansion/deflation process proved to be effective in obtaining ptosis, in maintaining permanent volume symmetry and in keeping the base of tubular breast unfolded.

[The cost as an additional variable in the choice among different techniques of postmastectomy breast reconstruction]. / Il costo come ulteriore variabile di scelta tra le diverse metodiche di ricostruzione mammaria postmastectomia.

Breast reconstruction is an important step for patients after mastectomy. In our Department for immediate reconstruction, smooth or textured temporary tissue expanders filled with saline solution or permanent expandable implants (PEI) with silicon gel saline solution or soyabean oil are usually used. Only in a few selected cases reconstruction using autologous tissues are performed. Delayed reconstruction is performed using autologous tissues: Transversus Rectus Abdominis Myocutaneus Flap (TRAMF) or Latissimus Dorsi flap (LD). The choice between reconstruction with prostheses or muscular flaps depends on previous demolition, local skin condition, contralateral breast size and ptosis, body structure, medical problems, patients' wishes and expectation. Following the legislation defining the privatisation of Italian Health Care Structure and in particular the Decree of December 14, 1994, the need to accurately assess the costs incurred for surgical operations is very important. The aim of this study is to evaluate the clinical limits of each surgical technique and their cost in order to optimize the cost-benefit relationship.

[Perioperative teicoplanin prophylaxis in patients undergoing breast reconstruction with the abdominal wall. A case-control study]. / Profilassi perioperatoria con teicoplanina in pazienti sottoposte a ricostruzione mammaria con retto addominale. Studio caso-controllo.

The authors report the results of a randomized clinical trial of antibiotic prophylaxis of postoperative infection following breast reconstruction by transposition of rectus abdominis myocutaneous flap (TRAMF). The aim was to evaluate the efficacy and tolerability of a short-term parenteral prophylaxis with Teicoplanin and the end-point of the study was the evaluation of wound contamination assessed by means of microbiologic culture of drainage fluid. From October 1990 to March 1992 38 patients were recruited: 20 patients in the antibiotic prophylaxis arm and 18 patients in the control group. Analysis of drainage fluids showed a higher contamination rate (15/18 = 83%) in the control group as compared to the prophylaxis arm (2/20 = 10%) (p < 0.0001). Moreover, 11 patients in the control arm suffered from fever > 37.5 degrees C for at least 3 days as compared to 1 patient in the antibiotic prophylaxis group; the postoperative stay was 13.3 +/- 4.3 and 9.0 +/- 1.6 in the control and antibiotic arm respectively. No antibiotic related side effects were evidenced through the study. These results seem to confirm the value of parenteral short-term antibiotic prophylaxis of postoperative infection in such kind of "clean" operative procedure.

[Psychological assessment of patients who have ++undergone breast reconstruction using 2 different technics: autologous tissue versus prosthesis]. / Valutazione psicologica di pazienti sottoposte a ricostruzione mammaria mediante uso di due differenti tecniche: tessuti autologhi verso protesi.

Breast reconstruction has become an available option for most patients undergoing mastectomy: in fact many authors agree that breast reconstruction does not interfere with possible therapies and improves the quality of life of women. The aim of the study was to evaluate the psychological adjustment of patients who had immediate or delayed reconstruction using 2 different methods: implants and autologous tissues. The study population (115 patients) was derived from patients who underwent breast reconstruction in the period January 1988-December 1991, in follow-up at the Department of Plastic and Reconstructive Surgery; no patient was undergoing psychological therapy. 58 patients underwent breast reconstruction using implants and 57 using Transverse Rectus Abdominis Myocutaneous Flap (TRAMF). Informations were gathered, including the patient's age, the number of offspring, the marital status, the scholastic education, the job and the relapse between mastectomy and reconstruction. The psychological instruments consisted in three standardized self-administered questionnaires: Psychological Distress Inventory (PDI), State Trait Anxiety Inventory form Y (STAI), Eysenk Personality Inventory (EPQ-R). These tests were chosen to gauge the psychological distress, such anxiety, anger, depression and psychosocial maladjustment. To better perform the changes of body image after breast reconstruction, women were requested to answer three more specific questions about the sexual desire, physical image and social relationships. The 102 patients assessed in this study indicate low incidence of psychological distress and adaptive coping strategies. Impairment was reported, regarding body image, by patients undergoing delayed reconstruction; in these patients higher scores in distress tests were observed.

Vertical mammaplasty: a personal approach.

We have been using the vertical mammaplasty technique with personal adjustments for reduction mammaplasty and glandular resection since 1989. There were 63 cases of aesthetic reduction mammaplasty and mastopexy and 38 cases of reduction mammaplasty and mastopexy contralateral to breast reconstruction with implants and/or autologous tissues performed during the period from 1989 to 1993. The aim of this work is to discuss the complications, long-term results, and limitations to this technique.

Mammographic visualization of a nonpalpable breast mass through a radiolucent breast implant.

We report a woman who underwent augmentation mammaplasty as part of a clinical trial of the Trilucent (soybean oil-filled) breast implant in Genoa, Italy. Five months after surgery a mammography was performed in response to the patient's complaints of pressure and tightness in the area of her left breast. The mammogram clearly demonstrated a 5-mm fibroadenoma of the left breast. This is the first documented case of a nonpalpable breast lesion that was detected by mammography through the new radiolucent, triglyceride-filled implant.