Search

Summary Background Mastectomy flap necrosis remains a major cause of failed breast reconstruction with an associated significant financial/psychological burden. Language describing ischemic mastectomy flaps is imprecise as ischemia can result from many causes and can manifest in different ways. Similarly, management of mastectomy flap ischemia varies depending on its etiology. Intraoperative near-infrared imaging (NIR) with indocyanine green (ICG) is an established modality for evaluation of mastectomy flap perfusion. Herein, we define the types of flap ischemia demonstrated via NIR imaging and propose an algorithm for its management. Method A retrospective review was performed of patients who underwent mastectomy and NIR imaging of mastectomy flaps from 2014 to 2017. Patient characteristics, operative details, and outcomes were recorded. Following retrospective review, distinct patterns of ischemia were identified, and a classification system and treatment algorithm were developed. Result Type A; diffuse hypoperfusion can be caused by a number of factors (hypotension, vasoconstrictive agents, etc.). It is best treated with delayed reconstruction. Type B; geographic hypoperfusion may be caused by electro-cautery burn, inaccurate dissection, or retractor injury. It can be treated by resection/primary closure or delayed reconstruction. Type C; marginal/incisional hypoperfusion is best treated with debridement. Type D; diffuse marginal perfusion is seen with overfilled tissue-expanders or an oversized implant within a smaller skin envelope. Management includes deflation/downsizing. An algorithm was developed for treatment of the four ischemia types. Conclusion NIR imaging aides in delineating the type of ischemic injury. Classification of mastectomy flap ischemia allows precise communication between providers and provides a framework for decision-making.

Background The authors report their experience using extended transversely oriented skin paddles in muscle-sparing latissimus dorsi pedicled flaps for breast reconstruction as an alternative to thoracodorsal artery perforator flaps. Methods A retrospective review was conducted of patients who underwent muscle-sparing latissimus dorsi flap pedicled breast reconstruction from January of 2009 to July of 2014 with at least 3-month follow-up. Surgical outcomes and complications were analyzed. Results Fifty-three patients underwent a total of 81 muscle-sparing latissimus dorsi pedicled flaps for breast reconstruction. Extended transversely oriented skin paddles ranged from 7 to 9 cm vertically by 25 to 35 cm horizontally and were perfused by a strip of latissimus dorsi muscle that was approximately 25 percent of the total muscular volume. Twenty patients had indocyanine green angiography revealing three distinct zones of perfusion in the extended transversely oriented skin paddles. The area of earliest perfusion (designated zone 1) was directly over the muscle containing the perforators. The second best area of perfusion (zone 2) was lateral to the muscle (toward the axilla). The last and relatively least well-perfused area (zone 3) was medial to the muscle (toward the spine). Zone 3 still had adequate viability. There were no flap losses. Minor complications included wound infection [six of 81 (7.4 percent)], fat necrosis [three of 81 (3.7 percent)], and seroma [four of 81 (4.9 percent)]. Conclusions Muscle-sparing latissimus dorsi pedicled flaps with extended transversely oriented skin paddles are reliable alternatives to thoracodorsal artery perforator flaps for breast reconstruction. Three zones of perfusion were delineated in the extended transversely oriented skin paddles on indocyanine green imaging, and all three zones were viable. Clinical question/level of evidence Therapeutic, IV.

Background Solid organ transplant patients frequently develop posttransplant malignancies including breast cancer. They may desire breast reconstruction after mastectomy, which could potentially be complicated by their transplant status, immunosuppressive regimen, and previous operations. We review our experience with patients who have undergone solid organ transplant and subsequent breast reconstruction after mastectomy Methods After institutional review board approval, we queried our prospective breast reconstruction and solid organ transplant databases for corresponding patients. Inclusion criteria comprised breast reconstruction after solid organ transplant. A chart review was conducted of identified patients. Results Seventeen patients were identified: 1 pulmonary transplant, 4 cardiac transplants, 2 liver transplants, 1 pancreas transplant, 2 combined kidney/pancreas transplants, and 7 kidney transplants. Indications for mastectomy included posttransplant malignancy and prophylaxis. Median time from transplant to completion of reconstruction was 186 months (range, 11-336 months). Median age at transplant was 34.5 years (range, 21-65 years) with the median age of the patients at reconstructive surgery 51.5 years (range, 34-71 years). Median body mass index was 25.3 (range, 21.3-46.5). No significant complications were noted after reconstructive surgery. All patients were on full immunosuppression at time of reconstruction. Conclusions Breast reconstruction is a viable option for transplant patients after mastectomy and should not be refused based on their transplant status. Close coordination with the transplant team and careful preoperative planning is essential for optimal outcomes.

Background The goal of cleft lip repair is a symmetrical balanced lip with minimal scar. Fat grafting is an established procedure in cosmetic and reconstructive surgery for restoration or correction of contour deformity, volume loss, and improved tissue characteristics. In this study, we evaluated the use of fat grafting in correction of cleft lip volume asymmetry. Methods We performed a retrospective analysis of our series of patients who underwent fat grafting using the Coleman technique for cleft lip volume asymmetry. Sex, age at primary repair, age at fat grafting, perioperative data, and preoperative and postoperative photographs were reviewed. Results A total of 52 children underwent fat grafting as secondary revision for both unilateral and bilateral cleft lip repair. Fat was hand suctioned from the abdominal or buttock region with a mean yield of 3.0 mL (range, 2.0-5.0 mL). An average total volume of 3.0 mL (range, 2.0-4.5 mL) of fat was injected via an intraoral incision into the philtrum, vermillion, and volume deficiencies in the vertical component of the lip for volume restoration. No complications were noted with fat harvest or with fat grafting. Mean follow-up was 48 months. Postoperative assessment revealed improved volume symmetry in all patients, and all patients or families were pleased with the results. Conclusions Fat grafting via an intraoral incision is a minimally invasive, safe, and reliable secondary procedure to improve volume asymmetries after cleft lip repairs.

IntroductionDisparities in access to medical care and outcomes of medical treatment related to insurance status are documented. However, little attention has been given to the effect of health care funding status on outcomes in trauma patients.Hypothesis/ProblemThis study evaluated if adult trauma patients who arrived by air transport to a trauma center had different clinical outcomes based on their health insurance status.MethodsA retrospective analysis was performed of all adult trauma patients arriving by prehospital flight services to a Level I Trauma Center over a 5-year period. Patients were classified as unfunded or funded based on health insurance status. Injury severity scores (ISS) were compared, while the end points evaluated in the study included duration of stay in the intensive care unit (ICU), duration of hospitalization, and mortality.ResultsA total of 1,877 adult patients met inclusion criteria for the study, with 14% (n = 259) classified as unfunded and 86% (n = 1,618) classified as funded. Unfunded patients compared to funded patients had a significantly lower average ISS (12.82 vs 15.56; P < .001) but a significantly higher mortality rate (16.6% vs 10.7%; P < .01) and a 1.54 relative risk of death (95% CI, 1.136-2.098). Neither mean ICU stay (3.44 days vs 4.98 days; P = .264) nor duration of hospitalization (11.18 days vs 13.34 days; P = .382) was significantly different when controlling for ISS.ConclusionUnfunded health insurance status is associated with worse outcomes following less significant injury. Further investigation of baseline health disparities for identification and early intervention may improve outcomes. Additionally, these findings may have implications for the health systems of other countries that lack universal health care coverage.GurienLA, ChesireDJ, KoonceSL, BurnsJBJr. An evaluation of trauma outcomes related to insurance status in patients requiring prehospital helicopter transport. Prehosp Disaster Med. 2014;29(6):1-4.

Pharyngo-cutaneous fistula is a serious complication of laryngectomy, with a significant associated morbidity and mortality. The oncologic success of organ-preservation protocols with radiotherapy or chemo-radiotherapy for laryngeal carcinoma means laryngectomy is increasingly reserved for surgical salvage in the event of persistent or recurrent disease. A retrospective review of fistula incidence after laryngectomy in 171 patients in a UK tertiary referral centre over the last decade was conducted to identify trends in this complication in the epoch of non-surgical organ preservation. The overall fistula incidence following laryngectomy is 29.2% (50/171). Fistula incidence following salvage total laryngectomy is significantly higher than after primary total laryngectomy [19/51 (37.3%) vs. 8/47 (17.0%), χ2 = 5.02, p = 0.03]. There is no significant effect of prior treatment on fistula incidence following laryngo-pharyngectomy or pharyngo-laryngo-oesophagectomy [14/39 (35.9%) vs. 9/27 (33.3%), χ2 = 0.05, p = 0.83]. Prophylactic vascularised tissue flaps to reinforce the pharyngeal suture line may reduce fistula incidence and fistula severity in salvage total laryngectomy.

To compare the accuracy of preoperative parathyroid adenoma localization in patients with primary hyperparathyroidism (pHPT) due to a single adenoma using a detailed 4-quadrant analysis and to identify patient and tumor characteristics associated with accurate preoperative localization.Retrospective review of 203 patients who underwent parathyroidectomy for pHPT due to a single adenoma between 2008 and 2011. Results from preoperative ultrasound and Tc-99m-sestamibi were compared to operative findings to determine accuracy of localization studies. Associations between clinicopathologic features and accurate preoperative adenoma localization were evaluated.Ultrasound was performed on 198 patients, sestamibi on 177 patients, and both on 172 patients. Accurate localization occurred significantly more often for ultrasound than sestamibi (63% vs. 41%, P0.001). For ultrasound, accurate localization was found in patients with larger or heavier adenomas, those with adenomas located inferiorly, patients not having a reoperative procedure, and patients with higher post-operative serum calcium levels. For sestamibi, greater adenoma size or weight, adenomas located inferiorly, and patients with associated thyroid cancer on pathology were most predictive of accurate preoperative localization.Our results provide evidence that ultrasound is more accurate in localizing parathyroid adenomas in patients with pHPT due to a single adenoma when compared to sestamibi scan using 4-quadrant location analysis and may be the preferred preoperative imaging modality in these patients. No significant preoperative patient factors were associated with accurate localization by ultrasound or sestamibi, but adenoma size, weight, and location in an inferior position were predictive of accurate preoperative localization.

Introduction The use of tissue adhesives for the closure of surgical incisions is increasing. Few studies directly compare tissue adhesives to one another or focus on the difference in wound closure time between tissue adhesives. We compared the use of N-butyl-2 cyanoacrylate (Histoacryl), octyl cyanoacrylate (Dermabond), or subcuticular suture in incisions resulting from reduction mammoplasty, mastopexy, panniculectomy, and abdominoplasty. Methods A 2-armed prospective randomized controlled trial was performed. Part 1 compared closure of surgical incisions with N-butyl-2 cyanoacrylate and octyl cyanoacrylate. Part 2 compared the closure of surgical incisions with N-butyl-2 cyanoacrylate and subcuticular suture. End points were closure time, scar width, and satisfaction ratings. Results Both study arms revealed significantly faster closer times with N-butyl-2 cyanoacrylate [9/10 in part 1 (P = 0.022) and 10/10 in part 2 (P = 0.002)]. Scar width difference did not reach statistical significance, and there was no difference in surgeon, independent reviewer, or patient satisfaction among the materials. Conclusions Our results demonstrate a decreased time required for wound closure using N-butyl-2 cyanoacrylate compared to both suture and octyl cyanoacrylate regardless of incision type with no significant difference in scar width or satisfaction ratings.

The National Surgical Quality Improvement Program (NSQIP) is a risk-adjusted database designed to benchmark quality initiatives. NSQIP captures uniform morbidity variables for all operations and calculates expected morbidity probabilities. Given the frequent need for reoperation following breast-conserving surgery (BCS) and mastectomy, we hypothesized that NSQIP may inaccurately reflect surgical morbidity after breast cancer operations.Using the 2008 NSQIP database, we identified 24,447 breast surgery patients. We calculated the observed versus expected (O/E) morbidity ratios, compared them to other general surgery procedures, and analyzed the O/E morbidity ratios among benign and malignant breast diagnoses.The NSQIP database shows that breast surgery has an O/E morbidity ratio of 3.11, which is higher than other general surgery procedures. Additionally, breast operations for malignancy have higher O/E morbidity ratios (3.22) than those performed for benign disease (2.59). Analysis of malignant patients by CPT code revealed that BCS patients had an O/E morbidity ratio of 7.75 and attributed 89 % of morbidity to reoperation, whereas mastectomy patients had an O/E morbidity ratio of only 1.7. Elimination of the reoperation variable from morbidity calculations in breast surgery reduces the O/E morbidity ratio to less than expected in all breast procedures.Breast surgery has a higher O/E morbidity ratio than other general surgery procedures. Reoperations are expected in BCS for positive margins and in mastectomy for completion ALND. Breast surgeons should advocate for benchmarking by surgical site-specific metrics, because current NSQIP criteria may negatively affect the quality assessment of high-volume breast centers.

Background Chronic tubo-ovarian abscess is an uncommon finding in postmenopausal women. This abscess may rupture or fistulize to adjacent organs into the ischiorectal space. Case A gravida three, para three, postmenopausal woman with extensive sigmoid diverticulosis presented with perianal fistula of 2 years' duration. Magnetic resonance imaging showed the tract to have a supralevator origin adjacent to the sigmoid colon. She had no recent instrumentation other than preoperative colonoscopy. Intraoperatively, the fistula tract origin was noted to be from a right tubo-ovarian abscess. She was treated with right salpingo-oophorectomy and tract excision/sealing. At 4-month follow-up, the fistula tract was healed with no further drainage. Conclusions Tubo-ovarian abscess should be considered in the differential diagnosis of supralevator fistula in postmenopausal women when no other source can be localized.