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Extensive experience with infected sternotomy wounds treated by aggressive debridement and immediate, laterally based pectoralis muscle flaps has shown this to be a reliable and effective treatment for a major complication previously associated with high morbidity and mortality. This is a plastic surgery operation that saves lives and health care dollars.
Massive pharyngocutaneous fistulae may be arbitrarily defined as those involving two-thirds or more of the circumference of the pharyngeal wall. Three such patients are presented, all after failed radiotherapy and surgery. The principles of management consist of salivary diversion, complete debridement, nutritional support, prophylactic antibiotics, and two-layer, well-vascularized overlapping closure. We currently recommend a radial forearm flap used in conjunction with a pectoralis muscle (or musculocutaneous) flap for rapid rehabilitation of these patients, particularly in the presence of obesity or an irradiated bed.
A prospective study was performed to determine whether thoracic CT yielded useful information regarding the status of axillary lymph nodes (LNs) in patients with breast cancer. Thirty-five consecutive patients with clinically suspected stage II or III breast carcinomas were scanned preoperatively from the supraclavicular regions to the lung bases. Axillary LNs measuring greater than or equal to 1 cm were considered abnormal. The lymph nodes were classified according to their relationship to the pectoralis muscle. Extracapsular lymph node extension was diagnosed when there was irregularity and spiculation of the lymph node margin with surrounding fatty infiltration. Correlation with axillary dissection was obtained in 20 patients, giving a positive predictive value for axillary metastases of 89% with 50% sensitivity, 75% specificity, and 20% negative predictive value. CT was also able to detect the level of axillary involvement accurately when the lymph nodes were enlarged and to evaluate extracapsular LN extension. Although superior to physical examination, CT was not an accurate predictor of axillary LN involvement, primarily because of its low negative predictive value.
The purpose of the study in this article was to evaluate the physical impairment of patients with breast hypertrophy and to justify the medical necessity of reduction mammaplasty. In 50 women, 20 to 40 years old, with a body mass index below 25, breast size was measured by volumetry and correlated to a functional spine score. This score was determined by the presence of scoliosis, deviated head position, shoulder protraction, shortening of the pectoralis muscle, mobility of the cervical spine, and strength of the abdominal and back extensor muscles. Impairment of the spine in correlation to the breast size was statistically significant (r = 0.71, p < .0001).
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Three young women who had significant unilateral hypoplasia of the breast, accentuated by marked rib deformities and hypoplasia of the pectoralis muscle, were treated by two-staged reconstructions. A custom-made chest wall implant and a breast prosthesis were used. In the absence of cardiorespiratory compromise, these are simpler operations than rib osteoplasties and the cosmetic result is better.
The authors present a patient who had aplasia of the right breast associated with absence of the pectoralis muscles and a chest wall deformity. The insertion of combined breast-chest wall implants improved her appearance markedly.
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A modification of an established technique to augment the breast is described. Thirty patients underwent subpectoral augmentation though a periareolar incision with a follow-up period of 10 to 16 months. The purpose was to combine the benefit of subpectoral placement (to minimize capsular contracture) with an inconspicuous scar, which usually results from the periareolar approach. Under general anesthesia a periareolar incision was used. Dissection proceeded straight down to the pectoralis muscle, which was split between its fibers to enter the areolar subpectoral plane. The origin of the muscle from the ribs and part of the sternum was detached and the pocket was subcutaneously extended lateral to the muscle. Thus a larger than otherwise expected implant could be inserted without the problem of displacement by the muscle, Postoperative tonometry was done to quantitate the degree of breast softness. Initial results suggested that (1) the incidence of capsular contracture can be reduced by virtue of using th subpectoral plane; (2) breast tonometry measurements of brest softness or firmness correlate well with the clinical impression; (3) the periareolar scar is superior to the inframammary scar; and (4) the periareolar approach allows easy access to the subpectoral plane and allows for better visualization of the muscular detachment.
Plasma levels of lidocaine and the main binding proteins of lidocaine in plasma alpha1-acid glycoprotein (AAG) and albumin were measured in 10 otherwise healthy women during and after breast augmentation. A total dose of 825 to 1280 mg of 0.2% and 0.5% lidocaine with epinephrine corresponding to 16.3 to 21.8 mg/kg (mean 18.2 mg/kg) was injected in the spatium between the pectoralis muscle and the mammary gland. The peak plasma concentrations of lidocaine varied between 0.96 and 3.12 microg/ml (mean 1.49 microg/ml) and occurred between 4 and 12 hours (mean 7.3 hours) postoperatively. The plasma concentration of AAG varied between 0.42 and 1.73 g/liter (mean 0.49 g/liter, normal range 0.54 to 1.17 g/liter). There was a significant correlation between the plasma concentration of AAG and lidocaine. The mean concentration of albumin was 37.2 g/liter, ranging from 33 to 42 g/liter (normal range 35 to 50 g/liter). No patient showed signs of lidocaine toxicity. These data indicate that a dose of 20 mg/kg of lidocaine with epinephrine probably is safe in breast augmentation when the drug is administrated as described in this study. There are significant individual differences in the plasma concentration curves between patients, partly explained by different concentrations of AAG. Further studies with a larger number of patients are needed to establish definitive recommendations of safe maximal doses.
MEGX (monoethylglycinexylidide) is the main metabolite of lidocaine and is 83 percent as potent as an antiarrhythmic drug and with the same toxicity as lidocaine. In this study, plasma levels of MEGX were measured in 10 other wise healthy women during and after breast augmentation. A total dose of 825 to 1,280 mg of lidocaine of 0.2% and 0.5% lidocaine with epinephrine corresponding to 16.3 to 21.8 mg/kg (mean, 18.2 mg/kg) was injected in the spatium between the pectoralis muscle and the mammary gland. The peak plasma concentrations of MEGX varied between 0.40 and 0.99 microg/ml (mean, 0.49 microg/ml) and occurred between 8 and 12 hours (mean, 9.1 hours), postoperatively. In three patients, the concentration of MEGX was still increasing after 12 hours. In comparison, the peak plasma concentrations of lidocaine varied between 0.96 and 3.12 microg/ml (mean, 1.49 microg/ml) and occurred between 4 and 12 hours (mean, 7.3 hours) after the end of the injection. The peak lidocaine + MEGX concentrations varied between 1.45 and 3.58 microg/ml (mean, 2.02 microg/ml) and occurred between 5 and 12 hours (mean, 8.5 hours), postoperatively. These data suggest that MEGX might contribute to lidocaine toxicity when high doses of lidocaine are injected. The substantial interindividual variation strongly indicates that recommendations about maximum safe doses of lidocaine should be made with caution.
Forty-eight patients who suffered sternal wound infections following coronary artery bypass grafting were retrospectively reviewed over a 5-year period. All patients in this study had clinical signs of major infection including redness, pain, and purulence at the time of mediastinal drainage and debridement. One patient died 11 days postoperatively because of heart failure, leaving 47 patients available for long-term follow-up. All muscle flaps (pectoralis and rectus abdominis) survived completely. All wound complications were related to chest wall skin flap dehiscence or continued infection. Seventeen of 22 patients (77 percent) undergoing flap closure 4 days or less after sternal debridement and irrigation suffered wound complications. Five of these 22 patients (23 percent) had major wound complications, meaning that the wound required more than 2 months of care before healing was complete. No major wound complications and only three minor complications (12 percent) occurred in 25 patients undergoing sternal flap closure 5 days or more after mediastinal debridement and irrigation. The frequency and severity of wound complications were significantly decreased in the group of patients undergoing sternal flap closure 5 or more days after sternal drainage and debridement (p < 0.00005). In the majority of cases [29 of 47 (62 percent)], secure sternal wound closure was obtained with a single, split, medially based, right pectoralis major muscle flap.
Poland's syndrome, a rare congenital anomaly characterized by pectoralis muscle defect and ipsilateral hand abnormalities, has been reported in association with various malignancies. Gastric cancer associated with Poland's syndrome has not been described previously. To our knowledge, the case of the 21-year-old man we describe herein represents the first report of Poland's syndrome associated with gastric cancer. Although previously there was no certain evidence that linked Poland's syndrome and cancer, elucidating the molecular mechanisms that cause this syndrome may further clarify the relationship between Poland's syndrome and malignancies. At least, these associations confirm the relationship between Poland's syndrome and malignancies, and require oncologic awareness.
Current criticisms regarding vertical mammaplasty include problems with poor immediate postoperative appearance, nipple-areola complex malposition, and excessive lower pole length. These problems can be avoided by proper patient selection, by utilizing correct concepts of skin design, and by observing correct glandular resection and closure concepts. Vertical mammaplasty also can result in other problems, such as hypertrophic circumareolar scars and lower pole deformities, including notching, boxy shape, infra-areolar depression, and flatness. These problems are also largely avoidable by using correct technique. Several basic concepts described previously have not proven necessary to achieve good results. Abandoning some of these principles has contributed to the ability to establish an aesthetically ideal breast shape intraoperatively as well as to a decrease in morbidity. This includes eliminating liposuction as a major integral component of the procedure, eliminating suturing the gland to the pectoralis muscle, not undermining the lower pole skin, and avoiding overly wide skin resection and tight wound closure that produces significant lower pole distortion in the early postoperative period. An important concept that has proven reliable is to use a "closed" design that does not predetermine the areolar opening whenever circumstances permit. When this is not possible, a modification that utilizes the smallest possible circumference as an open design is better than a large "mosque." These alternatives allow greater flexibility in determining final nipple position and also reduce the risk of hypertrophic circumareolar scars. Important glandular resection concepts include creating pillars that are attached to both the skin and the chest wall; making them of adequate dimension to avoid postoperative lower pole shape problems, such as flattening; resecting closer to the skin lateral to the pillars to avoid a boxy breast shape; and using a drain both to assist in accurately determining the endpoint of resection and to avoid postoperative seromas. Key closure concepts include approximation of the superior surfaces of the pillars at their base to maintain vertical height and thereby prevent lower pole flattening; approximation of the inferior surfaces of the pillars to the base of the breast to prevent notching; and proper management of the vertical incision by restricting the purse-string suture effect to only the inferior portion of the incision, where there may be skin excess present. Inclusion of these concepts leads to predictable and improved aesthetic results in vertical mammaplasty. This allows full realization of the purported advantages of vertical mammaplasty and allows this method to be utilized with a level of confidence similar to that seen with inverted-T techniques.
Eight cases of free muscle transfer with the use of microsurgical technique are reported, comprising five patients with Volkmann's contracture of the forearm, two with poliomyelitis, and one with an old brachial plexus injury. Operation was successful in the six patients with traumatic injuries, but proved unsuccessful in the two with poliomyelitis. Generally, the vessels and nerves of the recipient site were anastomosed with their counterparts in the grafted muscle. In one patient with an old brachial plexus paralysis in whom nerves in the recipient site could not be used, muscle graft an intercostal nerve transfer procedures were employed. In six cases, only muscle was transferred, and in two cases, the muscle together with an overlying skin flap was removed to reduce tension of the skin at the recipient site.