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Copyright of Plastic Surgery & Burns / Chirurgia Plastyczna i Oparzenia is the property of Evereth Publishing Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: Lymph node metastases are the most significant prognostic factors in patients with breast carcinoma. A positive sentinel lymph node (SLN) biopsy is followed by an axillary lymph node (ALN) dissection. In sentinel lymph node negative cases the risk of positive non-sentinel ALN is very low though not absent. The aim of this study was to determine predictive factors for non-sentinel lymph node metastases on the basis of sentinel lymph node metastasis characteristics as well as features of the primary tumour., Material and Methods: 128 patients who had a positive SLN biopsy for breast carcinoma in 2005-2007 were identified. The breast carcinoma metastases in each SLN were assessed according to their location within the node (subcapsular, mixed subcapsular and parenchymal, parenchymal, multifocal or extensive) and metastatic infiltration of perinodal tissue was also reported. These data were correlated with the ALN involvement and characteristics of the primary tumour., Results: The strong predictors of the ALN metastasis included the SLN metastasis diameter (7.6 vs. 4.4 mm) and size classified according to WHO classification (ITC 0 vs. 100%, micrometastasis 23.5 vs. 76.5%, macrometastasis 51.9 vs. 48.1%). The SLN metastases with a diameter of above 3 mm were associated with approximately twice more frequent ALN metastases. In an extensive location of SLN metastasis the highest percentage of ALN metastases was found (65 vs. 35%). The weak predictors of ALN metastases were: primary tumor diameter (> 2 cm), immunohistochemical HER2 positive status, infiltration of sentinel perinodal tissue by metastasis, histological primary tumour grade., Conclusions: Some additional details, which can be easily evaluated in a routine SLN examination in breast carcinoma, have a predictive value of the ALN metastatic status and should be included in the histopathological report.

Introduction: The history of voice rehabilitation following laryngectomy is as long as the history of laryngectomy itself. The multitude of methods which have been employed to reduce the disability associated with the loss of the larynx, illustrate the difficulty of finding an optimal method of reestablishing verbal communication while preserving the ability to breathe and swallow., Material and Methods: The world literature was reviewed using various Internet and medical search engines and library facilities. Landmark articles were identified and summarized., Results: A coherent history of voice rehabilitation following laryngectomy was constructed., Discussion: The methods employed to reestablish voice after extirpation of the larynx may be grouped into the categories of: esophageal speech, surgical methods of creating competent tracheo-pharyngeal shunts to create lung powered voice with and without the use of prosthetic devices to prevent aspiration, "near-total" resection of the larynx with dynamic phonatory shunt, and the use of external pneumatic or electrical devices to create sound which is then transmitted through the oral cavity and pharynx., Conclusion: For the past two decades, simple shunt devices inserted either primarily, at the time of laryngectomy, or later as a secondary procedure, have mainly supplanted the other methods of voice rehabilitation, with the exception of an occasional patient who has acquired good esophageal speech, or for whom external devices may be the only practical method of voice production.

The history of the surgical treatment of cervical lymph node metastases began in the 19th century, and, unfortunately, the initial attempts at surgical treatment of neck metastases were disastrous. Although some European surgeons reported few cases of radical en bloc dissection, the first successful surgical procedure was performed and described in detail by Franciszek Jawdyński, a Polish surgeon, in 1888. George Washington Crile popularized and illustrated radical en bloc neck dissection in the early 20th century.

The significance of metastatic disease in the lymph nodes of the neck as a critical independent prognostic factor in head and neck cancer has long been appreciated. Although 19th century surgeons attempted to remove involved cervical lymph nodes at the time of resection of the primary cancer, a systematic approach to en bloc removal of cervical lymph node disease, described in detail by Jawdyński in 1888 and popularized and illustrated by Crile in the early 20th century, provided consistent and more effective treatment, and forms the basis of our current techniques. During the first half of the 20th century, developments included preservation of the accessory nerve in selected cases, elective neck dissection performed in association with resection of various primary tumors, bilateral neck dissection and limited neck dissection. The greatest impetus to the status of radical neck dissection came from Martin, whose technique consisted of resection of all lymph nodes from level I-V together with the accessory nerve, internal jugular vein, sternocleidomastoid muscle and various other structures in a single block of resected tissue. Martin's technical precepts were followed until the latter part of the 20th century when modifications in technique began to find general acceptance. The first description of an effective technique of modified radical neck dissection was published in Spanish by Suárez, in 1963. This technique, which preserves important structures, such as the internal jugular vein, sternocleidomastoid muscle and accessory nerve, was refined and popularized by various authors who published their results in the English language literature during the period from 1964 through 1990 and beyond. Modified or "functional" neck dissection avoids much of the morbidity of radical neck dissection while achieving equivalent degrees of control of regional disease in properly selected cases. By the late 20th century, the concept of selective neck dissection, consisting of resection of only the nodal groups at greatest risk for metastasis from a given primary site, was studied and developed. These limited dissections are now widely employed for elective, and in properly selected cases, therapeutic treatment and staging of the neck, and have been proposed for limited cervical recurrences after various chemoradiation protocols. Prospective studies have demonstrated similar rates of neck recurrence and survival after elective selective neck dissection compared to elective modified radical neck dissection. Other modifications and factors applied to treatment of cervical lymph node disease include the use of adjuvant and neo-adjuvant radiation and chemotherapy, a revised system for classification of neck dissections, the identification of various adverse prognostic factors such as extracapsular spread and extranodal soft tissue deposits, application of sentinel lymph node biopsy to staging of the neck, the use of immunohistochemical and molecular techniques for identification of lymph node metastases not detectable by light microscopy, and the possibility of endoscopic neck dissection. The authors conclude that neck dissection, as evolved over the past century, is a fundamental tool in management of patients with head and neck cancer, but is still a work in progress.

The medical achievements of Sir William Osler (1849-1919), although numerous and important in his time, contribute less to his continued presence in medical literature. What remains is his literary and historical heritage, which is preserved in numerous essays and addresses. Some of his thoughts, which might be worth reading by today's busy plastic surgeons, were chosen from his writings, and they are presented here.

Vascular compromise is a relatively frequent complication of breast reconstruction performed with the use of pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps. The authors present their experience in delaying TRAM flaps by preelevating the island 7 to 10 days before flap transfer. The skin island is fully incised and raised from the lateral tip to the lateral border of the rectus muscle on one side, and is raised from the tip to the midline on the opposite side. The inferior epigastric pedicle of the rectus muscle remains intact. This method was used in 55 patients. No total flap loss, and only two cases (3.6%) of partial flap necrosis were observed. Preelevating the island is a very simple and effective method of TRAM flap delay, alternative to the ligation of the inferior epigastric pedicle.

In the Head and Neck Cancer Department of Cancer in Warsaw between August 1997 and September 1998 twenty patients with primary unresectable oral cavity cancer were referred for combined modality treatment with cisplatin based chemotherapy followed by wide resection (in the case of tumor regression) with immediate reconstruction and adjuvant radiotherapy. Tumor regression after chemotherapy was obtained in 15 patients and all of them were referred to surgery; wide resection and reconstruction using pectoralis major (PM) flap. 14 patients completed all treatment protocol, also with adjuvant radiotherapy. Tolerance of treatment was excellent and there was no influence of chemo- and radiotherapy for adaptation of PM flaps. During observation local recurrence was observed in two cases. Twelve patients are alive without evidence of disease. Study is continued.

Breast reconstruction using a modified latissimus dorsi island flap is presented. The whole muscle is raised on its vascular pedicle, folded beneath the skin island and sutured in layers, thus substituting the volume of an endoprosthesis. The method may give satisfactory results in carefully selected cases (mostly in women with a small contralateral breast). It can also be applied in reconstruction after subcutaneous mastectomy.

The lower transverse rectus abdominis myocutaneous (TRAM) flap may give excellent results in breast reconstruction using autogenous tissues alone, however, surgical technique is demanding, and the risk of necrosis owing to vascular failure is high. We observed excellent vascularity of the flap in all 20 cases operated upon so far; in all these cases skin island was surgically delayed for one week before final transfer.

Early experience with the modified transverse incision for mastectomy is presented. A 'fish-shaped' incision, by adding two triangles at the lateral tip, decreases the amount of excess skin and prevents the 'dog ear' deformity, makes up the difference in the length of the transverse edges depending on the location of the tumour and provides easy access to the axilla.

The results of salvage surgery or cryosurgery performed in 62 cases of oral or oropharyngeal cancer, recurring or persisting after radical radiotherapy, were analysed retrospectively. Salvage surgery was performed in 33 cases. The relatively high frequency of postoperative complications observed in years 1973-1984, has declined since 1985, concomitant with the introduction of myocutaneous flaps for reconstruction. Twenty-nine patients who were disqualified from major surgery, were treated by cryosurgery. Using both methods, 3-year overall survival was obtained in 24.1% of cases.

Experience with cheek reconstruction after resection, using a single pectoralis major island flap with its inner surface previously split-skin grafted, is presented. No complications were observed in the initial series of 4 cases. The method appears to be a valuable alternative in selected cases, whenever local tissues cannot be used for reconstruction.

Four modifications of a classical pectoralis major myocutaneous flap are presented: the extended flap incorporating anterior rectus abdominis sheath, the peninsular flap used whenever the pedicle cannot be tunnelled under cervical skin, the flap with external pedicle for the longest arc of rotation, and the double-face flap for reconstruction of full-thickness cheek defects.