CHAPTER 09: TRUNK Flashcards
What is gynaecomastia?
Abnormal breast development in ♂, increase in ductal tissue and stroma.
What is the pathophysiology?
↑ oestrogen, ↓ androgen, or deficit in androgen receptors.
↑ oestrogen : testosterone ratio leading to unopposed oestrogen
What is the aetiology?
Idiopathic - majority
Physiological
- Neonatal (maternal oestrogens)
- Pubertal (andogen - oestrogen imbalance) 75% resolve
- Senile (peripheral fat conversion of testosterone -> oestrogen by aromatase, testicular failure, inc fat levels)
Pathological
Congenital - Hypogonadism o Pituitary ↓ GRH (=LH) o Androgen insensitivity syndrome (5α reductase deficiency) o Klinefelter’s (XXY) 20-60x ↑ breast ca risk o Congenital anorchism - Hyperoestrogenic o True hermaphrodite o Congenital adrenal hyperplasia o ↑ peripheral aromatase
Acquired
- metabolic
- liver cirrhosis
- testicular tumours (seminoma, teratoma, choriocarcinoma - BhCG, Leydig, Sertoli cells - oestrogen.
- adrenal & pituitary, hypothalamus tumours
- breast cancer
- lung ca
- renal disease
Pharmacological
- recreational drugs - marijuana, anabolic steroids
- spironolactone, digoxin, TCA
- prostate ca Rx - Zoladex (LHRH analogue), antiandrogens (cyproterone acetate), oestrogens (stilboestrol)
What is the classification of gynaecomastia?
Simons Classification - PRS 1973
Grade I = small (or subareolar button)
- excise
Grade IIa = moderate enlargement with no skin excess
- lipo +/- excise
Grade IIb = moderate enlargement with extra skin
- excise +/- liposuction
Grade III = marked enlargement with extra skin
- BBR or horizontal ellipse excision
Other classifications
Rohrich 2003
Cordova JPRAS 2008
What is the histological classification of gynaecomastia?
- Florid pattern - highly cellular fibroblastic stroma, increased budding ducts (1st 4mths)
- Intermediate type
- Fibrous type - extensive stromal fibrosis, minimal ductal proliferation (after 12mths)
Gynaecomastia - history and examination
History
- age of onset, rate of growth
- psychological effects
- symptoms: pain, nipple discharge
- PMH, THx, FHx, SHx recreational drugs
Examination
- chest wall, pectus, scoliosis, skin quality, symmetry, testicular, abdominal, thyroid
What medical treatments are there?
Tamoxifen (reduce pain)
Danazol (60% intermediate response rate)
Clomiphene (in proliferative phase)
usu not very effective
What tests may be indicated?
Breast pathology - triple assessment
Testicular cancer - Testosterone, oestrogen, α-FP, β-HCG, PSA, hGH
Intracranial pathology - prolactin, FSH, LH
Hepatic abnormality - LFT
Biochemistry - prolactin, LFT, testosterone, oestrogen, LH, FSH, TFT, U&E
α-FP, β-HCG, γ-GT, PSA, hGH
Mammography
What is the aim of treatment?
restoration of normal chest contour
minimising scars
protecting NAC
What are the principles of gynaecomastia surgery
- may avoid scars in younger pts, liposuction & disc excision 1st stage
- allow skin to settle +/- skin excision 2nd stage
- liposuction makes excision easier
What are the surgical options?
Liposuction
Open excision
Skin resection
What types of incisions are there?
Inferior Periareolar (Webster 46)
Circumareolar (Davidson 79, Smoot 98, Saad & Kay, Ann.R.Coll.Surg.Eng 1984)
Transverse or hemi transverse = through nipple
PERS incision - horizontal skin ellipse, with NAC vertical bipedicle leaving transverse scar
Inframammary
Wise Pattern or Vertical Scar
What is the surgical treatment for gynaecomastia?
Consider skin excision and fat / glandular excision separately (like breast reduction)
Grade 1
Liposuction
circumareolar incision and excise disc of breast tissue (button)
Grade 2
A - liposuction and circumareolar incision to excise button
B - skin: donut mastopexy, beveled excision of breast disc and liposuction to feather edges
Grade 3
Breast reduction
- inferior pedicle markings
- skin : circumareolar + subcutaneous mastectomy
- MWL : free nipple grafting
- horizontal skin ellipse and NAC vertical bipedicle, leaving transverse scar (Pers)
What are the complications?
Complications
- High comp rates with open (Courtiss 87, Steele 02)
Early
Haematoma
Infection
Late Asymmetry Hypertrophic scarring Altered nipple sensation Saucer deformity Inadequate correction of gland volume or skin excess Nipple stuck to chest wall
TUBEROUS BREAST AND POLANDS SYNDROME
SEE AESTHETIC BREAST
Describe the embryology and anatomy of the chest wall
development of ribs, costal cartilages and sternum begins at week 6
ribs 1-7 fuse with sternum wk 9
Inspiratory muscles → SCM, scalenes
Expiratory muscles → Rectus abdo, Ext. Oblique, Int. Oblique.
Flail segment = >4 rib fractures or >5cm segment
What is the incidence of pectus deformities?
1 in 300 live births pectus excavatum (concave) > carinatum
What is pectus excavatum and how can it be treated?
Abnormal growth of costal cartilage, and posterior displacement of sternum
can be corrected by prosthesis or ribcage recon
Surgical treatment of pectus excavatum
Ribcage reconstruction
- Ravitch procedure - abnormal costal cartilages resected, sternum mobilised anteriorly & stabilised with metal bar
- Nuss procedure - thoracoscopic guided metal bar insertion
Remove & reshape sternum
- complete removal, osteotomies, fixation
Customised implants
- CT guided, absolute accuracy difficult, migrates
How is sternal wound dehiscence classified?
1% of median sternotomies (more common if IMAs harvested)
50% mortality
Pairolero Classification
Type 1 → serosanguinous discharge without evidence of cellulitis, chondritis or osteomyelitis.
Type 2 → Purulent mediastinitis assoc with costochondritis and osteomyelitis
Type 3 → Chronic wound infection assoc with costochondritis and osteomyelitis
Who classified sternal wound dehiscence?
Pairolero type 1: serosanguinous drainage within first 3 days negative cultures no cellulitis or osteomyelitis Rx: reexplore, debride, close
Type 2 purulent mediastinitis within 1st 3 wks positive cultures cellulitis and osteomyelitis Rx: reexplore, debride, flap
Type 3
draining sinus tract from chronic osteomyelitis
months to yrs after op
Rx: reexplore, debride, flap
other classification – Starynski classification of sternal defects
What are the principles of sternal wound dehiscence treatment?
radical debridement of non-viable tissue, necrotic bone & foreign material
microbiology (+/- temporising TNP therapy)
fill dead space with well-vascularised tissue
What flaps are used for sternal wound dehiscence recon?
What additional regional pedicle flaps can be used for intrathoracic / lateral chest recon?
- pec major
- turnover - medial perforators
- transposition - pectoral branchesof thoraco-acromial axis - rectus abdominis - sup epigastric (beware IMA harvest, but 8th intercostal vessels may be ok)
- omental flap + ssg - gastroepiploic (L/R)
Lateral
- serratus anterior
- LD
What is the aetiology of acquired abdominal wall defects?
Trauma
Infection
Cancer
Radiotherapy damage
What are the aetiological factors of abdominal wall defects
trauma tumour infection prior surgery radiation congenital (gastroschisis, omphalocele)
What is important in the evaluation of abdominal wall defects?
Patient
- history, nutritional status, co-morbidities
Defect
- what tissue is lost / damaged, imaging
What are the principles of abdominal wall reconstruction?
Stages - 1 / multiple / temporising measures (dressings, VAC, mesh, SSG) Static vs functional reconstruction - components separation - functional muscle transfer - sensate flap transfer Prevention of adhesions Aesthetic considerations
what are the goals of abdominal wall recon?
- Debride all devitialised / infection / irradiated tissue
- obtain tumour free status if possible
- restore integrity of abdominal wall (protect abdo viscera, prevent herniation)
- cosmesis
What are the options for abdominal wall reconstruction?
- Healing by secondary intention / VAC (small wounds)
- Primary closure
- Prosthetic / alloplastic materials
(a) Vicryl / Dexon mesh (Polyglactin 910, polyglycolic acid)
absorbable, good temporary cover, will absorbe and result in hernia
(b) Polypropylene (Marlex)
non-absorbable
can extrude
can cause enterocutaneous fistulas (bowel rubs on mesh)
(c) Polypropylene fibre (Prolene)
non-absorbable, more pliable and soft than marlex, more easily removed
(d) Expanded polytetrafluoroethylene (ePTFE – Gore-Tex)
non-absorbable, non-meshed
no fibrous ingrowth
soft, pliable, fewer adhesions, watertight
- Skin grafts
temporary coverage over bowel/viscera, requires vascularised wound bed
difficult to remove later (can de-epithelialise)
5. Tissue expanders can be placed endoscopically or open under skin/sc tissue b/t internal and external oblique b/t internal oblique and transversus abdominis
6. Local flaps Rectus abdominis (transposition or turnover muscle flap, superior or inferiorly based) TRAM or VRAM flap External oblique Components separation
7. Regional flaps LD Groin TFL Rectus femoris Vastus lateralis Gracilis ALT Omentum
8. Free tissue transfer may have problems finding donor vessels TFL LD ALT
- Others
Alloderm / Strattice
freeze-dried cadaveric/procine dermis, ADM
What is the timing of abdominal wall reconstruction?
Immediate
- hernia repair
- after tumour resection
Delayed
- patient instability
- infected or contaminated wound
- extensive injury that has not fully declared itself
What is the basic algorithm of abdominal reconstruction?
Acute and contaminated
- place mesh (Vicryl), allow to granulate, skin graft, - consider delayed recon
Non-contaminated / delayed reconstruction
- components separation
- tissue expansion nad closure
- permanent mesh +/- relaxing incisions +/- flap coverage
- Alloderm
- TFL (pedicled/free)
Draw and who described the components separation technique
Described by Ramirez 1990 (PRS)
separation of components of the abdomen - peritoneum, muscles, fascia and skin
KEY SEPARATION = plane b/t ext & int oblique
Skin and fat separated from underlying musculature
What is components separation?
Described by Ramirez
- rectus muscle peeled off posterior rectus sheath
- external oblique muscle separated from internal oblique at linea seminlunaris
- can obtain advancement of a composite flap (rectus, anterior rectus sheath, attached internal oblique and tranversus abdominis muscles for variable distances
Epigastrium - 5cm
Waist – 10cm
Suprapubic – 3cm
Describe the components separation technique
Vertical incision 1cm lat to Linea Semilunaris
Develop plane under ext oblique, superficial to int. oblique fascia.
Do not go under internal oblique = segmental n. supp. to rectus ->risk of Spigelian hernia.
Cont developing plane to ant axillary line.
This release will allow advancement of skin edges to close defect
What measures can be done to achieve more advancement?
What precautions are necessary postop?
Can lift rectus off post sheath for 2cm extra advancement. If the posterior sheath is not clearly defined, the pleural peritoneum can be separated
Drains in each separated plane
NBM, drip and suck as for post laparotomy
unilateral rectus complex mobility = 4cm at epigastric, 8cm waistline, 3cm pubic (+2 if rectus mobilised)
Watch for ventilatory distress & abdominal compartment syndrome
Ventral hernia repair - delayed closure
- running suture technique
- anterior rectus sheath turned medially
- running nylon darn to linea semilunaris
- gradual closure (tightening shoelace)
Other abdo closure methods (excluding flaps)
VAC - temporising
SSG - will take directly on bowel (temporising)
Fascial grafts - TFL / ant rectus sheath instead of mesh
Prosthetic materials
- Polypropylene – Marlex and Prolene
- PTFE (Gore-Tex) doesn’t allow effusion of fluid
- Absorbable – Dexon and Vicryl – delayed hernia eventually
- Composite – Vicryl and Prolene – Vypro I and II (II is softer)
Have an opinion on:
- In-lay vs. onlay vs. combination of both
- Continuous vs. interrupted sutures
- Non-absorbable (Ethibond better because knots and ends less palpable)
- Absorbable? - PDS – many Gen Surgeons use this for rectus plication.
- Naguib El-Muttardi’s sandwich technique BJPS 2005 – 2 omental flaps and mesh in between – genius idea.
Local flaps for abdo closure
Groin ‘Anterior Thigh’ – Rectus Femoris FC flap Anterior Rectus Fasciocutaneous Iliolumbar Rectus muscle External Oblique myocutaneous
Distant flaps for abdo closure
ALT – pedicled or free TFL – pedicled or free Combination of ALT and TFL Gracilis Rectus Femoris Lat Dorsi Omentum
What are the post-operative considerations?
multiple drains urinary catheter abdo binder antiemetics early ambulation agrressive resp physio avoidance of strenuous activity 6wks min
What regional pedicled flaps can be used for back recon?
LD (thoracodorsal)
Distally based LD turndown
Trapezius
Rhomboid major
