Delayed nipple-sparing modified subcutaneous mastectomy: Rationale and technique

The problem of nipple-areola complex (NAC) preservation during mastectomy is a very intriguing and stimulating issue. In fact, in order to perform an oncologically safe operation, no mammary tissue (enclosed in the main galactophoric ducts) should remain; on the other hand, without the blood supply coming from the breast gland, NAC viability is greatly impaired because the surrounding vascular dermal network is not developed enough to support its metabolic requirements. We suggest therefore a two-step surgical procedure. The first step, on an outpatient basis with local tumescent anesthesia, is a mini-invasive cutting and coagulating procedure. It addresses the autonomization of the vascular supply to the NAC by detaching the galactophore stalk from the nipple and coagulating the deep vascular plexus. The second step, under general anesthesia and again with tumescent technique, removes the breast within its capsule, with careful checks of any remnant and adequate approach to the axilla. A subpectoralis prosthesis completes the procedure. In our view, this technique is electively suitable for prophylactic mastectomy, but also for stage I breast cancer, 2.5 cm from the NAC and 1.5 cm from the skin and pectoralis fascia, and it is very safe, simple, and effective

Multidisciplinary, single center approach to 261 cases of peripheral arteriovenous malformations: A retrospective analysis

BACKGROUND: Treatment strategy of arteriovenous malformations (AVM) is difficult and discussed due to variability and different treatment possibilities. Results reported are often limited to an area or to a single technique. METHODS: Two hundred sixty-one cases of AVM treated by a multidisciplinary group were analyzed. Site of defect and type (limited, infiltrating and direct fistulas) were recorded as well as technique treatment, combination and results. Surgery, embolization, percutaneous alcohol and interstitial laser treatment were used. RESULTS: One hundred thirty-four (55%) were female and 118 (45%) males. One hundred fifty-four (58%) were infiltrating forms, 100 (39%) limited forms and 7 (3%) direct A-V fistulas. Main location in limited forms was: Head and neck (52 [52%]), lower limbs (24 [24%]) and upper limbs (14 [14%]); in infiltrating forms: Lower limbs (50 [33%]), upper limbs (43 [28%]) and head and neck (36 [23%]). Sixty-nine patients were not treated because asymptomatic or refuse of the patient. Treatment sessions were in limited forms: Percutaneous alcohol occlusion (79), surgery (34), catheter embolization (24) and interstitial laser (6 sessions). In infiltrating forms: Alcohol occlusion (119), catheter embolization (106), surgery (31) and interstitial laser (13). A single treatment was done in 48 (63%) of limited cases and in 29 (37%) of infiltrating forms. Combination of treatments was done in 26 (34%) of limited AVM and in 59 (55%) of infiltrating forms. In limited forms: 43 patients were healed with no residual AVM (56%), 18 asymptomatic with residual AVM (24%), 12 improved (15%), 0 unchanged; in infiltrating forms 19 were healed (17%), 26 asymptomatic (24%), 44 improved (41%), 14 unchanged (13%) and 5 amputated (5%). Recurrence was 5% in limited cases and 20% in infiltrating forms. CONCLUSIONS: Multidisciplinary approach to AVM, having access to all four techniques, is an effective form to treat these diseases. Recurrence had a reduced incidence in this study