CHAPTER 09: TRUNK

Question 1

What is gynaecomastia?

Answer 1

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

Question 2

What is the pathophysiology?

Answer 2

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

↑ oestrogen : testosterone ratio leading to unopposed oestrogen

Question 3

What is the aetiology?

Answer 3

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)

Question 4

What is the classification of gynaecomastia?

Answer 4

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

Question 4

What is the histological classification of gynaecomastia?

Answer 4

1. Florid pattern - highly cellular fibroblastic stroma, increased budding ducts (1st 4mths)
2. Intermediate type
3. Fibrous type - extensive stromal fibrosis, minimal ductal proliferation (after 12mths)

Question 5

Gynaecomastia - history and examination

Answer 5

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

Question 6

What medical treatments are there?

Answer 6

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

Question 7

What tests may be indicated?

Answer 7

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

Question 8

What is the aim of treatment?

Answer 8

restoration of normal chest contour
minimising scars
protecting NAC

Question 9

What are the principles of gynaecomastia surgery

Answer 9

• may avoid scars in younger pts, liposuction & disc excision 1st stage
• allow skin to settle +/- skin excision 2nd stage
• liposuction makes excision easier

Question 10

What are the surgical options?

Answer 10

Liposuction
Open excision
Skin resection

Question 11

What types of incisions are there?

Answer 11

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

Question 12

What is the surgical treatment for gynaecomastia?

Answer 12

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)

Question 13

What are the complications?

Answer 13

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

Question 14

TUBEROUS BREAST AND POLANDS SYNDROME

Answer 14

SEE AESTHETIC BREAST

Question 15

Describe the embryology and anatomy of the chest wall

Answer 15

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

Question 16

What is the incidence of pectus deformities?

Answer 16

1 in 300 live births
pectus excavatum (concave) > carinatum

Question 17

What is pectus excavatum and how can it be treated?

Answer 17

Abnormal growth of costal cartilage, and posterior displacement of sternum
can be corrected by prosthesis or ribcage recon

Question 18

Surgical treatment of pectus excavatum

Answer 18

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

Question 19

How is sternal wound dehiscence classified?

Answer 19

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

Question 20

Who classified sternal wound dehiscence?

Answer 20

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

Question 21

What are the principles of sternal wound dehiscence treatment?

Answer 21

radical debridement of non-viable tissue, necrotic bone & foreign material
microbiology (+/- temporising TNP therapy)
fill dead space with well-vascularised tissue

Question 22

What flaps are used for sternal wound dehiscence recon?

What additional regional pedicle flaps can be used for intrathoracic / lateral chest recon?

Answer 22

1. pec major
   - turnover - medial perforators
   - transposition - pectoral branchesof thoraco-acromial axis
2. rectus abdominis - sup epigastric (beware IMA harvest, but 8th intercostal vessels may be ok)
3. omental flap + ssg - gastroepiploic (L/R)

Lateral

4. serratus anterior
5. LD

Question 23

What is the aetiology of acquired abdominal wall defects?

Answer 23

Trauma
Infection
Cancer
Radiotherapy damage

Question 24

What are the aetiological factors of abdominal wall defects

Answer 24

trauma
tumour
infection
prior surgery
radiation
congenital (gastroschisis, omphalocele)

Question 25

What is important in the evaluation of abdominal wall defects?

Answer 25

Patient
- history, nutritional status, co-morbidities
Defect
- what tissue is lost / damaged, imaging

Question 26

What are the principles of abdominal wall reconstruction?

Answer 26

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

Question 27

what are the goals of abdominal wall recon?

Answer 27

• Debride all devitialised / infection / irradiated tissue
• obtain tumour free status if possible
• restore integrity of abdominal wall (protect abdo viscera, prevent herniation)
• cosmesis

Question 28

What are the options for abdominal wall reconstruction?

Answer 28

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

Question 29

What is the timing of abdominal wall reconstruction?

Answer 29

Immediate

• hernia repair
• after tumour resection

Delayed

• patient instability
• infected or contaminated wound
• extensive injury that has not fully declared itself

Question 30

What is the basic algorithm of abdominal reconstruction?

Answer 30

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)

Question 31

Draw and who described the components separation technique

Answer 31

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

Question 32

What is components separation?

Answer 32

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

Question 33

Describe the components separation technique

Answer 33

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

Question 34

What measures can be done to achieve more advancement?

What precautions are necessary postop?

Answer 34

 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

Question 35

Ventral hernia repair - delayed closure

Answer 35

• running suture technique
• anterior rectus sheath turned medially
• running nylon darn to linea semilunaris
• gradual closure (tightening shoelace)

Question 36

Other abdo closure methods (excluding flaps)

Answer 36

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.

Question 37

Local flaps for abdo closure

Answer 37

 Groin
 ‘Anterior Thigh’ – Rectus Femoris FC flap
 Anterior Rectus Fasciocutaneous
 Iliolumbar
 Rectus muscle
 External Oblique myocutaneous

Question 38

Distant flaps for abdo closure

Answer 38

 ALT – pedicled or free
 TFL – pedicled or free
 Combination of ALT and TFL
 Gracilis
 Rectus Femoris
 Lat Dorsi
 Omentum

Question 39

What are the post-operative considerations?

Answer 39

multiple drains
urinary catheter
abdo binder
antiemetics
early ambulation
agrressive resp physio
avoidance of strenuous activity 6wks min

Question 40

What regional pedicled flaps can be used for back recon?

Answer 40

LD (thoracodorsal)
Distally based LD turndown
Trapezius
Rhomboid major