ObjectiveTo examine the incidence of local recurrence (LR) and factors associated with it in a population of patients who underwent skin-sparing mastectomy (SSM) and immediate reconstruction for invasive carcinoma. Summary Background DataThe efficacy of SSM has been challenged by concerns about increased risks of LR. MethodsA consecutive series of 173 patients (176 cancers) with invasive carcinoma underwent SSM and immediate breast reconstruction (June 1986 to December 1997). Data were analyzed by the Kaplan-Meier method, the log-rank statistic test, and the Cox proportional hazards model. ResultsMean patient age was 47 Ϯ 9 years (27% were 40 or younger). The AJCC stages were 1 ϭ 43%, 2 ϭ 52%, and 3 ϭ 5%.Thirty percent of tumors were poorly differentiated. With a median follow-up of 73 months, the LR rate was 4.5%. The mean local relapse-free interval was 26 months. Seventy-five percent of patients who presented with LR developed distant metastases and died of disease within a mean of 21 months. On univariate analysis, factors associated with higher LR rate were tumor stage 2 or 3, tumor size larger than 2 cm, nodepositive disease, and poor tumor differentiation. Actuarial 1-, 3-, and 5-year overall survival rates were 98%, 94%, and 88%, respectively. On multivariate analysis, factors associated with decreased survival were advanced stage, presence of LR, and absence of hormone therapy. LR was a highly significant predictor of tumor-related death. ConclusionsThere is a low incidence of LR after SSM, and it is associated with advanced disease at presentation. LR is an independent risk factor for tumor-related death.Skin-sparing mastectomy (SSM) has been advocated as an oncologically safe approach for the management of patients with early-stage breast cancer. This operation also minimizes deformity and improves cosmesis through preservation of the skin envelope of the breast.1-5 Chest wall skin is a common site of local failure after mastectomy, and the incidence of this event after SSM has been reported to be 0% 5 to 7%. 6 Although the results of SSM have been analyzed in previous reports, many of these series included patients with invasive and noninvasive breast cancer with variable lengths of follow-up. The objective of this study was to examine survival rates, incidence of local recurrence (LR), and factors associated with it in a population of patients who underwent SSM and immediate breast reconstruction for invasive breast cancer at a single institution. METHODSA retrospective review was performed of patients who underwent SSM and immediate breast reconstruction from Correspondence: Marshall M.

From 1985 to 1995, a total of 311 patients underwent nasoplasties. During this time period, the number of patients receiving grafts increased from 94 percent in 1985-1989 to 100 percent in 1993-1995. The donor grafts averaged 72 percent nasal cartilage, 10 percent conchal cartilage, 9 percent fascia, and 9 percent rib allograft. Graft recipient sites averaged 41 percent in the tip, 31 percent in the dorsum, 17 percent in the columella, and 3 percent in the region of the lower lateral cartilage; 8 percent were spreader grafts. During this time frame, tip grafting increased from 34 percent in 1985-1989 to 54 percent in 1993-1995. Reoperation for complications decreased from 17 percent in 1985-1989 to 2 percent in 1993-1995. During the time span examined, the use of rib allografts declined, the use of autologous cartilage increased, the use of onlay tip grafts increased, and the incidence of reoperations declined. Early in the series, 80 percent of the malplaced tips were shield type grafts. With the use of the onlay tip graft, the complication of a malpositioned tip has been substantially diminished. The increased use of crushed cartilage has resulted in improvement in results and patient satisfaction, as it serves to camouflage slight irregularities in the tip and dorsum of the nose.

Muscle sparing and perforator flaps techniques for breast reconstruction have focused in reducing the donor site morbidity. Theoretically this may result in a less robust blood supply to the flap. The purpose of this study was to assess flap ischemic complications with the pedicle, free, and the different muscle sparing transverse rectus abdominis myocutaneous (TRAMs) flaps for breast reconstruction and determine the factors associated with these complications. A total of 301 consecutive patients that underwent 399 breast reconstructions were retrospectively reviewed. Patient, oncologic, and reconstruction data were recorded. A flap ischemic complication scale was design including: wound healing problems, skin flap necrosis, fat necrosis, partial flap loss, and total flap loss. Analysis of donor site complications, bilateral and unilateral reconstructions were also performed. There were 147 pedicle TRAM and 154 free TRAM with the following subgroup distribution: MS-0 = 102; MS-1 = 37; and MS-2 = 15 patients. The groups were comparable in relation to age, comorbidities, cancer stage, and treatment. The overall complication rate after reconstruction had no statistical differences between the groups. The variables related to flap ischemia were statistically lower in the free TRAM. Mild and severe fat necrosis were the indicators with a statistical difference. The MS-0 group had lower ischemic complications and fat necrosis than the pedicled group, but no differences were observed for the MS-1 and MS-2 groups. The same results were seen in the unilateral reconstructions but not in the bilateral ones. No differences in donor site bulging or hernia were observed between the groups. In our study, the free TRAM flap demonstrated lower ischemic complications than the pedicle TRAM. A trend for decreased flap blood supply when more muscle is preserved and less number of perforators are used with a constant tissue volume was observed.

The midface is an area where definite and consistent improvement is still hard to achieve. Vertical suspension of the malar fat pad is an effective midface lift that complements facial rejuvenation to obtain an overall appearance of youth and beauty while maintaining the personal features of the patient. To substantiate its effectiveness, the authors evaluated the complications and long-term results of the malar fat pad elevation proper and in conjunction with other facial procedures. A retrospective review of the medical records of 458 consecutive patients who underwent malar fat pad elevation by the senior author (B.C.D.) from January of 1994 to January of 2000 was conducted. Because 14 patients had their malar fat pad re-elevated, the number of midface lifts totaled 472. Of these, 437 had a combined superficial musculoaponeurotic system excision and tightening, 19 had a combined limited superficial musculoaponeurotic system plication/imbrication, and 16 had elevation of the malar fat pad only. Elevating the malar fat pad appears to be a sound, straightforward, and effective means of rendering a youthful midface. It consistently reshapes the malar eminence, softens the nasolabial fold, and rejuvenates the lower eyelid. This technique provides lasting results, with an acceptable complication rate. Facial nerve injury, in particular, was infrequent and temporary. In addition, the prehairline scar happened to be quite inconspicuous, especially in patients older than 55 years. This experience confirms that malar fat pad elevation is a safe and effective method to rejuvenate the central third of the face.

Superficial inferior epigastric artery (SIEA) flap breast reconstruction has advantages over deep inferior epigastric perforator flap (DIEP) and muscle sparing transverse rectus abdominus myocutaneous flap (TRAM) reconstructions with less donor site morbidity and less complicated flap dissection. Not all patients have an adequate SIEA and superficial inferior epigastric vein (SIEV) to support free tissue breast reconstruction, and dissection of the SIEA in all patients can be time consuming. Preoperative computed tomography (CT) angiograms can be used to identify the SIEA and SIEV in patients planning to undergo free abdominal tissue breast reconstruction and direct more efficient dissection in patients with a large SIEA. Retrospective analysis of free abdominal tissue flap breast reconstruction from a single plastic surgeon was performed. All patients undergoing free abdominal tissue breast reconstruction had a preoperative CT angiogram using a protocol for the evaluation of the abdominal wall perforating arteries. CT scans were reviewed by the surgeon preoperatively and evaluated for the presence, caliber, and image quality of the SIEA and SIEV. All patients, regardless of CT angiogram findings, had operative dissection and evaluation of the SIEA and SIEV. A total of 177 free flaps were performed on 113 patients who underwent preoperative CT angiogram and free abdominal tissue breast reconstruction. Of them, 64 patients had bilateral breast reconstruction. Twelve SIEA flaps (10.6%) were performed on 12 patients. During preoperative CT angiographic evaluation, 49 patients (43%) were noted to have at least one visible SIEA, whereas only 24 of those patients (21%) were felt to have an SIEA of adequate caliber. No flaps were lost during the postoperative period. All 12 SIEA flaps performed had an adequate SIEA when observed on preoperative CT angiogram. Overall, 50% of patients found to have at least one adequate SIEA on CT angiogram had a single breast reconstructed with an SIEA flap. If the SIEA was not visualized on CT angiogram, no usable SIEA was found during surgery. Preoperative CT angiogram of the abdominal wall perforating arteries can help predict which patients may have adequate anatomy for an SIEA-based free flap. This information may help direct more efficient dissection of the abdominal flaps by selecting out patients who do not have an adequate SIEA.

Endoscopy has provided a significant improvement in the surgical rejuvenation of the upper face. It offers a minimally invasive alternative that avoids many of the undesirable effects associated with the coronal approach. The standard minimal access forehead endoscopic procedure consists of a subperiosteal undermining through three small triangular prehairline incisions. To successfully elevate the eyebrows, it is essential to release the periosteum at the level of the supraorbital rims and ablate the brow depressor muscles of the glabella. Until the periosteum reattaches itself, elevation is maintained by a temporary suspension suture between staples at the incision sites and 5 cm posterior to the hairline. The transverse closure of the triangular skin incisions achieves some additional elevation. The biplanar approach adds a partial subcutaneous undermining of the forehead to the endoscopic technique and allows plication of the frontalis muscle and excision of excess forehead skin. It is offered to patients with very ptotic eyebrows, deep transverse wrinkles, or a high forehead. The prehairline incision is a disadvantage but is tolerated quite well in older patients. The medical records of 393 consecutive patients who underwent endoscopic forehead lift from 1994 to 2000 were reviewed. Because seven patients had the endoscopic forehead lift repeated, the number of forehead endoscopies totaled 400. The complication rate was quite acceptable and did not markedly increase when a forehead lift was performed in combination with other facial procedures. The endoscopic forehead lift consistently attenuated the transverse forehead wrinkles, reduced the glabellar frown lines, and raised the eyebrows. It provided an appearance that was less tired and angry in addition to opening the area around the eyes. Long-term follow-up has shown that the endoscopic forehead lift produces lasting and predictable results.

Endoscopy has provided a significant improvement in the surgical rejuvenation of the upper face. It offers a minimally invasive alternative that avoids many of the undesirable effects associated with the coronal approach. The standard minimal access forehead endoscopic procedure consists of a subperiosteal undermining through three small triangular prehairline incisions. To successfully elevate the eyebrows, it is essential to release the periosteum at the level of the supraorbital rims and ablate the brow depressor muscles of the glabella. Until the periosteum reattaches itself, elevation is maintained by a temporary suspension suture between staples at the incision sites and 5 cm posterior to the hairline. The transverse closure of the triangular skin incisions achieves some additional elevation. The biplanar approach adds a partial subcutaneous undermining of the forehead to the endoscopic technique and allows plication of the frontalis muscle and excision of excess forehead skin. It is offered to patients with very ptotic eyebrows, deep transverse wrinkles, or a high forehead. The prehairline incision is a disadvantage but is tolerated quite well in older patients. The medical records of 393 consecutive patients who underwent endoscopic forehead lift from 1994 to 2000 were reviewed. Because seven patients had the endoscopic forehead lift repeated, the number of forehead endoscopies totaled 400. The complication rate was quite acceptable and did not markedly increase when a forehead lift was performed in combination with other facial procedures. The endoscopic forehead lift consistently attenuated the transverse forehead wrinkles, reduced the glabellar frown lines, and raised the eyebrows. It provided an appearance that was less tired and angry in addition to opening the area around the eyes. Long-term follow-up has shown that the endoscopic forehead lift produces lasting and predictable results.

The objectives of abdominal hernial repair are to reconstruct the structural integrity of the abdominal wall while minimizing morbidity. Current techniques include primary closure, staged repair, and the use of prosthetic materials. Techniques for abdominoplasty include the use of the transverse lower abdominal incision and the resection of excess skin. By incorporating these aspects into hernial repairs, the procedures are made safer and the results are improved. The medical records were reviewed of 123 consecutive patients who underwent hernial repair. Seventy-six of these patients underwent a total of 82 herniorrhaphies using an abdominoplasty approach. This included using a transverse lower abdominal incision with or without extending it into an inverted-T incision. The hernial defect was then identified and isolated. Repair was obtained with primary fascial closure and plication, primary fascial approximation and reinforcement with absorbable Vicryl mesh, or placement of permanent mesh with or without fascial approximation. Overall, 8 of 82 hernias recurred. Most complications were minor and could be managed with local wound care only. Major complications included one enterocutaneous fistula, one occurrence of skin flap necrosis requiring operative debridement and skin grafting, and one delayed permanent mesh extrusion 2 years after repair. The abdominoplasty approach isolates the incision from the hernial defect and repair. This technique is safe with a low risk of complications and a low rate of recurrence. It is particularly helpful in obese patients, in patients with multiple hernias, and in those patients with recurrent hernias.