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Options for immediate breast reconstruction after mastectomy are directly affected by nodal status. Historically, axillary dissection has been performed simultaneously with mastectomy. The advent of sentinel lymph node biopsy (SLNB) drastically changed the trends in breast cancer surgery. SLNB is often performed at the time of mastectomy and may negate the need for a formal axillary dissection. The algorithm presented here outlines an approach where SLNB is performed as a separate outpatient operation several days prior to mastectomy when immediate reconstruction is planned. While this approach requires a separate procedure, SLNB can be performed with minimal morbidity with monitored anesthesia care and local anesthesia. The significance of this algorithm is that it allows time for complete pathologic evaluation prior to definitive surgery, eliminating the dependency on frozen section diagnosis. This method also decreases the possibility of irradiating a fresh autologous flap if radiation therapy is deemed necessary after further pathology review of the sentinel node specimen. We endorse SLNB as a separate outpatient procedure prior to definitive surgery with reconstruction, particularly latissimus dorsi myocutaneous flap. This method involves a close team approach between the breast and plastic surgeons.

This retrospective study reviews 720 patients referred for evaluation of their silicone gel-filled breast implants from December of 1992 to January of 1996. Of the 720 patients evaluated, 282 (39.2 percent) subsequently underwent explantation, and 59 of these patients (20.9 percent) had a breast contouring procedure performed at the time of explantation. Our definition of explantation is the operative removal of the implant as well as the implant capsule. The overall complication rate for explantation was 5 out of 282 patients (1.8 percent), whereas the rate of complication among the patients who underwent simultaneous breast contouring was 2 out of 59 patients (3.4 percent). This article presents the management of the breast following explantation, implant removal, and capsulectomy. We review both the preoperative assessment of patients seeking explantation and our technique of explantation. Additionally, we address the importance of preoperative breast ptosis in technique selection and have developed a practical clinical algorithm for guiding simultaneous explantation and breast contouring. We also identify those patients who should undergo delayed breast contouring due to associated risk factors (smoking, need for > 4 cm of nipple movement, and paucity of breast parenchyma).

Failure to control the projection, shape, and rotation of the nasal tip is a common occurrence among patients with weak lower lateral cartilages. These patients' noses are characterized by a weak midvault, a plunging tip with "Polly beak," and drawn-up alae. The purpose of our study was to identify methods for controlling the position and shape of the nasal tip in these high-risk patients. Twenty patients at risk of losing nasal tip projection were retrospectively identified, and measurements made from their preoperative and postoperative photographs were compared. Loss of tip projection occurred in all but one patient whose columella strut was fixed to the caudal septum. Prompted by these failures, we studied the relationship between the dorsum and tip in cadaveric specimens with and without a supratip break. From our observations, a structural extension of the septum-an anterior septal extension graft-was developed to predictably control this relationship. The clinical application of septal extension grafts in open rhinoplasty was subsequently evaluated in 20 patients who were deemed to be at risk of losing tip projection. Postoperative photographic analysis showed nasal tip projection to be maintained or increased in all but one patient with the use of septal extension grafts. A stable caudal septum is essential to the success of the technique.

The anatomy of the internal mammary vessels is poorly understood and thought to be unreliable clinically for use as a recipient vein in free-tissue-transfer breast reconstruction. This study of 10 fresh cadaver thoracic cavities demonstrated by anatomic and dye resection studies that the internal mammary veins become smaller (< or = 2 mm) distally (fourth rib) and bifurcate [left (90 percent) > right (40 percent)], becoming unsuitable for consistent venous anastomoses at or below the fourth interspace. Furthermore, this study suggests that the most consistent interval is the third rib, which offers an appropriate recipient vein (40 percent > or = 3 mm on the left and 70 percent > or = 3 mm on the right). However, at the fourth interspace, 20 percent of the cadaver specimens had a vein on one side that was 1 mm or less and therefore unsuitable as a recipient. This enhanced understanding of the anatomy (size, location, and consistency) of the internal mammary recipient veins offers our patients another recipient option to enhance the safety and technical ease of microvascular breast reconstruction.

Objective: Nontumorous perfusion defects occur during CT arterial portography (CTAP) as normal variants or in cirrhosis, focal fatty infiltration, and portal vein obstruction. The purpose of this study was to determine whether delayed CT 4-6 hr after CTAP improves sensitivity to hepatic tumors and differentiates them from other hepatic perfusion defects., Subjects and Methods: CTAP was done at 1-cm increments on 26 patients for evaluation of hepatic tumors. Delayed CT scans were obtained 4-6 hr later in all patients. Two observers retrospectively reviewed the CT scans obtained during CTAP and recorded size, shape, and location of suspected hepatic tumors. Confidence levels were assigned for each tumor. The delayed CT scan was then interpreted in conjunction with the CT scans obtained during CTAP, and confidence levels were reassigned. Surgical correlation was obtained for all patients. In the 26 patients, 86 masses were found at surgery. The sensitivity and number of false-positives for both CTAP alone and CTAP combined with delayed CT were compared with a two-tailed Student t-test. Receiver-operating-characteristic analysis also was performed., Results: CTAP detected 73 (85%) of the 86 hepatic masses. Delayed CT had no effect on the sensitivity of CTAP. However, adding delayed CT decreased the total number of false-positives by 11, a statistically significant difference (p < .05). Receiver-operating-characteristic analysis revealed a significantly greater (p < .05) area under the curve (Az index) of 0.927 +/- 0.025 for CTAP combined with delayed CT compared with 0.886 +/- 0.032 for CTAP alone. Delayed CT was most useful for larger (> 1 cm) wedge-shaped perfusion defects and least useful for smaller (< 1 cm) round defects., Conclusion: Delayed CT has no effect in detecting tumors but may be useful for differentiating tumors from other hepatic perfusion defects seen on CTAP. The greatest benefit of delayed CT is in evaluating regions obscured by large wedge-shaped perfusion defects on CT scans obtained during CTAP.