Although preservation of the sensitivity of the nipple and areola is an important goal in breast surgery, only scant and contradictory information about the course and distribution of the supplying nerves is found in the literature. The existing controversy might be due to the difficulty in dissecting the thin nerves and to frequent anatomic variations that bias the results if only a small number of cadavers are dissected. We dissected 28 female cadavers and found that the nipple and areola were always innervated by the lateral and anterior cutaneous branches of the 3rd, 4th, and 5th intercostal nerves. The most constant innervation pattern was by the 4th lateral cutaneous branch (79 percent) and by the 3rd and 4th anterior cutaneous branches (57 percent). The anterior cutaneous branches took a superficial course within the subcutaneous tissue and terminated at the medial areolar border in all dissected breasts. The lateral cutaneous branches took a deep course within the pectoral fascia and reached the nipple from its posterior surface in 93 percent of the dissected breasts. In 7 percent of the dissected breasts, the lateral cutaneous branches took a superficial course within the subcutaneous fat and reached the nipple from the lateral side. These findings suggest that the nerves innervating the nipple and areola are best protected if resections at the base of the breast and skin incisions at the medial areolar border are avoided.
Less than 1 percent of the women interested in having larger breasts elect to have surgical augmentation mammaplasty with insertion of breast implants. The purpose of this report is to describe and test the efficacy of a nonsurgical method for breast enlargement that is based on the ability of tissues to grow when subjected to controlled distractive mechanical forces. Seventeen healthy women (aged 18 to 40 years) who were motivated to achieve breast enlargement were enrolled in a single-group study. The participants were asked to wear a brassiere-like system that applies a 20-mmHg vacuum distraction force to each breast for 10 to 12 hours/day over a 10-week period. Breast size was measured by three separate methods at regular intervals during and after treatment. Breast tissue water density and architecture were visualized before and after treatment by magnetic resonance imaging scans obtained in the same phase of the menstrual cycle. Twelve subjects completed the study; five withdrawals occurred due to protocol noncompliance. Breast size increased in all women over the 10-week treatment course and peaked at week 10 (final treatment); the average increase per woman was 98 +/- 67 percent over starting size. Partial recoil was seen in the first week after terminating treatment, with no significant further size reduction after up to 30 weeks of follow-up. The stable long-term increase in breast size was 55 percent (range, 15 to 115 percent). Magnetic resonance images showed no edema and confirmed the proportionate enlargement of both adipose and fibroglandular tissue components. A statistically significant decrease in body weight occurred during the course of the study, and scores on the self-esteem questionnaire improved significantly. All participants were very pleased with the outcome and reported that the device was comfortable to wear. No adverse events were recorded during the use of the device or after treatment. We conclude that true breast enlargement can be achieved with the daily use of an appropriately designed external expansion system. This nonsurgical and noninvasive alternative for breast enlargement is effective and well tolerated.
Although the posterior cruciate ligament (PCL) is not frequently injured, a greater understanding of its role in stabilizing the knee joint, mechanism of injury and treatment has developed. Isolated avulsion injuries constitute only a subgroup of PCL injuries, but nevertheless several operative techniques have been described for the fixation of the avulsed bony fragment. In order to investigate whether K-wire or screw fixation yields better long-term results, we examined 26 patients at an average of 10.5 years after the initial operation. Clinical examination, activity level, radiographic evaluation and instrumented measurements did not reveal any significant differences. All the patients had an excellent functional result. Thus, both K-wire and screw fixation are recommended for bony PCL avulsion injuries.
W omen requesting reduction mammaplasty are generally more concerned with the improvement of the size and shape of their breasts than with the preservation of mammary sensation. Even after surgery, if not specifically asked, many patients do not mention changes in the sensitivity of the nipple and areola. The improved appearance of the breasts causes a positive change in body image 1-5 and makes the patients feel more sensual, 2,6,7 irrespective of the actual breast sensation. 6 It is therefore not surprising that, in the past, plastic surgeons who described reduction techniques have focused more on breast shape, scar length, and scar position than on preservation of sensation. Esthetic aspects and sensuality were considered more important than nerve supply and sexuality. Only during the last years has attention been directed toward the preservation of the nerves supplying the breast. The influence of surgery on the sensitivity of the nipple-areola complex, and hence on sexuality, is increasingly regarded as a criterion in the evaluation of reduction mammaplasty techniques. 8 -16 Recent studies have significantly added to our knowledge of the normal function and anatomy of the sensory nerves and helped to identify the factors which influence the preservation of sensation during breast reduction surgery.
Numerous reports have discussed the use of the external oblique abdominal muscle as a pedicled or a free flap for defect coverage. A detailed description of the supplying vessels and nerves is a prerequisite for successful tissue transfer but so far is not available in the literature. A study of the arteries and nerves supplying the external oblique abdominal muscle was carried out in 42 cadavers after injection of a mixture of latex and bariumsulfate. In seven fresh cadavers the motor branches were identified with the Karnovsky technique. Three different groups of arteries were identified as the nurturing vessels. The cranial part of the muscle is supplied by two branches of the intercostal arteries. While the lateral branches run on the outer surface of the muscle together with the nerves, the anterior branches enter the muscle from its inner surface. The caudal part of the muscle derives its main blood supply from one or two branches of the deep circumflex iliac artery (94.7%) or the iliolumbar artery (5.3%). The external oblique abdominal muscle is innervated by motor branches of the lateral cutaneous branches of the anterior spinal nerves in a segmental pattern. With the exception of the subcostal nerve the motor branches enter the outer surface of the muscle digitation arising from the rib above. The results show that the cranial half of the external oblique abdominal muscle has a strictly segmental blood and nerve supply while the caudal half of the muscle derives its main blood supply from one artery but still shows a segmental innervation.
Long-term breast enlargement without surgery is possible with an external tissue expander. The more it is used, the more the breasts grow. To avoid disappointments and drop-outs, women have to be well informed about the time and lifestyle commitment.
Ideal reconstructions of complex defects in the midface require the restitution not only of bone and soft tissue, but also of a thin and durable lining of the oral cavity. So far, split-thickness skin grafts, intestinal grafts, and in vitro cultured mucosal grafts have been used for the reconstruction of the oral lining. The use of skin as a substitute for oral mucosa is controversial because contraction, hair growth, maceration, and dysplastic changes can occur. This clinical and histologic study was performed to evaluate the suitability of dermis as a substitute for oral lining. Twelve complex defects of the midface were reconstructed with dermis-prelaminated scapula flaps. A bony flap from the lateral border of the scapula was prepared, and osseointegrated implants were placed. The bone flap was then prelaminated with dermis and covered with a Gore-Tex membrane to prevent adhesions. The composite flap was transferred to the midface 2 to 3 months later. The oral lining of the flap was evaluated clinically and histologically at 2, 4, and 6 weeks and at 3 to 41 months after the reconstruction. In all patients, the reconstructed bone was covered with a thin and lubricated surface without hair growth. None of the patients showed any signs of maceration. Histologically, these findings corresponded to a keratinized stratified squamous epithelium with highly developed connective-tissue papillae. These features closely resemble those of the normal mucosa of the hard palate and the gingiva. Thus, dermis prelamination is an effective method for reconstructing the mucosa of the alveolar ridge and the hard palate.
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