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Atypical Skin Lesions

Introduction The atypical skin lesions are a diverse group of tumors that are uncommon but clinically important. They include a spectrum from benign lesions through to those that demonstrate local invasion and/or distant metastatic potential. Since these lesions are only seen infrequently during clinical practice, it is important to know the patterns associated with the more malignant of these tumors, how they may be discerned from…

Nonmelanoma Skin Cancer

Introduction Nonmelanoma skin cancer (NMSC) is the most common malignancy amongst Caucasians and occurs sporadically in all other populations. NMSCs are comprised predominantly of basal cell (BCC) and squamous cell (SCC) carcinoma, among other rarer types of cutaneous malignancy. UV radiation exposure initiates approximately 90% of NMSCs, resulting in malignant transformation of keratinocytes. Despite improvements in public awareness and warnings of the harmful effects of excessive…

Melanoma

Epidemiology Over the past four decades, melanoma has shown a consistent increase in incidence in white populations, becoming one of the most frequent cancers in light skin populations. The incidence rate of this disease varies widely in relation to race, occurring much less commonly in black, Asian, or Hispanic populations. Although white and non-white populations have similar risks of developing plantar melanoma, non-white populations have a…

Tissue Engineering

Introduction The reconstructive options for today’s plastic surgeons are unprecedented in history. Despite this reality, the ideal reconstruction for many patients and defect types does not yet exist. The traditional paradigm of plastic surgery has centered around re-purposing existing tissues through grafting, locoregional or free flap transfer to replace “like with like” in keeping with the principles of Sir Harold Gillies. Re-purposing existing tissues is an…

Tissue Expansion

Background The process of tissue expansion in reconstructive surgery was first reported by Charles Neumann, who described its application for auricular soft tissue reconstruction in 1957. Neumann simply applied concepts found in both normal physiological as well as pathological processes of the human body. Examples of this phenomenon include pregnancy, where the abdomen increases in size to accommodate the enlarging fetus, and rapid neoplastic growth, which…

Lasers

General Principles LASER stands for Light Amplification by the Stimulated Emission of Radiation. Einstein first proposed the concept of stimulated emission in 1927. The first laser was developed in 1959 (ruby), and was first used on human skin in 1963. The use of these early lasers was crude, and damage to cutaneous tissues and hence scarring was common. It was the introduction of the concept of…

Local Anesthetics

Introduction Local anesthetic agents cause reversible blockade of the neuronal sodium (Na + ) channel, thereby blocking transmission of nerve impulses from nociceptive afferents. Mechanism of Action of Local Anesthetics In the un-ionized state, local anesthetics are varyingly lipid-soluble, thereby penetrating the phospholipid cell membrane into the axoplasm. Here, re-ionization of the molecule takes place. It is this re-ionized molecule that then enters and blocks sodium…

Biomaterials and Structural Fat Grafting

General Principles Living cells respond to physical and biochemical cues, e.g., hormones, cell–cell signaling molecules, and with the physical environment through the extracellular matrix (ECM), enabling them to adapt to changes in the physiological environment. Regulation of cell function (growth, migration, proliferation, and differentiation) is dependent upon contact or adhesion between cells and the substrate (ECM). ECM has three key components: collagen – the structural framework…

Basic Skin Flaps and Blood Supply

Introduction Flap surgery is the commonest procedure in plastic surgery and is the essence of the discipline. Critical to its success is a sound understanding of soft tissue’s blood supply, its compliance, and its mobility. As all flaps “rob Peter to pay Paul,” it is also about conceptualizing the secondary defect and minimizing its consequences. The art and craft of plastic surgery necessarily requires an esthetic…

Patient Satisfaction and Outcomes Following Oncoplastic Breast Surgery

Introduction Breast Conservation Increased compliance with breast cancer screening guidelines, as well as advancements in imaging technology, have led to earlier detection of breast cancer. Currently, the majority of breast cancers are diagnosed at earlier clinical stages. This should eliminate the need for mastectomy in a majority of cases as multiple randomized studies with extensive follow-up have established that breast conservation therapy (BCT) confers equivalent local…

Radiation Therapy Considerations and Oncoplastic Breast Surgery

Introduction The surgical treatment of breast cancer has undergone a paradigm shift and evolved from the Halsted radical mastectomy to the simple mastectomy and now includes breast conservation therapy (BCT). BCT is defined as local excision of the primary tumor (i.e., lumpectomy, quadrantectomy) or breast-conserving surgery (BCS) followed by radiation therapy (RT). BCT was ushered into standard of care by six large randomized prospective trials demonstrating…

Surveillance and Imaging Following Oncoplastic Breast Surgery

In this chapter, we will lay out the rationale for screening mammograms to start at age 40 and continued annually until age 70, at which time biannual imaging should be performed until life expectancy is less than 5 years, or a patient refuses intervention of any kind. Exceptions for high-risk patients are addressed later in the chapter. We will also list the current guidelines and recommendations…

Local Recurrence and Reconstructive Options Following Oncoplastic Breast Surgery

The management of recurrent breast cancer is a multidisciplinary challenge. Clinical and radiological follow-up of patients following breast cancer treatment aims to detect early locoregional and distant metastasis. Local breast recurrence represents the reappearance of cancer and can occur at or near the site of excision following breast-conserving surgery (BCS) or in the soft tissues of the anterior chest wall or skin flap following mastectomy. In…

Complications of Oncoplastic Breast Surgery

The surgical management of breast cancer has evolved significantly over recent years, commonly trending away from radical procedures, toward those with less extensive resections and decreased patient morbidity. Such types of breast conservation therapy have also been accompanied by simultaneous reconstructive procedures to the breasts, allowing maintenance of ideal aesthetics to preserve the breast mound. These joint oncoplastic procedures have allowed for improved aesthetic outcomes and…

Oncoplastic Variations Based on Tumor Location

Introduction The type of reconstruction used for partial mastectomy defects depends on (1) the size of the resection, (2) the size of the breast, and (3) the location of the tumor. Tumor location on the breast and relative to the nipple–areolar complex is critically important. A recent study of 350 patients demonstrated that the maximal volume of tissue resected with lumpectomy without resulting in unacceptable aesthetic…

Extreme Oncoplasty

Introduction The surgical management of breast cancer has seen a paradigm shift from radical ablation to maximum conservation. The Halstedian radical mastectomy of the late 1800s gradually evolved by 1975 to spare muscle, lymph nodes, skin, and ultimately manifested in the modern-day nipple–areola sparing mastectomy. The 1970s and 1980s brought forth prospective randomized trials supporting breast conserving therapy for tumors ≤5 cm as a viable alternative…

Lipofilling and Oncoplasty

Funding Sources/Financial Disclosures This work was not supported by any external funding. Dr. Alexandre Mendonça Munhoz is a consultant to Motiva/Establishment Labs Corporation. Contributor’s Statement Dr. Alexandre Mendonça Munhoz is the principal investigator of this study. The principal investigator made significant contributions to the conception and design of this study and made substantial contributions to the acquisition, analysis, interpretation of data, and manuscript preparation. The author…

Oncoplastic Breast Reconstruction Using a Three-Dimensional Absorbent Coil

Introduction Advancements in oncoplastic breast surgery have enabled many women to conserve their natural breast tissue and avoid mastectomy. The available techniques can be applied to the majority of women and provide outcomes that range from good to excellent. Techniques related to volume displacement include reduction mammaplasty, adjacent parenchymal rearrangement, and mastopexy, which are usually indicated for women with mammary hypertrophy. Techniques related to volume replacement…

Breast Augmentation Technique (Biplanar) for Oncoplasty

Conflict of Interest Statement No funding was provided for this chapter. Dr. Barnea is a speaker for Johnson Medical. Introduction Breast conservation therapy (BCT) has become the mainstay in surgical breast oncology practice and is now a routine technique for the treatment of early-stage cancers. Improvements in diagnostic technology and mammographic screening as well as increased use of preoperative local and systemic therapies have extended the…