CHAPTER 09: TRUNK Flashcards by Lydia Tang

What is gynaecomastia?

Abnormal breast development in ♂, increase in ductal tissue and stroma.

How well did you know this?

Not at all

Perfectly

What is the pathophysiology?

↑ oestrogen, ↓ androgen, or deficit in androgen receptors.

↑ oestrogen : testosterone ratio leading to unopposed oestrogen

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What medical treatments are there?

Tamoxifen (reduce pain)
Danazol (60% intermediate response rate)
Clomiphene (in proliferative phase)
usu not very effective

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What is the aim of treatment?

restoration of normal chest contour
minimising scars
protecting NAC

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What are the surgical options?

Liposuction
Open excision
Skin resection

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

TUBEROUS BREAST AND POLANDS SYNDROME

SEE AESTHETIC BREAST

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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?

1. Healing by secondary intention / VAC (small wounds) 2. Primary closure 3. 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 4. 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 ``` 9. 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