Several studies indicate that mammographic evaluation of the breast is inhibited by both submammary and submuscular implants, regardless of implant composition. Two hundred radiographs were evaluated following subpectoral placement of 25 combination gel/saline and 25 saline-filled tissue expanders. Within 3 months after augmentation, mammograms were performed using the standard and displacement techniques; patients with inflated implants were followed by a repeat displacement study (with the expander deflated). After completion of the mammogram, expanders were reinflated. Our experience demonstrates that better visualization of breast tissue may be accomplished by implant-deflated views in patients with small amounts of breast tissue, tight skin envelopes, or capsular contraction. In each of these circumstances, the displaced view failed to adequately demonstrate glandular tissue. The presence of the inflated implant impairs mammographic visualization in a number of ways, including implant opacity, impaired automatic exposure control, interference with breast compressibility, and implant displacement. These effects are consistently present in small breasts (< an estimated 300 g), in breasts with grade III or IV capsular contracture, and in breasts with minimal skin laxity (i.e., nonptotic breasts). Breast compression was compromised to a greater degree in the presence of grade III and IV capsular contracture; however, deflation of an adjustable implant optimized radiographic interpretation to a high degree. The deflatable saline implant yields a less obscured evaluation of the augmented breast. We suggest that an extended-use deflatable device (i.e., tissue expander) be considered as an optien in our search for a safe and reliable implant for augmentation mammoplasty, particularly in patients with small breasts, tight skin envelopes, or a propensity for capsular contracture.
Barry A. Davidson, MD
W. Earle Matory, Jr., MD
Sheldon A. Rosenthal, MD
Edward O. Terino, MD
Dr. Davidson: The first patient (Figure 1) is a 21-year-old woman who seeks volume reduction in the lower lip and volume augmentation in the upper lip.
Figure 1
Twenty-one-year-old-woman seeks augmentation of the upper lip and reduced volume in the lower lip.
She would also like increased prominence of the philtral column. Dr. Matory, what procedures would you suggest for this patient?
Dr. Matory: I'm a little concerned that she may have some lip incompetence. If that were the case, reducing her lower lip volume might exaggerate any existing deformity. Even if she does not have a full lip incompetence and is able to approximate her lip voluntarily, thinning the lower lip would exacerbate any deficit that she has.
Dr. Davidson: That's an excellent point. How would you reduce this patient's lower lip if she didn't have incompetence?
Dr. Matory: I would use an alveolar sulcus incision and undermine the mucosa. I could then adjust the lip height before actually resecting mucosa. This maneuver lessens the potential for exaggerated labial incompetence.
The goal in reducing the lower lip is to bring it up to at least 1 to 2 mm above the medial incisors. If the lower lip falls below the medial incisors, unattractive incisal show will develop.
Dr. Davidson: What would be your approach to giving this patient a fuller upper lip?
Dr. Matory: Several options are available for augmentation. My primary goal would be to give her a mucosal enlargement as opposed to reducing what seems to be a slightly elongated upper lip. For mucosal enlargement, I prefer autologous tissue. I typically perform a mucosal advancement along with some form of soft tissue augmentation—for example, a fat graft, dermal fat graft, or temporalis …
This study was undertaken to determine the aesthetic changes inherent in partial mastectomy followed by radiation therapy in the treatment of stage I and stage II breast cancer. A retrospective analysis of breast cancer patients treated according to the National Surgical Adjuvant Breast Project Protocol B-06 was undertaken in 57 patients from 1984 to the present. The size of mastectomy varied between 2 × 1 cm and 15 × 8 cm. Objective aesthetic outcome, as determined by physical and photographic examination, was influenced primarily by surgical technique as opposed to the effects of radiation. These technical factors included orientation of resections, breast size relative to size of resection, location of tumor, and extent and orientation of axillary dissection. Regarding cosmesis, 80 percent of patients treated in this study judged their result to be excellent or good, in comparison to 50 percent excellent or good as judged by the plastic surgeon. Only 10 percent would consider mastectomy with reconstruction for contralateral disease. Asymmetry and contour abnormalities are far more common than noted in the radiation therapy literature. Patient satisfaction with lumpectomy and radiation, however, is very high. This satisfaction is not necessarily based on objective criteria defining aesthetic parameters, but is strongly influenced by retainment of the breast as an original body part.
Twenty-two digital nerve repairs were performed in the finger using autogenous vein grafts. Eighty-two percent of the repairs were available for follow-up. Results of sensibility return were assessed using moving two-point discrimination, Semmes-Weinstein monofilaments, and vibratory testing. Two-point discrimination averaged 4.6 mm for 11 acute digital nerve repairs using vein conduits 1 to 3 cm in length. Delayed digital nerve repair with vein conduits yielded poor results. Semmes-Weinstein values demonstrated comparable levels of return of slowly adapting fiber/receptors to the quickly adapting fiber/receptors, as evidenced by moving two-point discrimination tests. Vibratory sensibility was present in all. A review of previous experiences with end-to-end digital neurorrhaphies and digital nerve grafting suggests that repair of 1− to 3-cm gaps in digital nerves with segments of autologous vein grafts appears to give comparable results to nerve grafting. Further laboratory and clinical research is necessary to better define the role of interpositional vein conduits for repair of peripheral nerves.
