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Breast reconstruction after mastectomy for malignant breast disease is a viable option that should be offered to all women undergoing mastectomy. Reconstruction can be done either at the time of the mastectomy or at any convenient time in the postoperative period when the oncologic care givers and the patient feel comfortable with the decision. Reconstruction of the breast will not interfere with either further therapy or the detection of recurrent tumor. Today more and more women who are fully informed about reconstruction opt for the treatment. No contraindications to reconstructive surgery arise for the properly selected patient.

This article presents the tissue expansion technique for the treatment of the tuberous breast and its variant, the tubular breast. The treatment objectives are different in the two deformities, but, in general, one has to expand the base circumference of the breast, expand the skin of the lower hemisphere of the breast, release the skin tightness at the skin-areola juncture, lower the position of the inframammary fold, increase the volume of the breast skin envelope, reduce the size of the areola and correct its deformity, and perform a mastopexy when necessary. To achieve these objectives, we use a tissue expander introduced either beneath the breast or beneath the pectoral muscle through an incision along the inframammary fold. It is slowly expanded to the appropriate volume. The reconstruction is completed at the second stage when the size of the areola is reduced, the expander is exchanged for an implant, or the fill-port is removed. The tissue "herniation" is corrected and a mastopexy is performed when necessary. We treated seven tuberous breasts and three tubular breasts by the two-stage method. Eight reconstructions were completed successfully in two stages. An additional operation became necessary in two cases; one to treat an exposed expander, and another to correct a capsular contracture. The results have been uniformly good and compare favorably with those presented in the literature done by other methods. We recommend use of the combination expander/implant.

The author reports his experience treating moderate macromastia using the inferior dermal pedicle technique in 23 patients. The skin flap design is bases on anatomical points along the inframammary line and on the areola. Nipple-areolo position is determined after skin closure about the breast mound, eliminating the guesswork in selecting the new site. Tissue resections ranged from 175 to 1,200 gm per breast and averaged 572 gm per breast. My experience indicates that the method is best suited to instances of moderate macromastia but is applicable over a wide range.

We have presented the evolution of our current methods of breast reconstruction, which utilize the tissue expander in a variety of ways. We strongly support the concept that expansion should occur in the subcutaneous layer of the lower thoracic region. It is, after all, the region occupied by a mature breast that has descended normally with age, or one that is relatively large in size. A tissue bank is created that places skin and subcutaneous tissue right where it is needed to ensure that the breast will not appear as a simple mound. The upper pole of the reconstruction has never been the problem in cases in which a relatively normal pectoral musculature has been left following mastectomy. Therefore, whether the expander and implant should be completely "submuscular" is no longer an issue holding back further developments in the field of breast reconstruction utilizing tissue expansion techniques.

We have used tissue expanders to treat 10 patients with breast deformities, 2 the result of burns and 8 congenital in origin. The expanders are placed in the subglandular plane and expanded incrementally until the desired amount of growth is obtained. In patients with congenital deformities, the desired size of the reconstructed breast (implant size) is determined during the expansion phase. Reconstructions of the nipple-areola complex are done either at the time of the exchange or as separate procedures. Patients with burn deformities present a variety of problems not seen with the congenital deformities. The expander is placed in the subglandular plane and filled to the desired volume. We have noted a marked permanent softening of the scar and grafts encasing the breast, which persists after the expander is removed and the breast reconstructed. The interval between expansion and definitive reconstruction is delayed for several months to allow scar softening to take place. If the parenchyma is not burned and pedicle tissue is not required, the expander can be deflated and the skin coverage observed to determine if it will remain soft. If it does, the expander can be removed and the breast reconstructed. In patients who require pedicle coverage in the reconstruction and who have unburned scar surrounding the breast, massive overexpansion is carried out. The pedicle skin is used to resurface the breast after removal of the appropriate areas of scar and skin grafts. In all burned patients, the inframammary fold must be reconstructed if the breast is to be protuberant. The nipple-areola complex also requires reconstruction. To date there has been great acceptance by patients with both congenital and burn deformities; however, we believe that tissue expansion techniques offer possibilities that have not as yet been fully explored.

Can a breast-shaped skin envelope that is pendulous be formed through the use of a shaped expander? Once formed, can its shape be maintained following the exchange of the expander for a round implant? My colleagues and I set out to answer these questions by constructing a breast-shaped expander by altering a standard round expander. It was introduced through an inframammary incision while performing a Pennisi-Ryan type reconstruction. The expander was placed in a limited pocket beneath the pectoralis major muscle. The lower pole of the expander was left in the subcutaneous plane. The skin expanded into a mature, pendulous breast shape that exhibited a slight degree of ptosis. The shape was maintained following the exchange of the expander for a high-profile round implant. If contracture occurred, the distortion detracted from the initial pleasing shape. We present our experience with the first 15 reconstructions using this method. The best results were seen in delayed reconstruction cases. The method is of no value in cases of primary reconstruction. Lessons learned from this small series of cases are detailed, and complications are discussed. The follow-up for these patients is a minimum of one year from the beginning of expansion.

ULNAR-nerve severance destroys the innervation to the bulk of the intrinsic muscles of the hand, robbing it of its ability to perform the refined motions so necessary to the artisan and skilled wor...

ULNAR-nerve severance destroys the innervation to the bulk of the intrinsic muscles of the hand, robbing it of its ability to perform the refined motions so necessary to the artisan and skilled wor...

Summary Twenty cases of ˦sthetic rhinoplasty were studied using a small-bore polyethylene tube at the site of nasal infracture in an attempt to reduce post-operative tissue reaction. One side of each patient acted as a control. No advantage appeared to be gained from the use of the tube in reducing the amount of reaction. Following removal of the tubes, the amount of tissue reaction on each side became the same in most cases.

It is possible to reconstruct a breast mound of almost any size by utilizing tissue expansion. In order to produce a pendulous breast which is also ptotic, the tissue-expansion technique has been combined with two other procedures. A new technique is being introduced. It is that of elevating the lower third of the mature breast capsule surrounding the tissue expander at the time the permanent prosthesis is to be exchanged for the expander. The established techniques of inframammary fold reconstruction of Pennisi and Ryan are used to provide pedicle skin coverage for the undersurface of the breast and the bed of the elevated capsule. Internal and external surgical approaches are described, and two examples of each are illustrated. Breasts reconstructed in this manner have remained pendulous structures. Some loss of the initial degree of ptosis has been noted in some cases.