Risk of breast implant bacterial contamination from endogenous breast flora, prevention with nipple shields, and implications for biofilm formation.

BACKGROUND: Capsular contracture (CC) is a common complication of breast augmentation that is thought to arise from bacterial contamination and subsequent biofilm formation on the implant. Endogenous breast flora expressed through the nipple may contaminate the sterile field during breast augmentation, acting as a possible source for initiation of biofilm formation. OBJECTIVES: The authors investigate the incidence of nipple bacterial contamination with endogenous breast flora after standard chest wall sterilization during breast augmentation. METHODS: Bacterial contamination of nipples and nipple shields was assessed in a series of 32 consecutive patients presenting for breast augmentation (63 breasts: 31 bilateral procedures and 1 unilateral procedure). After standard sterilization of the chest wall, occlusive nipple shields were applied and breast augmentation was performed. At the conclusion of breast augmentation, the nipple shields were removed and, using the same swab, both the nipple/areolar area and occlusive dressings were cultured. RESULTS: Data from 63 cultured nipples and nipple shields revealed that 22 nipples/nipple shields (34.9%) were positive for bacterial contamination. Three patients, all of whom had negative cultures, developed CC after augmentation. CONCLUSIONS: The exposed nipple is a potential source of implant contamination during breast augmentation. An improved understanding of biofilms and related risk factors for CC can provide surgeons with insights for addressing this common complication. Meticulous hemostasis, use of nipple shields, and submuscular device placement may contribute to a lower incidence of CC.

Meet me at the crossroads: clinical research engages practitioners, educators, students, and patients.

PURPOSE: Many nurse researchers struggle to communicate the relevance of their work to colleagues in education and clinical practice, while making research "come alive" for graduate and undergraduate students. Last and most important, clinical research must be understandable and meaningful to the participants. DESIGN AND METHODS: Randomized trial. FINDINGS: In this article, nurses in each of these roles review the same research project through their unique lens, discussing their unique project roles, highlighting multiple meanings and exploring implications. PRACTICE IMPLICATIONS: We call for nurses in multiple roles to consider the meanings of research from multiple perspectives and to communicate research findings in a manner understandable to all stakeholders.

Special considerations in vascular anomalies: operative management of craniofacial osseous lesions.

The treatment of vascular anomalies of the head and neck typically focuses on restoration of abnormal structures of the soft tissues. However, vascular anomalies can affect the craniofacial skeleton, and osseous reconstruction may be indicated. Osseous involvement occurs as either a primary or secondary phenomenon. In primary osseous involvement, the vascular anomaly expands the bone from within. Secondary osseous involvement occurs when bony hypertrophy develops because of increased flow of the surrounding soft tissue. This article focuses on the management of the osseous deformities associated with vascular anomalies.

The comprehensive management of chemosis following cosmetic lower blepharoplasty.

BACKGROUND: Chemosis can cause persistent discomfort and aggravation in the postoperative period following surgery of the eyelids. This article focuses on chemosis associated with cosmetic lower blepharoplasty. The cause is multifactorial and includes exposure, periorbital edema, and postoperative lymphatic dysfunction. METHODS: A chart review of 312 primary bilateral lower transcutaneous blepharoplasties was performed. Data were collected to identify the incidence of chemosis, define associated etiologic factors, develop a chemosis classification system, and outline a successful treatment algorithm. RESULTS: The incidence of chemosis was 11.5 percent in this population of lower lid blepharoplasty patients. Chemosis presented intraoperatively or up to 1 week postoperatively. The median duration was 4 weeks, with a range from 1 to 12 weeks. Associated etiologic factors included conjunctival exposure, periorbital and facial edema, and lymphatic dysfunction. The four general patterns of presentation were classified as type 1, acute mild chemosis with complete lid closure; type 2, acute severe chemosis that prohibits complete lid closure (chemosis-induced lagophthalmos); type 3, subchronic chemosis that persists longer than 3 weeks; and type 4, chemosis associated with lower lid malposition. Successful treatment existed along a continuum from liberal lubrication to ophthalmic steroid preparations and ocular decongestants to eye-patching to minor surgical procedures such as drainage conjunctivotomy and temporary tarsorrhaphy. In all cases, chemosis ultimately resolved. CONCLUSIONS: Chemosis is a common complication of lower blepharoplasty. Pharmacologic, mechanical, and surgical therapies may be used alone or in combination for the successful management of chemosis. Prevention by minimization of triggering factors intraoperatively and immediately postoperatively is important.

Single-stage muscle flap reconstruction of the postpneumonectomy empyema space: the Emory experience.

BACKGROUND: Postsurgical chronic empyema continues to present a complicated treatment scenario for thoracic and reconstructive surgeons. Muscle flaps are an important option in the management of complex thoracic wounds. This study was designed to report the Emory experience with muscle flaps for the management of complex postsurgical empyema. The authors also present their treatment algorithm for managing empyema thoracis. METHODS: The authors retrospectively reviewed the charts of 55 patients requiring different treatment modalities, including muscle flap transposition. Patients were divided into four groups according to the initial thoracic procedure: group A, no surgical resection; group B, postpneumonectomy; group C, postlobectomy; and group D, prophylactic postpneumonectomy or postlobectomy. The study included 42 men (76.4 percent) and 13 women with a mean age of 62 years (range, 39 to 77 years). RESULTS: Fifty-one muscle flap procedures were performed in 42 patients (serratus anterior flaps, 16 patients and 23 flaps; latissimus dorsi flaps, 16 patients and 18 flaps; pectoralis major muscle flaps, intercostal muscle flaps, and rectus abdominis flaps, three patients each: omental flap, one patient). The mean number of ribs resected before flap intervention, usually during the open window thoracostomy, was three. The average time from initial thoracic operation to flap intervention was 4 months. Average time from flap intervention to discharge was 12.5 days. Average hospital stay was 26.6 days. The 51 muscle flaps represented an average of 1.2 procedures per patient. CONCLUSION: Because of the excellent blood supply of extrathoracic muscle flaps and their ability to reach any place in the pleural cavity, they represent an ideal tissue with which to fill the contaminated pleural space.

Unusual case of right-sided May-Thurner syndrome and review of its management.

May-Thurner syndrome is a phenomenon commonly described as an acquired stenosis of the left common iliac vein as a result of right common iliac artery compression. We report an unusual case of right-sided May-Thurner syndrome in a patient found to have a left-sided inferior vena cava. We also review the management of this patient using angioplasty, intraoperative thrombolysis, and endoluminal stent placement.

Infonomics and breast reconstruction: are patients using the internet?

The World Wide Web provides access to an enormous amount of medical information. In particular, it enables the nonmedical community a chance to better understand breast reconstruction. The purpose of this survey is to determine patient access to the Internet for information related to their breast reconstruction and to evaluate the role of internet-based information in patient education. One hundred six consecutive breast reconstruction patients over a 7-month period were included in the study. All patients were given an anonymous survey querying patient demographics, education, type of reconstruction, internet usage, and how it affected their decision. Data were evaluated and comparisons were made. The average age was 50 years, with the majority of the reconstructions being pedicled TRAM flaps (50%). Ninety-two percent of the patients had internet access, most of them at home (71%). Sixty-eight percent of the patients reported having used the internet for information related to breast reconstruction. The categories searched were procedure (39%), risks/outcome (35%), surgeon (13%), pictures (11%), and hospital (4%). Seventy-two percent found it helpful, 69% easy to understand, and 63% trusted the information. The information they found influenced their decision regarding procedure (53% yes), surgeon (36% yes), and hospital (25% yes). Eighty-one percent felt that it would be useful to communicate with their surgeon via e-mail. Breast-reconstruction patients are using the internet as a research tool. They are influenced by this information on multiple levels. Infonomics is a growing field, and plastic surgeons must take an active role in guiding patients towards accurate online sources and becoming more accessible in the information superhighway.

Management and short-term patency of lower extremity venous injuries with various repairs.

BACKGROUND: Although several methods of repair of extremity venous injuries have been shown to be efficacious, patency rates have varied significantly from center to center. METHODS: A retrospective review was made of treatment outcomes of adult and pediatric patients with major venous injuries of the lower extremity. RESULTS: From 1997 to 2002, 82 patients sustained 86 major lower extremity venous injuries. Venous injuries were treated with primary repair in 27, complex repair in 37 (autogenous vein, 10, and ringed polytetrafluoroethylene [PTFE], 27) and ligation in 20. Prior to repair, temporary intraluminal venous shunts were used in 18 patients. Follow-up duplex imaging or venography or both were performed on 42 extremities at a mean of 10.9 +/- 7.1 days after repair with an overall patency rate of 73.8% (primary repair 76.5%; autogenous vein graft 66.7%; and PTFE 73.7%). CONCLUSIONS: Overall early patency rate of venous repairs performed by an experienced trauma team is similar irrespective of the type of repair. The use of temporary intraluminal shunts is acceptable in selected circumstances, while ringed PTFE grafts are reasonable alternatives when the contralateral saphenous vein is too small.