Faculty Bibliography

This study is an economic comparison of various methods of breast reconstruction after mastectomy. The hospital bills of 287 patients undergoing breast reconstruction at three institutions from June of 1988 to March of 1991 were analyzed. The procedures examined included mastectomy, implant and tissue-expander reconstruction, and TRAM and latissimus pedicle flaps, as well as free TRAM and free gluteal flaps. These procedures were subdivided into those which were performed at the time of mastectomy and those performed at a later admission. In addition, auxiliary procedures (i.e., revision, nipple reconstruction, tissue-expander exchange, and contralateral mastopexy/reduction) also were examined. Where appropriate, these procedures were subdivided into those performed under general or local anesthesia and by inpatient or outpatient status. Data from the three institutions were converted to N.Y.U. Medical Center costs for standardization. A table is presented that summarizes the costs of each individual procedure with all the pertinent variations. In addition, a unique and novel method of analyzing the data was developed. This paper describes a menu system whereby other data regarding morbidity, mortality, and revision rates may be superimposed. With this information, the final cost of reconstruction can be extrapolated and the various methods of reconstruction can be compared. This method can be applied to almost any complex series of multiple procedures. The most salient points elucidated by this study are as follows: The savings generated by performing immediate reconstruction varies between $5092 (p < 0.05) for free gluteal flaps and $10,616 (p < 0.05) for pedicled TRAM flaps.(ABSTRACT TRUNCATED AT 250 WORDS)

The dysplastic nevus, both the sporadic and familial type, has a significant association with melanoma of the skin. The congenital nevus, which ranges in size from less than 1 cm to a giant hairy nevus, are treated primarily for aesthetic reasons and, in the giant variety, are also treated as a prophylaxis against the possibility of malignant change

Fifteen patients with augmentation mammoplasties had mammography demonstrating nonpalpable breast lesions. Of the 15 patients, three (20%) had adenocarcinoma confirmed by open biopsy and histopathology. All patients underwent stereotactic localization for fine needle aspiration biopsy. Four of the 15 patients had benign cysts (26%). None of the cysts could be diagnosed by ultrasound. The remaining eight patients had mammary dysplasia of a proliferative or nonproliferative type of fibroadenoma. These benign entities were followed with interval mammography demonstrating no change. The data suggest that fine needle aspiration biopsy is an effective technique to assess nonpalpable breast lesions in patients who have had augmentation mammoplasties

Twenty-two cases of traumatic below-knee amputation stumps with inadequate soft-tissue coverage salvaged with microvascular free flaps were reviewed retrospectively. All patients would have required an above-knee amputation for prosthesis fitting had microvascular free flaps not bee utilized. A total of 24 flaps were used in 22 patients; parascapular 11 (46%), foot filet six (25%), latissimus dorsi four (17%), lateral thigh, tensor fascia lata, and groin one (4%). Free flaps were performed immediately after injury in five (21%) cases, within the first week in two (8%), between 1 and 3 months in 12 (50%), and after 3 months in five (21%). Fifty per cent of the patients had significant other injuries. The patients had a total of 107 operations (mean, 4.9) related to their injury: 33 (mean, 1.5) of those operations were after the free flap, 27 (25%) of which were either performed because of a complication of the free flap or for revision of the free flap. Complications included partial necrosis in five (21%), neuroma in three (13%), hematoma in two (8%), donor site complication in two (8%), thrombosis requiring reoperation in one (4%), and flap failure in one (4%). Patient followup ranged from 12 to 116 months. All patients maintained a functional below-knee prosthetic level. The mean time to ambulation was 5.75 months, and was not significantly affected by flap complications. Most patients employed before their injury were employed after their injury. Despite a protracted course in these severe injured trauma patients, a functional below-knee amputation level was preserved in all cases utilizing microvascular free flaps

Mammograms of 152 patients after mammoplasty were studied and 37 patients were noted to have calcifications. The pattern of these calcifications was studied to determine if specific characteristics could be identified. The calcifications were found to occur within the skin of the breast, mainly at a periareolar location. The ability to identify these benign calcifications further aids in reliably monitoring patients by mammography after reduction mammoplasty

Breast reconstruction using inflatable expanders has become an established and preferred technique. Although our knowledge of the biomechanical changes occurring in expanded skin has increased greatly, little information is available regarding average aesthetic results achieved with this technique. In order to eliminate the bias of best case selection reports, this study of 60 consecutive patients undergoing skin-expansion breast reconstruction was undertaken. Results of the study demonstrated a significant frequency and diversity of complications. In particular, immediate breast reconstruction with skin expanders was identified as a high-risk procedure because of its association with skin necrosis and delayed wound healing. Although two procedures--insertion and replacement--had been anticipated, patients from both the Boston and New York groups required approximately three operations to complete the expansion process. Average aesthetic results, often characterized by problems of symmetry, ptosis, and contour, need to be recognized and improved.

A case of a possible primary carcinoid tumor of the skin in a 40-year-old man is presented. The neoplasm was diagnosed as consistent with carcinoid tumor on the basis of conventional light microscopy, immunohistochemical studies, and electron microscopy. Workup revealed no evidence of carcinoid tumor elsewhere. Metastases to the skin from internal carcinoid tumors are uncommon, but presumed primary carcinoid tumors that arise in the skin are extremely rare; only three cases have been found in the English-language literature

The aesthetic and functional reconstruction of the orbital and periorbital anatomy poses a complex challenge to the reconstructive surgeon. Four clinical cases are illustrated regarding the restoration of contour, and coverage of vital structures following tumor resections.

Reconstruction of a large postmastectomy irradiated chest wall defect was accomplished with a large musculocutaneous free flap of anterolateral thigh musculature and skin. The vascular anatomy of the donor area allows a very substantial flap and skin island to be transferred, leaving a well-tolerated donor defect