Nasal alar reconstruction using the nasolabial turnover flap.
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Humans↗
Biomedical subjects
S S Kroll
Publications and source records attributed to S S Kroll.
Mammographic and CT findings after breast reconstruction with a rectus abdominis musculocutaneous flap.
This essay illustrates the radiologic appearance of the reconstructed breast and the abdominal wall after breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap. The findings are based on a retrospective study of 42 mammograms, 17 abdominal CT scans, and two CT scans each of the chest and pelvis of patients who underwent this procedure.
Abdominal Muscles↗
Immediate reconstruction: current status in cancer management.
Immediate elective repair of various defects caused by ablative surgery for treatment of cancer is becoming increasingly common. In comparison with delayed reconstruction, immediate reconstruction has the advantage of lower costs and, in most cases, reduced anesthesia risks. Immediate repair is also technically easier in many cases and may provide better results. Furthermore, it often provides patients with a strong psychological boost, allowing them to progress toward total recovery and minimizing the time they must live with disability and deformity. Experience has shown that immediate reconstruction does not increase the risk of cancer recurrence or metastasis. Elective immediate reconstruction has proven useful for defects of the breast, chest wall, mandible, nose, oral cavity, and extremities. Illustrative examples are provided so that the potential benefits of this approach can be more widely appreciated.
Breast Neoplasms↗
Staged sequential flap reconstruction for large lower lip defects.
A method for the reconstruction of total or nearly total defects of the lower lip is described that utilizes a staged sequence of flaps that are familiar to most plastic surgeons. The recommended sequence is an extended Karapandzic flap to reestablish the oral sphincter, then two sequential Abbé flaps from the upper lip to restore balance and augment the central lower lip, and finally a commissureplasty using a sliding myomucosal flap in conjunction with final revision of the scars. Intervals of 3 weeks separate the surgical procedures. Using this strategy, essentially normal lip function and a relatively normal appearance have been obtained in four patients with large lip defects.
Adult↗
The oncologic risks of skin preservation at mastectomy when combined with immediate reconstruction of the breast.
Most oncologic surgeons agree that removal of the nipple, the areola and any recent scar at the site of the biopsy is necessary during a mastectomy for treatment of carcinoma of the breast. There is less agreement about what should be done with the remaining uninvolved mammary skin. Its preservation facilitates the performance of immediate reconstruction of the breast and can lead to improved aesthetic results, but many oncologists fear that this practice could lead to an increased incidence of local tumor recurrence. To determine if that fear was justified, 87 patients who had undergone unilateral or bilateral mastectomy with immediate reconstruction for treatment of early carcinoma of the breast were studied. Preservation of uninvolved skin was used in all instances. All patients had a documented follow-up study of 12 months or more; the average follow-up time was 23.1 months. One peripheral local recurrence was observed. This 1.2 per cent rate of early local recurrence is lower than that reported from several series using modified radical mastectomy without skin preservation or immediate reconstruction, and suggests that skin preservation does not confer additional risks of local recurrence of carcinoma of the breast in properly selected patients.
Breast Neoplasms↗
Irradiation of prosthetically augmented breasts: a retrospective study on toxicity and cosmetic results.
Eleven patients with subcutaneous prosthetic breast implants were followed 3-16 years after mammary irradiation. Radiation doses ranged between 45 Gy and 50 Gy to the whole breast, supplemented in five cases with 10-21 Gy scar boost. Evaluation of the cosmetic results revealed a good score in three patients, moderate to fair in three, and poor in five. Of the five patients who had poor postirradiation cosmesis, three had fibrotic changes and encapsulation of the prostheses prior to the irradiation, and two received their irradiation 1 month after the reconstruction. In most of the patients, the nonirradiated breast was augmented with a prosthesis and both breasts could be followed for comparison. The irradiated side usually looked and felt on palpation worse than the nonirradiated, but both breasts exhibited a steady deterioration in appearance over time. The patients who enjoyed better cosmetic results after irradiation had better breast appearance before the radiotherapy. Of three patients treated with lower doses (45 Gy/4.5-5 weeks), two enjoyed good cosmesis. Both patients who received irradiation immediately after reconstructive surgery had poor cosmetic results. Three observations could be made: (a) when the implanted breast was free of fibrotic changes, radiotherapy produced acceptable results, (b) whenever feasible, 45 Gy/5 weeks seemed preferable over higher doses, (c) irradiation immediately after the reconstructive surgery appeared to produce poorer cosmetic results.
Adult↗
Nipple centralization for the correction of breast deformity from segmental mastectomy.
A breast deformed by lateral tissue deficiency and severe lateral displacement of the nipple, caused by the treatment of an early breast cancer with segmental mastectomy and radiotherapy, was corrected by a modification of techniques used commonly for mastopexy. The nipple and areola were moved medially on a central pedicle to create the illusion that the missing lateral tissues had been restored. Simultaneously, the opposite breast was reduced to improve symmetry. The result was a normalization of breast appearance without the need for distant tissue. It is possible that modifications of this approach could be used to treat similar deformities in other quadrants of the breast as well.
Adult↗
Analysis of complications in 168 pectoralis major myocutaneous flaps used for head and neck reconstruction.
One hundred sixty-eight pectoralis major muscular and myocutaneous flaps performed at the University of Texas M. D. Anderson Cancer Center during the past five years were reviewed retrospectively to determine complication rates following operation and to evaluate the effect of risk factors such as smoking, obesity, sex, previous radiotherapy, and tumor stage on the incidence of such complications. The overall rate of complications was 63%; however, most of these complications were self-limited, and the rate of total flap loss was only 2.4%. The risk of a complication developing was increased slightly in patients who smoked cigarettes and in patients with larger tumors. Obesity and previous radiotherapy had no effect on complication rates. Women who underwent pectoralis major myocutaneous flaps had a higher rate of flap necrosis than did men, presumably because of the interposition of breast tissue between the muscle and the skin paddle. In patients who had muscle flaps (without skin paddles), sex had no influence on complication rates. In all groups of patients, flaps consisting of muscle alone had fewer complications than did flaps with a cutaneous component.
Female↗
Long-term survival after chest-wall reconstruction with musculocutaneous flaps.
Reconstruction of chest-wall defects with musculocutaneous flaps permits resection of advanced chest-wall tumors and of tissues severely damaged by radiotherapy in patients who in a previous era were not surgically treatable. To determine the long-term outcome from this surgery, the records of 96 patients who had undergone chest-wall resection with musculocutaneous flap reconstruction were reviewed. Median survival for the entire group was 20.5 months, but a more accurate prediction of outcome could be obtained by dividing the patients into three groups. In group I, patients free of known malignancy and undergoing resection of radionecrotic tissues, median survival was 60.0 months. In group II, patients with resectable disease and free of tumor following surgery, median survival was 31.1 months. In group III, patients incompletely resected or known to have metastatic disease following surgery, median survival was only 12.5 months. Even in group III, however, some individuals achieved prolonged survival and lasting benefits from the surgery, so these data should not be used to exclude patients from undergoing necessary palliative procedures.
Analysis of Variance↗
Striving for excellence in breast reconstruction: the salvage of poor results.
Poor results in breast reconstruction can often be salvaged by turning to alternative techniques when the original treatment strategy has not produced optimum results. To do this, the surgeon must be willing to admit to aesthetic failures and correct them. If this is done honestly and vigorously, the multiplicity of methods presently available can allow us to turn many of our failures into successes. Five patients are presented to illustrate these principles and suggest some specific strategies for improving mediocre or poor results.
Adult↗
Midline fascial preservation in double-pedicle TRAM flap breast reconstruction.
The addition of a second pedicle to the transverse rectus abdominis musculocutaneous flap has enlarged the pool of potential candidates for breast and chest wall reconstruction with that method to include patients who smoke, those with midline abdominal scars, and others. Many surgeons are hesitant to try the double-pedicle technique, however, because of a concern about being able to close the fascial donor defect. Fortunately, what the flap requires for survival is blood supply, not fascia. This report describes two ways to preserve anterior rectus fascia in the donor area medial to the perforating vessels without compromising the blood supply to the flap. Consequently, primary closure of the donor defect in the fascia can generally be accomplished, making the use of synthetic mesh optional and encouraging wider use of the double-pedicle technique.
Abdominal Muscles↗
Chemotherapy-induced acral erythema: desquamating lesions involving the hands and feet.
Patients receiving very high doses of chemotherapeutic drugs, particularly cytarabine (cytosine arabinoside, ara-C, Cytosar), may develop chemotherapy-induced acral erythema, a painful toxic rash of the palmar surfaces of the hands that progresses to edema, blister formation, and desquamation. In more severe cases, the feet are involved, and they show similar changes. Plastic surgeons may be consulted because of the hand involvement and the clinical resemblance, after desquamation, to a very superficial second-degree burn. In patients who have had bone marrow transplantation, this diagnosis must be distinguished from graft-versus-host reaction--a desquamating skin lesion that can affect a similar anatomical area but that is progressive and productive of serious consequences. Acral erythema appears to be self-limited and requires only supportive treatment.
Adolescent↗
Delayed pedicle separation in forehead flap nasal reconstruction.
Nasal reconstructions with midline forehead flaps are often plagued by inadequate tip projection and excessively thick alar rims. These problems can be overcome by a combination of preliminary tissue expansion, which gains extra length, and delayed pedicle separation, which allows aggressive thinning of alar rims and shaping of the tip while its blood supply is still fully intact. Only when tip-shaping is completed is the pedicle divided and the reconstruction completed. In our experience this combination of increased flap length and improved tip shape has led to better tip projection and superior overall results. Three representative cases that demonstrate these principles are presented.
Basal Cell Carcinoma↗
Radical thinning of the pedicle of a gastrocnemius musculocutaneous flap.
Aggressive thinning of the muscle from the pedicle of a gastrocnemius musculocutaneous flap can change the nature of that pedicle radically. Instead of being bulky and causing contour deformity, the pedicle is reduced to a vascular leash that has virtually no effect on contour at all. Radical thinning of this type was performed on the pedicle of a medial gastrocnemius flap in one patient and on a lateral gastrocnemius flap in another. Both flaps survived, suggesting that such aggressive muscle thinning is feasible and that a more moderate degree of muscle thinning, which is all that most flaps probably require, entails only minimal risk.
Accidents, Traffic↗
Multiple and repetitive uses of the extended hamstring V-Y myocutaneous flap.
An extended hamstring V-Y myocutaneous advancement flap is described that may be used to cover unusually large defects in the ischial region. Technical points that allow a large amount of flap advancement are discussed. Because of its large size, the flap can be raised and used on repeated occasions to repair defects from recurrent ischial pressure sores. Two patients are presented in whom the same flap was used repeatedly on multiple occasions, demonstrating the potential for preservation of future options in such patients when this flap is used.
Humans↗
Nipple reconstruction with the double-opposing-tab flap.
The double-opposing-tab flap, a new method of nipple reconstruction used in 50 patients to date, is described. This technique uses two dermal-fat flaps, each similar to those described by Hartrampf, but with tab extensions inspired by the skate flap of Little. The donor sites of the two flaps are closed like Burrough's triangles, bringing the flaps into opposition so that they support each other's projection. The tabs cover all the exposed fat on the nipple so that no skin graft is required on the nipple proper. The result is a nicely shaped nipple that can be designed directly over a scar, maintains a projection averaging 3.8 mm at 10 months, and is technically easy to construct.
Breast↗
Complications of TRAM flap breast reconstruction in obese patients.
The records of 82 women who had undergone unilateral breast reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap at the University of Texas M. D. Anderson Cancer Center were analyzed to determine what effect obesity had on the rate of complications and the aesthetic quality of the ultimate result. The patients were divided into four groups--thin, average, moderately obese, and markedly obese--based on a weight/height index derived by dividing the weight in kilograms by the height in meters. In the thin group (13 patients), the complication rate was only 15.4 percent. In the average group (22 patients), the complication rate was 22.7 percent. In the moderately obese group (35 patients), the complication rate was 31.4 percent. In the markedly obese group (12 patients), the rate was 41.7 percent. Aesthetic results in the abdomen tended to be better in the nonobese group, but in the breast they correlated better with the number of revisions performed than with degree of obesity. The findings in this study suggest that the complication rate of TRAM flap breast reconstruction does increase in proportion to the degree of obesity. Surgeons can therefore avoid many of the complications from TRAM flap surgery by not operating on very obese patients. Reports of complication rates from different authors may vary in part depending on their mix of obese and nonobese patients.
Abdominal Muscles↗
Forehead flap nasal reconstruction with tissue expansion and delayed pedicle separation.
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Humans↗