Proteus syndrome: three case reports with a review of the literature

Proteus syndrome (PS) is a rare, progressive disorder that manifests as asymmetric, disproportionate overgrowth affecting tissues derived from any germline layer. Cases of PS from 2005-2010 were retrieved from the pathology files at our institution. Two confirmed cases and one possible case of PS were identified. All patients came from different ethnic backgrounds. Patient 1 displayed classic skin and overgrowth lesions. Patient 2 displayed various features, particularly vascular malformations. Patient 3 demonstrated a cerebriform connective tissue nevus alone. These patients demonstrate the spectrum of presentations of PS. Much is left to learn about this disfiguring disease.

A reconstructive algorithm for plastic surgery following extensive chest wall resection

Chest wall reconstruction following extensive resection is greatly facilitated by the use of vascularised flaps and prosthetic material. Plastic surgeons are often asked to assist with coverage of large chest wall defects. However, in addition to soft tissue coverage, we need to address other important issues such as the status of the pleural cavity, and the requirement for skeletal support. The purpose of this report is to analyse our experience, provide a reconstructive algorithm following the ablative procedure and review the literature. Two hundred chest wall resections were performed from 1975 to 2000. Defect location was divided into anterior (n = 73) lateral (n = 36) anterior-lateral (n = 36) posterior-lateral (n = 19) posterior (n = 22) and forequarter (n = 14) Average number of ribs resected was four. One hundred and fifty-eight patients (79%) required chest wall reconstruction with either prosthetic material and/or flap closure. Mesh closure was required in 85 cases (43%), being highest for lateral defects (61%), and lowest for anterior defects (31%). Vascularised flaps were needed in 112 patients (56%), more common in anterior defects (79%), and less common for the posterior-lateral defects (26%). Inpatient complication rate was 27% (43/158) following reconstruction, with a mortality of 6% (10/158). Chest wall reconstruction is common following extensive resection. This includes management of the pleural cavity, skeletal support and soft tissue coverage. A better understanding of the respiratory mechanics and local thoracoabdominal anatomy is crucial for managing these complex defects. The need for skeletal support was more prevalent in lateral and posterior-lateral defects. Flap reconstruction was required more often to cover large anterior defects, with regional flaps predominating.

Factors That Influence the Completion of Breast Reconstruction

Post mastectomy breast reconstruction continues to evolve in both timing and technique; however, multiple surgical procedures are usually required. The purpose of this report was to determine the number of secondary procedures required to complete the breast reconstruction and factors that influence this process. All patients who underwent breast reconstruction at Emory University Hospital between 1975 and 2000 were reviewed. The end point and inclusion criterion was completion to nipple reconstruction. Secondary procedures were determined per patient for either unilateral or bilateral reconstructions, and defined as any surgical manipulation of the reconstructed breast, contralateral breast, or donor site. The cohort was stratified by timing and method of reconstruction. Additional variables included risk factors, radiation therapy, and complications. A total of 888 patients completed the reconstructive process (738 unilateral and 150 bilateral). The average number of secondary procedures was 3.99 for unilateral, and 5.54 for bilateral. Delayed reconstructions had a higher number of secondary procedures in both groups. Transverse rectus abdominus musculocutaneous flap reconstruction tended to have more secondary procedures than implant or latissimus dorsi with or without implant reconstructions. Radiation therapy increased the number of secondary procedures in unilateral (3.9 versus 4.6, P < 0.001) and in bilateral reconstructions (5.7 versus 6.4, P = 0.032). The number of secondary procedures also increased exponentially with the number of risk factors (0-4), and patients with any complication had a higher number of secondary procedures for unilateral (4.5 versus 3.6, P < 0.001) and bilateral reconstructions (6.4 versus 4.5, P < 0.001). Secondary breast and donor site procedures were used as an outcome measure to formulate comparisons. Autologous tissue reconstruction required more secondary procedures, likely in part to donor site revisions. Delayed reconstruction, the need for radiation therapy, any complication, and more risk factors significantly increased the number of secondary procedures required to complete the reconstructive process.

Importance of right subcostal incisions in patients undergoing TRAM flap breast reconstruction

The presence of a preexisting subcostal incision alters the approach to breast reconstruction and is thought to predispose to donor site skin complications and flap loss. The purpose of this study was to determine whether the presence of a subcostal scar affects breast or donor site morbidity adversely after transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. Twenty-six patients with a right subcostal incision (group A) underwent TRAM flap breast reconstruction (13 immediate, 13 delayed). The average age was 51 years, and the patients had an average body mass index of 25.3. There were 15 right, 10 left, and 1 bilateral reconstruction (4 free flaps, 22 pedicled). Outcome measures were compared with 126 age- and risk-matched patients (group B) who underwent TRAM flap reconstruction without any preexisting abdominal scar. The average age in group B was 46.7 years, and the patients had an average body mass index of 24.8. The average length of stay in group A was 5.9 days, compared with 4.8 days in group B ( < 0.05). There were no significant differences in breast-related complications. Donor site complications were higher in group A, with abdominal wall skin necrosis being significantly higher in patients with a subcostal incision (25%) compared with those patients without abdominal wall scars (5%; = 0.02). Multivariate analysis revealed a 6.5-fold increase in donor site complications in patients with a subcostal incision and a smoking history ( < 0.05). When adjusted for radiation treatment, the increased incidence in donor site complication rate was only marginally significant ( = 0.08). TRAM flap breast reconstruction in patients with preexisting right subcostal scars is effective with certain technical modifications; however, there is a slight predisposition to increased abdominal wall complications. Smoking influenced outcome further in patients with a subcostal incision, stressing the importance of proper patient selection.

Trends in unilateral breast reconstruction and management of the contralateral breast: the Emory experience

Recent trends in breast reconstruction have transitioned toward the skin-sparing type of mastectomy and immediate reconstruction using autologous tissue. This study was designed to document trends in the management of patients with unilateral breast cancer and to determine how they influence management of the contralateral breast. All patients who underwent unilateral breast reconstruction at Emory University Hospitals from January of 1975 to December of 1999 were reviewed. The cohort was stratified by timing of reconstruction (immediate versus delayed), method of reconstruction, and mastectomy type (skin-sparing versus non-skin-sparing). The methods of reconstruction included implant, latissimus dorsi flap, and transverse rectus abdominis musculocutaneous (TRAM) flap. Contralateral procedures to achieve symmetry included augmentation, mastopexy, augmentation/mastopexy, and reduction. A total of 1394 patients were evaluated, including 689 delayed and 705 immediate reconstructions. Sixty-seven percent of delayed-reconstruction patients (462 of 689) had a symmetry procedure performed on the opposite breast, compared with 22 percent for the immediate-reconstruction patients (155 of 705) (p </= 0.001). The percentage of times a contralateral procedure was performed was highest for implant reconstructions (89 percent delayed and 57 percent immediate) and lowest for TRAM flap reconstructions (59 percent delayed and 18 percent immediate). Augmentation mammaplasty was the most common symmetry procedure for implant reconstruction (41 percent), whereas reduction was the most common procedure for autologous tissue reconstruction (57 percent). Immediate unilateral breast reconstructions were stratified into non-skin-sparing mastectomy (n = 205) and skin-sparing mastectomy (n = 500). Thirty-four percent of patients with a non-skin-sparing mastectomy defect (70 of 205) underwent a contralateral breast procedure, compared with 17 percent of patients with a skin-sparing mastectomy defect (85 of 500) (p = 0.001). The percentage of times a contralateral procedure was performed in immediate reconstruction, stratified by mastectomy and reconstruction type, was only significant for TRAM flap reconstructions (25 versus 11 percent). Trends in the management of unilateral breast cancer from delayed to immediate reconstruction and from implants to autologous tissue have reduced the incidence of contralateral symmetry procedures. Reduction mammaplasty is the most common symmetry procedure used for autologous tissue reconstruction, with augmentation predominating when implants are used. The type of mastectomy also effects the management of the opposite breast, with skin-sparing mastectomy further reducing the incidence of contralateral procedures in immediate TRAM flap reconstruction, compared with non-skin-sparing mastectomy.

Significance of intraabdominal compartment pressures following TRAM flap breast reconstruction and the correlation of results

Abdominal wall closure after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction is often performed under considerable tension and may theoretically cause a component of abdominal compartment syndrome. This prospective study examined intraabdominal pressure after TRAM reconstruction and correlated the findings with clinical course and outcome. All patients who underwent pedicled TRAM flap breast reconstruction from November of 1999 to December of 2000 (n = 77) were included and compared with nonoperative controls (n = 24). Intraabdominal pressures were measured indirectly using the urinary catheter in the postanesthesia care unit on postoperative days 1 and 2. Outcome measures included vital signs, urinary output, net 24-degree fluid balance, and complications. The preoperative variables were age, body mass index, parity, and presence of an epidural. For statistical analysis, the TRAM patients were divided into three groups on the basis of type of closure (bipedicle, unipedicle, and mesh), which were compared by analysis of variance. A multivariate logistic regression was performed to identify risk factors for patients with intraabdominal pressures > or =20 mmHg who were thought to have a component of abdominal compartment syndrome. The incidence of complications was compared by chi-square, with statistical significance determined for p < 0.05. Average intraabdominal pressures were significantly higher in the bipedicled TRAM (14.1 mmHg) and unipedicle TRAM (9.9 mmHg) groups when compared with the mesh group (5 mmHg) and controls (3.7 mmHg; p < 0.001). Increased intraabdominal pressure was transient and peaked on postoperative day 1. Elevated pressure was associated with decreased urinary output, decreased net fluid balance, and increased respiratory rate. Patients with intraabdominal pressures > or =20 mmHg (n = 10) had a higher incidence of complications (60 percent) compared with patients who had pressures <20 mmHg (18 percent; p < 0.05). Elevated intraabdominal pressures were strongly associated with donor-site and general complications. Positive predictive factors for elevated pressure included body mass index and type of closure (bipedicled or bilateral). Multiple pregnancies seemed to have a protective effect.A transient component of abdominal compartment syndrome does exist after TRAM flap breast reconstruction. Bipedicle closure, nulliparous women, and increased body mass index were risk factors for elevated intraabdominal pressures. Tension-free mesh closure seemed to have a protective effect. Symptomatic trends and certain complications were associated with, and possibly explained by, an elevated intraabdominal pressure.

Omental free flap reconstruction in complex head and neck deformities

BACKGROUND

Microvascular free flaps continue to revolutionize coverage options in head and neck reconstruction. This article reviews our 25-year experience with omental free tissue transfers.

METHODS

All patients who underwent free omental transfer to the head and neck region were reviewed.

RESULTS

Fifty-five patients were included with omental transfers to the scalp (25%), craniofacial (62%), and neck (13%) region. Indications were tumor resections, burn wound, hemifacial atrophy, trauma, and moyamoya disease. Average follow-up was 3.1 years (range, 2 months-13 years). Donor site morbidities included abdominal wound infection, gastric outlet obstruction, and postoperative bleeding. Recipient site morbidities included partial flap loss in four patients (7%) total flap loss in two patients (3.6%), and three hematomas.

CONCLUSIONS

The omental free flap has acceptable abdominal morbidity and provides sufficient soft tissue coverage with a 96.4% survival. The thickness \and versatility of omentum provide sufficient contour molding for craniofacial reconstruction. It is an attractive alternative for reconstruction of large scalp defects and badly irradiated tissue.

Thoracic reconstruction with the omentum: indications, complications, and results

This study provides a retrospective analysis of 60 patients who underwent thoracic reconstruction with the omentum. Patients were identified by searching several databases to determine demographics, indications for surgery, operative technique, and postoperative course, including donor and recipient site morbidity. From January 1975 to May 2000, the authors harvested and transferred the omentum successfully (57 pedicled, 3 free) in 60 patients (mean age, 60 years; age range, 21-86 years) for sternal wound infections (N = 34), chest wall resections (N = 17), pectus deformities (N = 2), intrathoracic defects (N = 4), and breast reconstruction (N = 3). The omentum was used as a primary flap in 39 patients and as a salvage flap in 21 patients. Average operative time was 3.9 hours and average hospital stay was 34.3 days. Partial flap loss occurred in 7 patients, with no total flap failures. Morbidity included six abdominal wound infections and seven epigastric hernias. Mortality was 11.7%. The omentum can be harvested safely and used reliably to reconstruct varying thoracic wounds and defects. Specific indications from this series include osteoradionecrosis, chest wall tumors, massive sternal wounds, and refractory mediastinitis. Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: indications, complications, and results.

Forehead reconstruction with a modified radial forearm flap: a case report

Forehead reconstruction, using a radial forearm flap with opposing long arterial and venous pedicles, is presented. Advantages of this flap design are discussed.

The reverse lateral upper arm flap for elbow coverage

Closure of soft tissue defects in the vicinity of the elbow has been attempted by numerous methods. The reverse lateral upper arm flap was conceived by applying concepts of previous work. Cadaver studies demonstrated the cutaneous territory and vascular anatomy of this region. The nature of the posterior recurrent radial artery and its perforators allows this fasciocutaneous flap to be perfused in a retrograde fashion. The flap can be used for covering various soft tissue defects around the elbow in a single stage with acceptable donor site morbidity. A case is presented in which the flap was used in a reverse flow fashion to cover an 8 X 11 cm acute cubital defect present after soft tissue release. Operative technique is discussed.

A dermal-fat flap for nipple reconstruction

A refinement in technique for nipple reconstruction utilizing local tissue is described. The operation has been performed on 31 patients who have previously undergone the transverse abdominal island flap breast reconstruction. The longest follow-up is 12 months. Preliminary results appear excellent with desired nipple size and projection.