Immediate breast reconstruction is an acceptable treatment option after mastectomy for prophylaxis of early breast cancer. Different options exist for implant placement, incision technique, patient ...suitability, and institutional experience. This article is a case series exploring the feasibility and outcomes of patients undergoing immediate breast reconstruction using skin-sparing mastectomy without mesh or acellular dermal matrix (ADM) and with a vertical inframammary incision.
A single-institution retrospective analysis was performed for all patients who underwent immediate single-stage reconstruction with subcutaneous silicon implants without ADM between 2009 and 2014 inclusive. Patient, operative and treatment variables were extracted. All patients with viable mastectomy skin flaps intraoperatively and at least 5 mm of subcutaneous tissue were eligible except for patients who were deemed too slim by the senior surgeon preoperatively and thus at risk of implant visibility or skin rippling.
There were 26 patients (bilateral n = 12 and unilateral n = 14) eligible for analysis, with a median long-term follow-up of 51.5 months. The majority of complications were classified as minor affecting 46.2% of the cohort (n = 12). There were 20 episodes of complications overall. The most frequent episodes were contour defects (x = 5), minor seroma (x = 4), and malrotation and minor infection (x = 3). There was 1 episode of capsular contracture.
Skin-sparing mastectomy with immediate subcutaneous silicon implant reconstruction with a vertical incision and without the need for mesh or ADM is an acceptable and safe treatment option. Accurate patient selection and skin flap viability is the key to achieving optimal outcomes with this approach.
Targeted α-therapy is an experimental approach to the management of cancer. Short range α-particle radiation from a radioisotope attached to a targeting monoclonal antibody kills targeted cancer ...cells. Survival results are analyzed from a previously reported Phase I study of systemic targeted α-therapy for patients with stage IV metastatic melanoma or in-transit metastases. Following intravenous administration of 46-925 MBq of the α-immunoconjugate, (213)Bi-cDTPA-9.2.27, 38 patients were followed to observe response and toxicity. Responses were measured by physical examination, computed tomography at 8 weeks and blood sampling. Toxicity was monitored by blood pathology, urine analysis, glomerular filtration rate and human antimouse antibody response. The maximum tolerance dose was not achieved as there were no adverse events of any type or level. However, an objective partial response rate of 10% was observed, with 40% stable disease at 8 weeks and a median survival of 8.9 months. These results were unexpected because of the short half-life of the (213)Bi and short range of the α-radiation. Survival analysis demonstrated melanoma-inhibitory activity, disease stage, lactate dehydrogenase and treatment effects to be significant prognostic indicators for survival.
With the rise in number of breast implant removals for a variety of indications, strategies to improve aesthetic outcomes, while minimizing scars and operating time, will prove to be of benefit. We ...present here a novel periareolar sickle skin excision as a good option for women with mild to moderate ptosis and central loss of breast volume following implant removal/capsulectomy.
The ECLiPSE (
xplant,
apsulectomy,
ft using
eriareolar
ickle skin
xcision) was utilized in 53 patients with a median follow-up of 24 weeks.
The majority of these patients had breast implants for cosmetic augmentation and the most common indication for implant removal was capsular contracture (n = 47, 88.7%). Forty-six patients (86.8%) scored a high or very high satisfaction with the outcome of the procedure.
We believe that the ECLiPSE procedure is a useful option that can produce a reasonable aesthetic outcome following implant removal/capsulectomy while minimizing visible scarring.
The introduction of seatbelts to legislation has dramatically reduced mortality and morbidity from motor vehicle accidents. However, overtime evidence has emerged of ‘seatbelt syndrome’ (SBS), ...particularly in the paediatric population. The report describes the diagnosis and management of this rare injury in a 12-year-old boy who sustained a chance lumbar fracture and mesenteric tear resulting in small bowel obstruction. His stay was subsequently complicated by superior mesenteric artery (SMA) syndrome. This is the first documented case of SBS with SMA syndrome. High index of suspicion and continuity of care, particularly in the setting of a ‘seatbelt sign’, is paramount to timely diagnosis and management.
Highlights • Midgut malrotation in adulthood is rare, with reported incidence 0.1–0.5%. • Acute appendicitis with undiagnosed midgut malrotation has been sparsely described. • Presenting symptoms are ...often atypical which delay diagnosis. • Early recognition with appropriate imaging is key to diagnosis and appropriate management.
Arterial occlusion following blunt trauma is an uncommon occurrence. We report an unusual case of delayed external iliac artery occlusion in a young male following blunt abdominal injury. He was ...successfully treated with thromboendarterectomy and saphenous vein patch repair. There have only been a handful of documented cases occurring in the paediatric population. All patients presenting with groin injury from this mechanism should be carefully investigated and monitored for risk of vascular injury.
For women undergoing breast conservative surgery or lumpectomy for early stage breast carcinoma, there are limited options for reconstruction. Options include the use of flap surgery and/or implants, ...and have a significant associated morbidity and cost. Autologous fat grafting is a new alternative that can achieve a good cosmetic result, while reducing patient morbidity and cost by avoiding more extensive surgery.
The primary objectives are to assess patient satisfaction using the Breast-Q questionnaire and to evaluate fat graft volume. The secondary objectives are fat survival and assessment for complication (eg, fat necrosis, cysts), local recurrence, and the number of sessions needed for a satisfactory outcome.
This study is a case series of 100 patients, at a single-center institute spanning one year. The inclusion criteria include: female sex, age 18 to 75, early state breast cancer (confirmed on ultrasound/ positron emission tomography-computed tomography and cytology), amenable to breast conservative surgery, and at least 6 months post-completion of radiotherapy/ hormone/chemotherapy. Exclusion criteria include patients with more advanced stages of breast cancer necessitating total mastectomy, those unsuitable for surgical excision, and those in whom lumpectomy is not feasible. The patients will have follow-up data collected at 6 months, 12 months and 5 years post-operatively.
This study will begin enrolment in January 2017. We anticipate that there will be good patient satisfaction with fat grafting. The risk for long-term breast cancer recurrence hasn't been evaluated extensively in literature, however some clinical studies have shown no increased risk of breast cancer in appropriately selected patients at one year. Although some patients may develop complications from fat grafting (eg, necrosis/cysts) this should not confuse the radiological detection of breast cancer recurrence.
Fat grafting is proving to be a viable option for reconstruction of lumpectomy defects with good patient satisfaction. The heterogeneous methods of reporting the harvesting of fat in literature may account for the variable outcomes described, and makes it difficult to compare results with similar studies. The long-term risk of breast cancer recurrence with fat grafting for lumpectomy defects is unknown.
Lengthening temporalis myoplasty, described by Daniel Labbe in 1997, is a facial reanimation procedure for the treatment of facial nerve palsy. It involves the mobilization of temporalis muscle ...antero-inferiorly, and the insertion of its tendon at the nasolabial fold-oral commissure region. Knowledge of the temporalis muscle is crucial in performing this procedure; however, previous anatomical studies are limited.
This study on cadavers, aimed to describe the anatomical location of the temporalis muscle insertion in relation to the adjacent structures, and its main pedicle to aid surgeons in performing this procedure.
Twenty-four temporalis muscles were dissected in 12 fresh frozen cadavers. The anatomical location of the temporalis muscle insertion, accessory attachments, the emergence of the posterior deep temporal artery, and the distance of sliding movements from the coronoid process to the nasolabial fold were recorded.
In addition to its origin from the temporalis fossa and its insertion at the coronoid process, the temporalis muscle was found to have multiple accessory attachments to adjacent structures. These findings explain the challenges in performing the sliding action without releasing the accessory attachments to the masseter and pterygoid muscles. The deep posterior temporal artery is located inferoposteriorly in relation to the muscle. Therefore, the muscle elevation maneuver performed without direct vision can be done with minimal risk to the muscle pedicle.
The knowledge of temporalis muscle insertion, its accessory attachments, and its main pedicle will facilitate surgeons in performing the lengthening temporalis myoplasty more confidently.
Background
Dynamic facial reanimation is one of the key treatment goals for lower facial palsy patients. Currently, temporalis myoplasty is the only non-free flap muscle transfer option considered ...feasible with good outcome. Although masseter transfer has been attempted, it was associated with poor results or considered to be technically challenging. This cadaveric study aimed to re-evaluate the feasibility of masseter transfer by looking at its geometry and offer a new approach to the muscle.
Methods
Twenty-four masseter muscles were dissected in 12 fresh frozen cadavers through a preauricular rhytidectomy incision and a pre-parotid approach. The muscle’s insertion and origin attachments were divided to allow for rotation toward the modiolus. The angle of rotation, vector of pull, transfer distance, and length of the muscle were measured.
Results
The mean angle of rotation was 40.1 degrees, and the mean vector of pull was 66.7 degrees. The mean transfer distance from the muscle’s origin and insertion attachments was 30 and 62.5 mm, respectively. The mean lengths of the muscle’s anterior, posterior, superior, and inferior borders were 55.3 mm, 46.3 mm, 42.6 mm, and 42 mm, respectively.
Conclusions
The distance, angle of transposition, and vector of pull measurements support the feasibility of pedicled masseter transfer in achieving optimal contraction vector with less risk of pedicle injury in lower facial palsy reconstruction. Tendon and fascial grafts can be adjuncts in cases where the masseter muscle length is short. The pre-parotid approach to the pedicled masseter transfer allows for a shorter operative time, which is desirable, particularly in the infirm.
Level of evidence: Not ratable .
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