Giant lipoma of the breast

Lipomas of the breast are usually small, benign neoplasms which can be treated by simple excision. Diagnosis of these masses, however, can be difficult because of the normal fatty composition of the breast. A number of radiological manoeuvres have been described for diagnosing deep lipomas in the breast, yet the clinical and radiographic identification of these masses remains challenging. We present a case of giant lipoma of the breast which was not appreciated on initial clinical and radiographic evaluation, and which was later found to comprise most of the mass of the breast. Following resection, the deformed breast was reconstructed using folded dermoglandular flaps from the areas expanded by the lipoma with excellent results. This case is an excellent illustration of the difficulties associated with diagnosis of these tumours and the reconstructive options available following excision.

Rotating shaft avulsion amputations of the thumb

In a three-year period twenty-nine patients were treated for rotating shaft avulsion amputations of the thumb. Twenty-three thumbs were considered suitable for replantation. A staged approach, consisting of primary replantation and secondary nerve grafting and tendon reconstruction, was used because of concern that survival rates would be low. Survival was achieved in nineteen of twenty-three replantations. At mean follow-up of 20.5 months grip strength was 94.6% of the unaffected side and key pinch was 77.1%. Five patients achieved a two-point discrimination less than five millimeters. Success was better anticipated and now a full reconstruction is carried out in a single-stage procedure.

Functional restoration in the upper extremity using free muscle transplantation

Since 1973, fourteen free muscle transfers for functional upper limb reconstruction have been performed in twelve patients at the Ralph K. Davies Medical Center in San Francisco. All of the patients in this series had lost finger flexion, extension, and/or thumb opposition and were not candidates for simpler methods of reconstruction because of weakness or traumatic loss of balancing musculature. The 12 patients have been followed for one to 9 years. All muscles were successfully transferred without flap loss. Evaluation of the EMG data has shown evidence of reinnervation beginning at approximately two months with fibrillation potentials decreasing and recruitment of increasing numbers of motor units over two to three years. Eleven of the 14 muscles attained movement against resistance; two had movement against gravity and one regained only a flicker of motion. In our experience, the use of free muscle transplantation to restore function is not only technically feasible, but moreover, has resulted in a relatively high degree of patient satisfaction.