JAMES ET ALll

POST-MASTECTOMY BREAST RECONSTRUCTION

mastectomy, which allows adequate scar resolution and reestablishment of skin circulation. Nipple reconstruction.The nipple reconstruction can be carried out at the first procedure or at a second operation some three months later, when, at the same time, the normal breast may be reduced to achieve symmetry. If the opposite nipple is adequate in size, a nipplesharing t e c h n i q u e p r o d u c e s an e x c e l l e n t reconstruction. The distal part of the normal nipple is used as a composite graft to produce the central prominence of the reconstructed nipple. If the opposite nipple is inadequate for the purpose, a local flap repair is carried out to produce the central prominence. The epithelium is removed from four centrally based skin dermis flaps, and these are sutured to themselves to form a small cylinder of dermis which is then wrapped in a split skin graft(Marshall et alii, 1978).

The areola is reconstructed with either a split skin graft from the outer aspect of the arm if the nipple is pale, or from the labia minora if a darkly pigmented nipple is required (Weimer and Freeman, 1977) (Figure 3). The optimum time for reconstruction is probably three to six months after mastectomy (Snyderman, 1979). This allows the patient to make a rational decision about a reconstruction after she has become accustomed to the loss of the breast, and it does not interfere with postoperative radiotherapy or chemotherapy.

REFERENCES MARSHALL, D. R.. ANSTEE. E. J. and STAPLETON, M. J. (1978). AUST. N.Z. J. SURG. 47: 774. PATEY, D. and DYSON (1948). Brit. J. Cancer, 2: 7. SNYDERMAN. R K. (1979), Aesthetic Plastic Surgery, 3 : 79. WEIMER,D. R. and FREEMAN, B. S. (1977),Plasf. reconsfr. Surg., 58: 310

SKIN FLAPS IN BREAST RECONSTRUCTION I. A. MCDOUGALL Brisbane IF the skin is of normal elasticity. reconstruction can be performed simply by inserting a mammary prosthesis. However, if the skin is tight or has been damaged by radiotherapy, or if skin grafts have been applied to the wound for initial closure, then further skin must be introduced into the breast area. The principle of keeping resultant secondary scars to a minimum should always be considered in breast reconstruction.

The medially based transverse abdominothoracic flap, being arterially based medially, extends to the midaxillary line, and can be raised without delay and transposed into a defect formed on the anterior chest wall. The resultant defect can be closed directly after some undermining of the abdominal skin, leaving a transverse scar situated at the level of the inframammary groove. The distal end of this flap can reach the infraclavicular hollow, but it may be necessary to revise later a small dog ear at the base of the transposed flap. Reconstructing the mound by a prosthesis may be combined with this initial operation. This prosthesis, if at all possible, should AUST. N.Z. J. SURG.VOL. 49-No.

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be implanted subpectorally, as there is then a greater depth of tissue covering the implant, and it appears that fewer patients develop capsular fibrosis. A myocutsneous flap based on the insertion of the latissimus dorsi muscle can introduce a largearea of skin up to 14 cm in diameter. This remains attached to the latissimus dorsi muscle as it is mobilized at its origin upwards and under the upper skin flap towards its insertion, and then tunnelled subcutaneously and exposed within the defect on the anterior chest wall. The resultant defect on the back can be closed directly, leaving an oblique or horizontal scar in this area. The lower edge of the origin of the latissimus dorsi muscle can be sutured to the edge of the sternum and fanned out tocover a large area of the chest wall. This is highly desirable in patients who have had a radical mastectomy. A second-stage operation to reconstruct the mound by inserting a mammary prosthesis is required, and this is usually performed at the time of nipple reconstruction and any necessary adjustments of the other breast to obtain symmetry. 525

Skin flaps in breast reconstruction [proceedings].

JAMES ET ALll POST-MASTECTOMY BREAST RECONSTRUCTION mastectomy, which allows adequate scar resolution and reestablishment of skin circulation. Nippl...
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