A total of 150 healthy women were studied to determine normal values for breast sensibility and to investigate the influence of breast size and ptosis on breast sensation. Cutaneous pressure thresholds were evaluated bilaterally in six areas including the nipple, the areola, and the skin of the breast using the Semmes-Weinstein monofilaments. We found that the skin of the superior quadrant was the most sensitive part of the breast, the areola was less sensitive, and the nipple was the least sensitive part. The cutaneous sensibility of all tested areas decreased significantly with increasing breast size and increasing breast ptosis. The nipple was less sensitive in women who had a previous pregnancy. Age, smoking history, or hormonal contraception had no significant influence on breast sensation. The study shows that the Semmes-Weinstein test is an adequate method for assessing sensation in the breast.
Unreliable skin perfusion has been reported frequently in the gracilis myocutaneous flap, resulting in moderately high partial flap necrosis. We modified the traditional myocutaneous operative technique by including all available regional fascia and created a myofasciocutaneous flap with increased skin viability. In addition, we defined the arterial anatomy of the flap that contributes to enhanced flap survival. In a cadaver study, blue latex was injected into the external iliac arteries of 11 cadaveric legs and the gracilis myofasciocutaneous flap dissected. Selective ink injection of the pedicle and perforating vessels also was performed in 8 legs. Two additional legs were injected with a barium-latex mixture, cut into 2-cm-thick transverse sections, and radiographed. Dissections demonstrated arterial connections between the pedicle vessel (medial femoral circumflex artery) and fasciocutaneous perforating vessels from the superficial femoral artery. Perforating vessels contribute to an axially oriented fascial network that supplies the overlying skin. Selective ink injections demonstrated the individual primary cutaneous vascular territories for each perforator. Radiographs of 2-cm-thick transverse sections confirmed the presence of arterial connections between the pedicle and the superficial femoral artery perforators. Twelve patients, previously pelvically irradiated, then underwent harvest of 18 large, longitudinally oriented (8-cm-wide, up to 30-cm-long) gracilis myofasciocutaneous flaps. All fascia beneath the skin paddle was taken in continuity with the deep fascia surrounding the gracilis muscle to minimize disturbance of any connecting vasculature held within the fascia. Patients were followed for an average of 12.1 months (range 3 to 31 months). Minor complications related to the flaps occurred in 6 of 12 patients (50 percent), i.e., seromas, mild wound infections, and a partial dehiscence; however, vascularity was excellent with no partial or complete flap necrosis. All wounds healed completely.
To reconstruct intraoral lining defects after radical tumor resection by reinnervated vascularized mucosa, eight distal radial forearm flaps and two fibula flaps were prelaminated. Prelamination was performed by exposing the vascularized fascia, onto which the split distal end of a sural graft was fixed. The fascia and the sural nerve graft were covered by device-meshed mucosa or small full-thickness mucosa pieces. These structures again were covered by a Silastic sheet as large as the future flap, and the wound was closed by the elevated skin and subcutaneous tissue. Coverage by a Silastic sheet enabled mucosal spreading on the fascia, and the final flaps were thin, mucus-producing, and larger than the originally inserted mucosa. The 10 neuromucosal prelaminated flaps were harvested together with the inserted sural nerve graft after 8 to 10 weeks. During this time, the patient underwent radiotherapy and chemotherapy. Donor sites were closed directly by the preserved skin and subcutaneous tissue. Intraoral defects were reconstructed successfully by eight neuromucosal prelaminated distal radial forearm flaps and two neuromucosal prelaminated fibula flaps. The sural nerve grafts, inserted between the fascia and the mucosa, were coaptated eight times with the lingual nerve and two times with the inferior alveolar nerve. Intended reinnervation of the mucosa could already be proved clinically and histologically in the first two patients after 11 and 9 months. Preservation of skin and subcutaneous tissue considerably lowered donor-site morbidity. Neuromucosal prelamination enables reconstruction of intraoral lining defects by reinnervated mucus-producing tissue. Reconstruction of other mucosa-lined structures by this method seems feasible. Avoidance of skin islands for reconstruction lowers donor-site morbidity.
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