Mastopexy on Reconstructed Breast Following Massive Weight Loss: An Innovative Technique Using Dermo-Capsular Flaps

Abstract

Background

We have developed a dermo-capsular flap mastopexy technique for patients who have experienced massive weight loss after breast reconstruction. The aim of this technique is to lift the inframammary fold, adequately cover the implant, and remove excess skin, elevating the breast and obtaining symmetry with the contralateral breast.

Methods

Between January 2014 and February 2017, we performed this technique on 20 women who were candidates for second-stage breast reconstruction following nipple-sparing mastectomy. All patients had experienced substantial weight loss (> 15 kg) and presented with ptosis after first-stage reconstruction.

Results

There were 8 patients with bilateral reconstruction following bilateral mastectomy (4 with bilateral nipple-sparing mastectomy). There were 12 patients with unilateral mastectomy, all with contralateral breast ptosis treated by augmentation via inverted-T mastopexy (n = 7) or crescent mastopexy (n = 5). The average lift of the nipple-areola complex was 5 cm (range 2–8 cm). The average follow-up was 12 months (range 4–36 months). Two patients had complications, including partial wound dehiscence (in a heavy smoker) and recurrence of breast asymmetry.

Conclusions

Implant breast reconstruction after massive weight loss is still possible even in the setting of thin, ptotic, and anelastic breast tissue. Our inverted-T dermo-capsular flap mastopexy technique for reconstructed breast is safe and effective with good outcomes and high patient satisfaction.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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Postoperative Pain Control by Intercostal Nerve Block After Augmentation Mammoplasty

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Effects of noise exposure on young adults with normal audiograms II: Behavioral measures

Publication date: Available online 25 October 2017
Source:Hearing Research
Author(s): Garreth Prendergast, Rebecca E. Millman, Hannah Guest, Kevin J. Munro, Karolina Kluk, Rebecca S. Dewey, Deborah A. Hall, Michael G. Heinz, Christopher J. Plack
An estimate of lifetime noise exposure was used as the primary predictor of performance on a range of behavioral tasks: frequency and intensity difference limens, amplitude modulation detection, interaural phase discrimination, the digit triplet speech test, the co-ordinate response speech measure, an auditory localization task, a musical consonance task and a subjective report of hearing ability. One hundred and thirty-eight participants (81 females) aged 18–36 years were tested, with a wide range of self-reported noise exposure. All had normal pure-tone audiograms up to 8 kHz. It was predicted that increased lifetime noise exposure, which we assume to be concordant with noise-induced cochlear synaptopathy, would elevate behavioral thresholds, in particular for stimuli with high levels in a high spectral region. However, the results showed little effect of noise exposure on performance. There were a number of weak relations with noise exposure across the test battery, although many of these were in the opposite direction to the predictions, and none were statistically significant after correction for multiple comparisons. There were also no strong correlations between electrophysiological measures of synaptopathy published previously and the behavioral measures reported here. Consistent with our previous electrophysiological results, the present results provide no evidence that noise exposure is related to significant perceptual deficits in young listeners with normal audiometric hearing. It is possible that the effects of noise-induced cochlear synaptopathy are only measurable in humans with extreme noise exposures, and that these effects always co-occur with a loss of audiometric sensitivity.



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An overview of cochlear implant electrode array designs

Publication date: Available online 18 October 2017
Source:Hearing Research
Author(s): Anandhan Dhanasingh, Claude Jolly
Cochlear implant electrode arrays are designed with specific characteristics that allow for the preservation of intra-cochlear structures during the insertion process, as well as during explantation. Straight lateral wall (LW) electrode arrays and pre-curved modiolar hugging (MH) electrode arrays are the two types that are commercially available. Although there is a third type of electrode array called the mid-scala (MS), which is positioned in the middle of the scala tympani (ST), and is usually considered as an MH type of electrode. Different lengths of straight LW electrode arrays are currently available which allow for insertion across a range of different sized cochleae; however, due to manufacturing limitations, pre-curved MH electrodes are generally only available to cover the basal turn of the cochlea, while the spiral ganglion cells are distributed in the Rosenthal's canal that extends into 1.75 turns of the cochlea. Both straight LW and pre-curved MH electrodes can cause a certain degree of intra-cochlear trauma, but pre-curved MH electrodes tend to deviate into the scala vestibuli from the scala tympani more often than the straight LW electrodes, resulting in damage to the osseous spiral lamina/spiral ligament which could initiate new bone formation and eventually affect the cochlear implant users' hearing performance. Structural damage to the cochlea could also affect the vestibular function. With pre-curved MH electrodes, higher degrees of trauma are related to the fixed curling geometry of the electrode in relation to the variable coiling pattern of individual cochleae, the orientation of the electrode contacts in relation to the modiolus wall, and how effectively the stylet was handled by the surgeon during the procedure. Wire management, metal density, and the shore hardness of the silicone elastomer all contribute to the stiffness/flexibility of the electrode. It is important to acknowledge the impact of bringing the stimulating contacts closer to the modiolus wall with an MH electrode type in terms of the resultant damage to intra-cochlear structures. The presence of malformed cochleae should be identified and appropriate electrodes should be chosen for each specific cochlea, irrespective of the cochlear implant brand. In order to utilize drug therapy, the cochlea should be free from any trauma.



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Tinnitus with a normal audiogram: Role of high-frequency sensitivity and reanalysis of brainstem-response measures to avoid audiometric over-matching

Publication date: Available online 14 October 2017
Source:Hearing Research
Author(s): Hannah Guest, Kevin J. Munro, Christopher J. Plack




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Musashi-2, a novel oncoprotein promoting cervical cancer cell growth and invasion, is negatively regulated by p53-induced miR-143 and miR-107 activation

Although previous studies have shown promise for targeting Musashi RNA-binding protein 2 (MSI-2) in diverse tumors, the role and mechanism of MSI-2 for cervical cancer (CC) progression and the regulation of MS...

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Reconstruction of extensive thoracic wall defect using the external oblique myocutaneous flap: An analysis on 20 Chinese patients with locally advanced soft tissue sarcoma

Background

Soft tissue sarcomas are rare neoplasms that can occur in the thoracic wall, abdominal wall, extremities, and inguinal region. Wide local resection, with precise histological margin control, results in large skin defects that are challenging to close. Various repair procedures, such as vertical rectus abdominis flaps (VRAM), latissimus dorsi flaps, and tensor fascia lata (TFL) flaps are used to cover broad thoracic wall defects. Although the cosmetic reconstruction results of using these flaps are often excellent, each has significant drawbacks. The external oblique musculocutaneous flap is a simple and safe surgical procedure for covering thoracic wall defects.

Objective

This study aimed to retrospectively assess the safety and technique of using the external oblique musculocutaneous flap to cover large thoracic wall defects after radical excision of locally advanced sarcomas in 20 patients at a single institution.

Method

From January 2006 to December 2016, 20 Chinese patients with large advanced sarcomas on their trunks received wide local resection, with precise histological negative margins. The external oblique musculocutaneous flap, mobilized from the ipsilateral abdominal wall, was harvested to cover broad thoracic wall defects.

Results

Among the 20 sarcoma patients (12 females and 8 males, ranging in age from 25 to 73 years), there were five patients with primary tumors and 15 patients with recurrent tumors. The median tumor diameter was approximately 15.3 cm. After excising the lesion, the median time to cover the defect with the external oblique myocutaneous flap was 66 min. The average blood loss when harvesting the flap was approximately 48 mL. For the 20 patients in our cohort, the external oblique flap achieved closure of defects measuring an average area of 256 cm. No other flaps or reconstruction techniques were used to cover the large defects in this study. There were no deaths directly related to the flap reconstruction procedures.

Conclusion

The external oblique musculocutaneous flap was a safe and reliable method of covering broad thoracic wall defects after radical tumor excision.

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Effective excision of cutaneous squamous cell carcinoma of the face using analysis of intra-operative frozen sections from the whole specimen

Background and Objectives

We excised cutaneous squamous cell carcinoma (cSCC) of the face while using intra-operative frozen section analysis of the margins in an optimized bread-loafing fashion (WIFSA).

Methods

Medical records were reviewed of 160 cSCCs of the face that were treated by surgical excision with WIFSA between April 2007 and January 2013. The accuracy of WIFSA was verified by comparing results with postoperative formalin-fixed paraffin-embedded (FFPE) sections. Also, recurrence and metastasis during follow-up were studied and duration of treatment and complications were analyzed.

Results

The 160 cSCCs affected 152 patients. In 131 cSCCs (mean follow-up: 41.0 months, SD: ±26.3, range: 3.0-110.7) occurred 6 (4.6%) recurrences and 2 (1.5%) metastases. Of the WIFSA results, 98.8% corresponded with postoperative FFPE sections. Mean duration of treatment was 77 min (SD: ±25, range: 34-159) and complication rate was 8.1%.

Conclusions

Surgical excision with WIFSA is an excellent treatment modality for cSCC of the face because of its accurate method for assessment of complete tumor removal, low recurrence and metastasis rate, short average duration of treatment, and low complication rate.

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Comment to: “Complications and Outcomes After Gynecomastia Surgery: Analysis of 204 Pediatric and 1583 Adult Cases from a National Multi-center Database”

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Comment to: “Complications and Outcomes After Gynecomastia Surgery: Analysis of 204 Pediatric and 1583 Adult Cases from a National Multi-center Database”

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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Augmentation Mastopexy with a Dermal Encapsulated Round or Anatomic Autoprosthesis

Abstract

Introduction

Several factors, such as aging, pregnancy, and weight loss, reduce the elasticity of the breast tissue, and ptosis occurs. Due to aging and gravity, it is not possible to completely prevent breast ptosis. The goal is to delay the recurrence of ptosis as much as possible.

Patients and Methods

This study included 20 female patients aged 25–55 years. The patients who underwent surgery had different levels of ptosis. Although the patients wanted their breasts to be lifted and an increase in projection, they did not want implants to be used. For this reason, autologous flaps were prepared from the patients, and these flaps were called autoprosthesis flaps. The flap donor area (FA) boundaries consisted of the inframammary fold at the bottom, the medial and lateral pillar legs at the two sides and the lower margin of the areola at the top. The skin on the FA was de-epithelialized. A hand dermatome was used to ensure that the extracted skin was not too thick because the rest of the dermal skin would form the cover of the planned autoprosthesis flap. Before surgery, the autoprosthesis flap baseline width, projection, and shape (round or anatomic) were planned for each patient. The autoprosthesis flap was prepared as a central pedicle, and the dermal layer, which was 1 cm wider than the flap, was then attached over the autoprosthesis flap to the pectoral muscle fascia with at least 10 sutures in the recipient area. For a round autoprosthesis flap, the flap base diameter was 10–12 cm on average, whereas for an anatomic autoprosthesis flap, the width of the flap was 10–12 cm and the height was 12–14 cm. Autoprosthesis flap projections varied from 4 to 6 cm.

Results

Because of the autoprosthesis flap, breast projection was more prominent, even in the lying position. All the patients were very satisfied with their size, shape, projection, and natural appearance. In particular, the image in the lying position was very similar to a mastopexy performed with an actual breast implant; thus, sagging was not observed.

Conclusion

In augmentation mastopexy patients who do not want implants, upper pole filling and adequate breast projection can be easily achieved with this method. The potential risks of capsule formation, implant rejection, and implant rupture were not observed with this technique.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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Comparison of Sensory Changes Following Superomedial and Inferior Pedicle Breast Reduction

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Comment to: “Complications and Outcomes After Gynecomastia Surgery: Analysis of 204 Pediatric and 1583 Adult Cases from a National Multi-center Database”

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Comment to: “Complications and Outcomes After Gynecomastia Surgery: Analysis of 204 Pediatric and 1583 Adult Cases from a National Multi-center Database”

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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Editorial Board

Publication date: November 2017
Source:Archives of Physical Medicine and Rehabilitation, Volume 98, Issue 11





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Longitudinal recovery and reduced costs after 120 sessions of locomotor training for motor incomplete spinal cord injury

Publication date: Available online 26 October 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Sarah A. Morrison, Douglas Lorenz, Carol P. Eskay, Gail F. Forrest, D. Michele Basso
ObjectiveTo determine the impact of long term, body weight supported locomotor training (BWSLT) after chronic, incomplete spinal cord injury (SCI). Also, health care costs were estimated related to lost recovery potential and preventable secondary complications that may have occurred due to visit limits imposed by insurers.DesignProspective observational cohort with longitudinal follow up.SettingEight outpatient rehabilitation centers that participate in the Christopher & Dana Reeve Foundation NeuroRecovery Network® (NRN).ParticipantsIndividuals with motor incomplete chronic SCI (Asia Impairment Scale C or D; n=69; 0.1-45 yr after SCI), who completed at least 120 NRN physical therapy sessions.InterventionsManually-assisted locomotor training in a body weight supported treadmill environment, overground standing and stepping activities, and community integration tasks.Main Outcome Measure(s)International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) motor and sensory scores, orthostatic hypotension, bowel/bladder/sexual function, SCI-FAI, Berg Balance Scale, Modified Functional Reach, 10-meter walk test and 6-minute walk test. Longitudinal outcome measure collection occurred every 20 treatments and at 6-12 month follow-up after discharge from therapy.ResultsSignificant improvement occurred for upper and lower motor strength, functional activities, psychological arousal, sensation of bowel movement and SCI-FAI community ambulation. Extended training enabled minimal detectable changes at 60, 80, 100, and 120 sessions. After detectable change occurred, it was sustained through 120 sessions and continued 6-12 months after treatment.ConclusionsDelivering at least 120 sessions of LT improves recovery from incomplete chronic SCI. Because walking reduces rehospitalization, LT delivered beyond the average 20 session insurance limit can reduce rehospitalizations and long term health costs.



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Table of Contents

Publication date: November 2017
Source:Archives of Physical Medicine and Rehabilitation, Volume 98, Issue 11





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Editors' Selections From This Issue: Volume 98 / Number 11 / November 2017

Publication date: November 2017
Source:Archives of Physical Medicine and Rehabilitation, Volume 98, Issue 11





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Masthead

Publication date: November 2017
Source:Archives of Physical Medicine and Rehabilitation, Volume 98, Issue 11





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Measuring Participation after Stroke in Africa: Development of the Participation Measurement Scale

Publication date: Available online 26 October 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Oyéné Kossi, Félix Nindorera, Charles Sèbiyo Batcho, Thierry Adoukonou, Massimo Penta, Jean-Louis Thonnard
ObjectiveTo develop a valid stroke-specific tool for the measurement of participation in Africa, named the Participation Measurement Scale (PM-Scale).DesignObservational study and questionnaire development.SettingOutpatient Rehabilitation centers.ParticipantsStroke patients (N = 276); mean age ± standard deviation of 58.5 ± 11.1 years; 57% male.InterventionNot applicable.Main Outcome MeasuresParticipants completed a 100-item experimental questionnaire of the PM-Scale. Items were scored as "not at all", "weakly" or "strongly". The Hospital Anxiety and Depression Scale was used to evaluate the depression and the modified Rankin Scale was used to categorize the severity of disability on the basis of observation.ResultsAfter successive Rasch analyses using RUMM2030 software package under unrestricted partial-credit parameterization, a valid, unidimensional and linear 22-item scale for the measurement of participation was constructed. All 22 items fulfilled the measurement requirements of overall and individual item and person fits, category discrimination, invariance, and local response independence. The PM-Scale showed good internal consistency (person separation index = 0.93). The test–retest reliability of item difficulty hierarchy (r = 0.96, p <0.001) and patient location (r = 0.99, p <0.001) were excellent. This patient-based scale covers all nine ICF domains of participation.ConclusionsThe PM-Scale has good psychometric qualities and provides accurate measures of participation in patients with stroke in Africa.



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