SEARCH · PubMed Health
Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
This article presents a systematic approach to the reconstruction of scalp defects, which includes a review of the anatomy of the scalp as it pertains to reconstruction, and a discussion of the various reconstructive options for scalp defects, such as grafts and flaps. Further, scalp flap selection, design, and execution are outlined. Finally, adjunctive techniques of tissue expansion and hair transplants are included to enhance the final aesthetic result.
By means of an ultrasonic technique, skin thickness was measured in 13 women subjected to mammary reconstruction by tissue expansion. Measurements were performed the day before introduction of the expander, after the last inflation, the day before introduction of the permanent implant, and at 2 weeks and 6 months after this operation. Five patients had their expanders inflated every day (rapid expansion), and 8 patients, once a week (slow expansion). A decrease in skin thickness during the inflation period was recorded, and this decrease was permanent even 6 months after the second operation. After exchange of the expander for a permanent implant, there was a transient statistically significant increase in skin thickness. There was no statistical difference between the groups of rapid and slow expansion.
Infection of the expander pocket is the most common complication encountered with soft-tissue expansion. It is usually due to direct inoculation with skin flora either at the time of expander insertion or from extrusion of the device. The authors report two cases of infection of tissue expanders in which the children had concomitant infected sites distant from the prosthesis. Etiological bacteria of common pediatric infections like otitis media and pharyngitis were cultured from the infected expander pocket, raising suspicion that translocation of the organism to the expander had occurred. Aggressive antibiotic treatment, removal of the prosthesis, and flap advancement is advocated.
The use of tissue expanders in reconstructive surgery has become well established, but their use has been associated with multiple complications. Salvage of expanded tissue after traumatic extrusion of the prosthesis has not been previously reported. We have outlined the principles involved in the management of such a case, and reviewed previously reported complications of tissue expansion.
The need for major surgery involving bone and skin grafting procedures in the treatment of severe alveolar atrophy has, for many patients, been obviated by the advent of reliable endosseous implant systems. However, some patients, usually for medical, psychological, or financial reasons are unsuitable for endosseous implant therapy. In such patients, ridge augmentation with particulate hydroxyapatite may result in significantly improved denture function. However, hydroxyapatite tends to disseminate throughout any surgically created subperiosteal space, resulting in an undesirable ridge form. This problem may be overcome by the use of tissue expanders in a two-stage surgical procedure. This article briefly reviews the concept of tissue expansion and describes its application to the technique of alveolar ridge augmentation.
Local infection remains a significant complication of tissue expansion. Subclinical infection of pockets with permanent prosthesis used in breast reconstruction has also been associated with capsular contracture around the implant. In an in vitro model, we used four groups of eighteen 50-ml tissue expanders, each containing Bactrim, Ancef, Nafcil, or saline only, in beakers containing fresh frozen plasma, placed in a rotary shaker for 48 hours. Inoculums of Staphylococcus aureus and Staphylococcus epidermidis were then selectively added to the medium external to the expanders in each group. The growth of such strains was found to be variably inhibited. We thus determined that antibiotics can diffuse through a tissue expander's Silastic membrane and establish an efficient bacteriostatic level in the surrounding fluid. This information could have potential clinical application in reducing infections associated with the use of expanders.
Breast reconstruction is an option for women undergoing modified radical mastectomy due to a diagnosis of breast cancer. In certain patients, breast reconstruction is performed by insertion of a temporary tissue expander prior to the placement of permanent breast implants. Some of these patients, following mastectomy, may require chest wall irradiation to prevent loco regional relapse. The compatibility of radiation and tissue expanders placed in the chest wall is of major concern to the radiation oncologist. Clinically undetectable changes can occur in the tissue expander during the course of radiation therapy. This can lead to radiation treatment set-up changes, variation in tissue expansion resulting in unwanted cosmesis, and deviation from the prescribed radiation dose leading to over and/or under dosing of tumor burden. At Howard University hospital, a CT scan was utilized to evaluate the status of the temporary tissue expander during radiation treatment to enable us to prevent radiation treatment related complications resulting from dosimetric discrepancies. CT images of the tissue expander were obtained through the course of treatment. To avoid a 'geographic miss' the amount of fluid injected into the tissue expander was kept constant following patient's satisfaction with the size of the breast mound. The CT scans allowed better visualization of the prosthesis and its relation to the surrounding tumor bed. This technique ensured that anatomical changes occurring during radiation treatment, if any, were minimized. Repeated dosimetry evaluations showed no changes to the prescribed dose distribution. A CT of the reconstructed breast provides an important quality control. Further studies with greater number of patients are required for confirming this impact on radiation treatment.
The demolition-reconstruction sequence in patients suffering from breast cancer may, in selected cases, be reduced to two surgical steps alone without compromising the radical nature of the surgery or the aesthetic result. The technical details of a protocol realisable in a short time that proposes on the one hand classical radical mastectomy (according to Patey or Madden) and on the other reconstruction by tissue expansion are described.
OBJECTIVE: To investigate the application of breast reconstruction that permits the surgeon to expand and recruit sufficient tissue for modified radical mastectomy, skin-sparing mastectomy and asymmetry deformity. METHODS: Placement of round tissue expander in subpectoral position below. Overexpansion of tissue expander to match over 30% approximately 50% opposite breast. After 3 months, removal of tissue expander and replacement with permanent implant. RESULTS: Postoperative follow-up for 3 months to 2 years demonstrated satisfactory results in all the cases. CONCLUSIONS: The breast reconstruction with a subpectoral silicone tissue expander is an ideal treatment to modified radical mastectomy, skin-sparing mastectomy and asymmetry deformity. The women can obtain a restored breast to approximate a full opposite breast and avoids a major distant surgical intervention and additional scars. Tissue expansion should be cautiously used in cases of patients with irradiated chest skin.
Experience with the surgical management of cranio-orbital neurofibromatosis in 14 patients is reported (age range, 6-40 years). The skeletal abnormality of the orbit that occurs in a small proportion (less than 1%) of patients with neurofibromatosis is, in essence, the absence of the membranous portions of the sphenoid and the adjacent bone forming the boundaries between the cranium and the orbit. The goal of surgery is tumor resection and reconstruction of the posterior bony defect by bone graft. Two additional procedures are also described that better enhance aesthetically-the mask lift and facial tissue expansion.
The application of a mass produced antral balloon catheter for intraoperative tissue expansion in the head and neck is described. This balloon catheter has the advantage of being cheap and readily available.
The original consulting microsurgeon should be present to assist in the identification and protection of the vascular pedicle during secondary procedures on microvascular transplants. Flap elevation, trimming, and bone graft placement should be completed during a single tourniquet time, whenever possible. Flaps can easily be resutured on the original bed while the tourniquet is still inflated. Although proximal pedicle transection is possible, it should be avoided by careful planning, because the transplanted tissue cannot be predictably expected to survive, especially with muscle transplants. The distal muscle should be transected only in situations in which the muscle inset is extremely complex. Transection in the extramuscular portion of the main pedicle may require prompt microsurgical repair in immature muscle transplants. The safest approach is to avoid the pedicle whenever additional secondary procedures are necessary following free microvascular tissue transplantation. Placement of vascular pedicles such that the anterior crest of the tibia is avoided if the Ilizarov technique is required permit uncomplicated distraction osteosynthesis. Simultaneous Ilizarov fixation and microvascular tissue transfer are safe, practical procedures for limb salvage. Placement of the Ilizarov fixator at the time of microvascular transplantation provides stable fixation and eliminates the need for a subsequent anesthetic for fixator placement. This form of stabilization, when performed at the time of microvascular tissue transfer, allows the orthopedic surgeon direct visualization of the fracture site as the fixator is placed and eliminates the need for placement of the fixation device through the transplanted tissue. Tissue expansion or suction lipectomy are sometimes needed to optimize the clinical result.
Cutis aplasia congenita (CAC), a congenital absence of skin and its appendages, may extend into underlying muscles and bones. The scalp is the commonest site and it may be associated with acrania. CAC presents either as a thin transparent membrane, a black eschar, an ulcer or a healed scar. The dilemma of either immediate surgical management or conservative treatment is much more pronounced in the presence of acrania. Two patients with scalp lesions measuring 12 x 8 cm and 14 x 12 cm respectively and one patient with 4 cm wide circumferential trunk cutis aplasia treated conservatively are presented. The conservative treatment is simple, easy to carry out, and effective even for large defects; therefore, it is recommended in cutis aplasia congenita till complete healing. Surgical interventions such as tissue expansion and resurfacing, contracture release, etc. are for the correction of subsequent deformity at a later date.
The island flap based distally on the posterior interosseous artery has been proven to be available for the correction of severe cicatricial contracture deformity of the ipsilateral hand. However, the main disadvantages of this flap are the second donor area deformity and muscle or tendon adhesions after skin grafting. Both these complications may be ameliorated by means of tissue expansion to obtain a secure blood supply to the flap. The surgical procedure has been performed in 7 patients with satisfactory result since August 1989.
In a case with a large forehead defect following tight scalp bandaging in childhood, a prefabricated microvascular shoulder free flap was used for reconstruction. A free forearm fascial flap, with the radial artery and the concomitant vein as pedicle, was harvested and inserted under a subcutaneous pocket opened in the left shoulder region which served as the future "prefabricated free flap". In addition, a tissue expander was placed in this pocket to provide the necessary tissue expansion to enable primary donor site closure.
In a sample of 31 sedentary, ad libitum-fed monkeys, most specimens had less than 5% adipose tissue by weight. Total fatness correlated closely with the number of adipocytes per kilogram lean body mass, but not at all with mean adipocyte volume, except in specimens below 5% fat. The total number of adipocytes per kilogram of lean body mass increased more than tenfold in the most obese specimens. These data suggest that, like humans but in contrast to laboratory rodents, adipocyte proliferation, not adipocyte enlargement, is the chief mechanism of adipose tissue expansion except in very lean monkeys. Adipose tissue was found in all the typical mammalian depots and in the superficial abdominal paunch, which enlarged disproportionately in obese specimens, forming an almost continuous layer over most of the body. Site-specific differences in the activities of some glycolytic enzymes were similar to those of other mammals. Adipocytes in the paunch depot showed biochemical properties in common with those in the groin depots. The distribution and cellularity of adipose tissue in normal humans were similar to those of exceptionally obese monkeys. Many of the interspecific and sex differences can be attributed to the much greater abundance of adipose tissue in humans, and may not be associated with hair reduction or aquatic habits. Some minor changes in the size or shape of certain adipose depots may have arisen recently under sexual selection. The relevance of laboratory rodents as animal models of human obesity is assessed from comparison of the cellular structure, anatomical distribution and enzyme profiles of adipose tissue in monkeys with those of human and other mammals.
Over the past 40 years, surgical reconstruction of the breast following mastectomy has become an important aspect of the cancer patient's rehabilitation process. While the surgical emphasis remains on a cure for the cancer, experience with breast reconstruction has not demonstrated any increased rate of cancer recurrence, even when reconstruction is performed immediately following tumor resection. Advances in surgical technique and biotechnology have made post-mastectomy reconstruction possible. The development of silicone gel and saline-filled implants as well as tissue expanders has revolutionized breast reconstruction. The elucidation of musculocutaneous flaps now provides the surgeon with the ability to transfer adequate quantities of vascularized tissue to reconstruct the surgical defects. The advent of microsurgical techniques has provided an additional reconstructive option, with free tissue transfer allowing the plastic surgeon to move musculocutaneous flaps from remote or distant sites to reconstruct the defect. The option of having the reconstruction immediately following the mastectomy procedure is now available to the patient. When reviewing the anatomy of the breast region, the surgeon must consider the mammary gland, its vascular supply, and its lymphatic system. The surgical techniques involved in reconstruction after mastectomy include the use of breast implants and tissue expansion, as well as reconstruction with autogenous tissues. Reconstruction with autogenous tissues includes the use of latissimus dorsi musculocutaneous flap, transverse rectus abdominus musculocutaneous flap, free flap transfer, as well as nipple-areola reconstruction. Breast reconstruction after mastectomy should be undertaken by a plastic and reconstructive surgeon with considerable training and experience with these diversified procedures.
BACKGROUND: Multiple prior reports are conflicted regarding the true incidence of complications following implant-based breast reconstruction. A review of a single surgeon's extensive experience with tissue expander/implant reconstruction provides the opportunity to critically evaluate outcomes in a uniformly treated patient population. The objective of this study was to analyze the development of early complications in patients following two-stage implant breast reconstruction. METHODS: A review of all tissue expander/implant reconstructions performed by a single surgeon over the 12-year period from July of 1992 to June of 2004 was performed. A prospectively maintained database was analyzed with respect to reconstructive and early complication data on 1522 reconstructions in 1221 patients. Early complications were defined as those occurring 12 months or less from initiation of reconstruction. RESULTS: The overall rate of early complications was 5.8 percent; the rate of premature expander removal was 2.7 percent. The most common complication was infection (2.5 percent). The incidence of complications after tissue expander insertion (8.5 percent) was significantly higher than that after the exchange procedure (2.7 percent). The rate of complications was significantly higher in patients with a history of preoperative chest wall irradiation. There was no difference in the incidence of complications in patients who were expanded during chemotherapy and those who were not. CONCLUSIONS: Tissue expander/implant reconstruction is a safe, reliable method of reconstruction with minimal early complications. Early complications are more common after expander insertion. Chemotherapy administered during tissue expansion does not increase the rate of complications. The rate of complications, although higher in previously irradiated patients, remains low.