The pedicled myocutaneous flap as a choice reconstructive technique for immediate adjuvant brachytherapy in sarcoma treatment.

Successful treatment of soft-tissue sarcomas is highly dependent on total tumour resection coupled with adjuvant radiation therapy to achieve local control and decrease recurrence. Reconstruction of soft-tissue defects after resection aims to cover vital structures, while providing enough stable tissue to withstand adjuvant brachytherapy treatment. In the present study, pedicled myocutaneous flaps were used as a vital adjunct in the treatment of soft-tissue sarcoma, and our experience with 2 such patients is described. The flaps served to reconstruct large three-dimensional defects while providing stable coverage over brachytherapy hardware to allow for delivery of radiation in the immediate postoperative period. Pedicled locoregional myocutaneous flaps provide a safe, easy, and reliable reconstructive technique in the treatment of soft-tissue sarcoma.

Mutilating facial acne conglobata.

Acne conglobata, a severe form of acne vulgaris, often produces pronounced disfigurement. We describe a 23-year-old man with acne conglobata. Although this type of acne is often more marked on the back rather than on the face, our patient was unusual in that it was localized mainly to the cheeks. Conventional medical therapy was ineffective, or contraindicated. Radical surgical excision with subtotal removal of cheek skin and subcutaneous tissue was performed with an excellent result.

Tissue repair after Mohs surgery. A plastic surgeon's view.

BACKGROUND: Goals of the treatment for skin cancer include completeness of removal of the lesion, minimal functional disability, and a good aesthetic result. With increasing standards for the quality assurance and the demand for cost-effectiveness, assessment of resource-consuming treatment modalities, especially those involving multidisciplinary approaches, seems appropriate. OBJECTIVE: The purpose of this study was to review the strategy of management and the approaches to tissue repair following cutaneous micrographic surgery from the plastic surgeon's point of view. METHOD: Retrospective review of personal experience based on approximately 800 patients treated between 1989 and 1996 and current plastic surgery literature. RESULTS AND CONCLUSIONS: Teamwork with the Mohs surgeon, recognition of the post-Mohs' procedure wound components, and familiarity with reconstructive techniques are essential for the multidisciplinary practice success. The pitfalls of the reconstructive approaches are discussed.

Pain after breast surgery: a survey of 282 women.

Breast surgery is a common procedure performed in women. Many women who undergo breast surgery suffer from ill-defined pain syndromes. Although there exists a few reports on the incidence of post mastectomy pain, there are no published reports on chronic pain after breast reconstruction. This investigation attempts to characterize the pain after four types of breast surgery: (1) mastectomy, (2) mastectomy with reconstruction, (3) cosmetic augmentation, and (4) breast reduction. A questionnaire was mailed to 479 women who underwent breast surgery at the University of California, San Diego Medical Center between January 1988 and December 1992. A second mailing was sent to women who did not respond to the first mailing. Women were divided into four groups; mastectomy, mastectomy with reconstruction, cosmetic augmentation, and breast reduction. In the mastectomy and mastectomy with reconstruction groups, only women who had a lumpectomy with axillary dissection, a modified radical mastectomy, or a radical mastectomy were used in the study. 59% of the women responded. The incidence of pain occurring at least one year after surgery in the mastectomy + reconstruction group (49%) was significantly higher than the mastectomy (31%) and breast reduction (22%) groups. Thirty-eight percent of the women with breast augmentation complained of pain. Women who had reconstruction using breast implants had a higher incidence of pain (53%) than those without (30%). The pain incidence in women who had reconstruction without implants was identical to women who had a mastectomy without reconstruction. There was no relationship between the use of silicone or saline implants and pain (22% and 33% respectively). However, the submuscular placement of the implants resulted in a significantly higher incidence of pain (50%) than the subglandular placement (21%). Of the women that reported pain, arm pain was significantly higher in the mastectomy and mastectomy + reconstruction group (56% and 42%, respectively) as compared to the breast reduction group (0%). Most patients reported intermittent pain in all groups. Of the women that reported pain, the mastectomy and mastectomy + reconstruction group had higher pain related to movement (41% and 42%, respectively) than the augmentation and breast reduction groups (15% and 9%, respectively). The peak pain intensity was significantly higher in the augmentation group as compared to the mastectomy group. Our incidence of post mastectomy pain is higher than most reports. The incidence of breast pain is highest in the mastectomy + reconstruction and augmentation groups which is assumed to be secondary to breast implants. Every effort should be made to achieve the best cosmetic result in breast reconstruction which in many cases justifies the use of breast implants. However, these women should be counseled on the possibility of developing chronic pain.

Outcome of mammary prostheses explantation: a patient perspective.

A retrospective study to characterize determinants of subjective outcome following removal of silicone gel-filled mammary implants was undertaken. One hundred consecutive female patients (aged 24 to 69 years, mean 46 years) who underwent removal of implants were surveyed. Eighty-two patients had mammary implants for cosmetic indications, 17 for postmastectomy reconstruction, and 1 for correction of congenital breast absence. The survey was conducted 6 to 12 months after explantation. Sixty-three patients (63%) returned questionnaires. Fifty-one patients were satisfied with the overall outcome of explantation (81% of respondees). Quality of life, as measured by self-assessed physical and cognitive functions, and improvement of symptoms attributed by the patients to the presence of implants, improved in 49 patients (78%), worsened in 2 patients (3%), and has not changed in 12 patients (19%). Twenty-one patients (33%) judged postexplantation and/or breast recontouring surgery aesthetic outcome as expected, 26 (41%) as an improvement better than expected, 9 (14%) judged their appearance as worse than expected, and 7 have not responded. Twenty-three patients (37%) perceived their postoperative course as "complicated" (scarring, inflammation, infection, seroma, asymmetry, distortion of breast contour, among those items listed). Five patients (8%) complained of mastalgia (not present prior to explantation). However, only 1 patient stated that the "complications" changed her opinion about "benefits" of this procedure. Sixty respondents (95%) indicated that comprehensive informed consent prior to explantation was instrumental in their acceptance of the outcome. If convinced that implants are safe, fifteen patients (24%) would and 41 patients (65%) would not like implants "back," and 7 patients (11%) gave no answer. Analysis of the patients' perspective should help to care for patients who contemplate or have undergone surgery with mammary implants.

Characterization of microbial presence at the surface of silicone mammary implants.

The purpose of this project was to examine the incidence of microbial presence on the surface of mammary implants and its correlation with clinical presentation. The significance of microbial presence without signs of overt infection is questioned. Several issues are raised, including whether the presence of micro-organisms may immunize the host, trigger autoimmune reactions, or locally change the course of healing (resulting in capsular contracture). A total of 150 explanted silicone mammary implants from 87 patients were cultured. Cultures of 81 devices were positive (54%); the predominant isolate was Staphylococcus epidermidis (found on 68 implants, or 84%). Bacteria were detected on 76% (62 of 82) of implants surrounded by contracted capsules and on 28% (19 of 68) of those without capsular contracture (p < 0.05). Among 40 patients (46%) who had no general health problems, 11 (28%) had positive cultures of explanted devices (15 of 62 explants, or 24%). In the remaining 47 patients (54%) who complained of myalgia (77%), arthralgia (68%), chronic fatigue (38%), skin rashes (21%), cognitive problems (19%), dry mucosal membranes (19%), episodes of low-grade fever (17%), and hair loss (13%), 38 (81%) had positive cultures (66 of 88 explants, or 75%) (p < 0.05). The hypothesis that capsular contracture or problems that might be related to chronic infection and immunization are associated with subclinical infection is supported by this study.

Clinical impact of breast implant magnetic resonance imaging.

Magnetic resonance imaging has become the state-of-art technique to diagnose the loss of silicone gel-filled mammary implant integrity (rupture, gel leak). In a series of 39 patients considering implant removal (40 procedures, 74 devices), the impact of magnetic resonance imaging on the decisions made by the patient and surgeon was examined. In this selected group of patients, implant rupture or gel leak was found in 17 patients (16 grossly ruptured devices and 7 with gel leak). In 9 (53%) of these patients, magnetic resonance imaging was the decisive factor leading to the request for explantation by the patient. Diagnosis of implant rupture based on history and physical examination was made in 4 patients (confirmed in 3 and negated by magnetic resonance imaging and intraoperatively in 1). In 10 of the 14 remaining patients (26%) with "unexpected" loss of implant integrity (negative history and physical examination), magnetic resonance imaging evidence was the decisive factor for advising explantation by the surgeon. Negative magnetic resonance imaging results did not influence the patient's or surgeon's decisions. Magnetic resonance imaging appears to be a sensitive and specific technique, and there were no false-negative and one false-positive (gel-leak diagnosis) findings in this series.

1,25-Dihydroxyvitamin D3 increases collagen production in dermal fibroblasts.

The effect of 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3) on proliferation and collagen type I and type III production in cultured human fibroblasts was examined. Previous studies have identified receptors for the vitamin in human dermal fibroblasts, and have suggested the skin to be a target tissue. While many studies examining keratinocyte modulation by 1,25-(OH)2D3 have been undertaken, very few have been performed on dermal fibroblasts. Neonatal foreskin fibroblast cultures were examined for cell number, extracellular collagen accumulation, and collagen mRNA levels, after 5 days exposure to 1,25-(OH)2D3 at a concentration of 10(-7) M. The vitamin significantly suppressed (P < 0.01) the proliferation of fibroblasts cultured in the presence of serum. Day 5 cell culture supernatants showed a significant per cell increase in collagen type I (P < 0.05) and type III (P < 0.01) as measured by ELISA. Type I collagen production in exposed cells was 11.64 + 0.531 microgram/10(6) cell vs. 9.53 + 0.500 microgram/10(6) cells in unexposed cells. Type III collagen production was 0.601 + 0.012 microgram/10(6) cell in exposed cells and 0.247 + 0.008 microgram/10(6) cells in unexposed cells. mRNA levels were increased after a 4-day exposure to 10(-7) M 1,25-(OH)2D3 for both type I (2.5-5-fold) and type III (5.5-7.76-fold) collagen. These results suggest a novel effect of increased collagen production by dermal fibroblasts upon exposure to 1,25-(OH)2D3 that is independent of proliferation.

Fibroblast behavior in vitro is unaltered by products of staphylococci cultured from silicone implants.

Our previous clinical study supported the concept that capsular contracture is associated with subclinical infection of silicone implants. If bacterial presence, indeed, contributes to capsular contracture, then fibroblast behavior might be expected to change in the presence of bacteria by-products. Therefore, study of possible alteration of fibroblast behavior by bacteria products was undertaken using an in vitro model with cultured dermal fibroblasts. Coagulase-negative staphylococci from silicone mammary and penile implants were isolated and their phenotypic features were characterized. All represented nonbiofilm-producing strains. Products of isolate cultures were noncytotoxic and did not alter matrix reorganization (collagen gel contraction model) or collagen production by fibroblasts. Isolates from either mammary or penile implants exerted similar effects.

Diagnosis and therapy of subclinically infected prostheses.

We believe 5 to 7 percent of prosthetic devices are "subclinically" infected by Staphylococcus epidermidis. These infections are manifested by chronic pain, migration and late extrusion of the devices. To examine this problem, we cultured penile and mammary prostheses. For the experimental arm, we cultured painful penile and mammary prostheses that were being removed because of symptoms (pain). For patients in a control group, we cultured penile prostheses being replaced because of mechanical failure (no pain) and mammary tissue expanders that were temporarily installed. Actual parts of the device were cultured in Trypticase Soy Broth. There were 14 and 12 painful penile and mammary prostheses, 13 and ten, respectively, were cultured positive, for an infection rate of 88 percent. The primary organism identified was S. epidermidis. The nonpainful penile prostheses (zero of five and three of 22 mammary prostheses) grew S. epidermidis. The differences were highly significant (p < 0.001), suggesting that the painful prosthesis is infected. In an attempt to resolve the problem of the painful prosthesis, ten prosthesis were removed and exchanged for new devices. Patients received preoperative and postoperative antibiotics. All ten had positive cultures and nine of ten were successfully exchanged (no pain).

Enhanced activity of lysosomal beta-galactosidase after silicone implantation: an experimental study in rats.

Biologic consequences of silicone implantation may include changes in host connective tissue metabolism. Lysosomal beta-galactosidase (beta-GAL) activity, which is a sensitive marker of fibrotic diseases and may be a useful marker of collagen turnover, was examined in the serum of rats with implanted silicones. No significant difference in spectrofluorometrically determined enzyme activity was demonstrated in rats subjected to dorsal submuscular pocket dissection without implantation and corresponding nonoperative controls. Rats with implanted solid silicone elastomer or free polydimethylsiloxane gel (both components obtained from mammary implant) revealed enhanced activity of serum beta-GAL. Higher enzyme activity was observed in animals with implanted silicone gel with a peak level of 2.73 +/- 0.08 pmol/30 min/ml 16 weeks after implantation. Increased collagen deposition and capsular thickness was demonstrated around implanted gel material as compared with that around elastomer shell. Animals with implanted absorbable and nonabsorbable materials, polyglactin and Teflon (polytetrafluoroethylene), respectively, after initial increase of beta-GAL activity demonstrated enzyme activity within the normal range. Findings indicate that there is enhanced lysosomal beta-GAL activity after silicone implantation in rats. Clinical relevance and its possible significance as a predictor or indicator of local or systemic fibrosis after silicone implantation seems worthy of further investigation.

Antidietary antigen antibodies in the sera of patients with burns as a potential marker of gut mucosa integrity failure.

It was hypothesized that a failure of gut mucosa integrity after burn injury may lead to translocation of food proteins as well as bacteria and endotoxins. Certain, normally digested proteins may stimulate the humoral immune response as they enter the circulation. To test this hypothesis, serum samples from 16 patients with burns and 10 healthy donors were tested for the presence of antigliadin and anti-beta-lactoglobulin antibodies of immunoglobulin M (IgM), IgG, IgA, and IgE classes by means of enzyme-linked immunosorbent assay. Patients and donors remained on a standard diet that included wheat (gliadin) and milk products (beta-lactoglobulin). In the group of six patients with severe burns (mean total body surface area burn = 50%), antigliadin and anti-beta-lactoglobulin IgG and IgA antibodies were detected. In the control group and in 10 patients with small to moderate burns (mean total body surface area burn = 15%), these antibodies were not observed. There was a significant correlation between antigliadin IgG and IgA titers (r greater than 0.9) and anti-beta-lactoglobulin antibodies (r greater than 0.7) in patients with burns. Results suggest immunization by gliadin and beta-lactoglobulin in the group of patients with severe burns.

[Attempts at reconstitution of skin continuity]. / Próby odtwarzania ciaglosci skóry.

Biological and clinical principles of living skin equivalents preparation and application are reviewed. Different models of living skin equivalents, based on both autogenic of allogenic elements, are described.

Subclinical infection of the silicone breast implant surface as a possible cause of capsular contracture.

In order to reexamine the possible association between bacterial presence and capsular contracture, 55 silicone devices (mammary implants or tissue expanders) were cultured at the time of their removal from 40 patients. Special culture techniques were used in an attempt to recover bacteria adhering to the smooth-surfaced implant and encased in glycocalyx biofilm. Bacteria were detected on 56% (15 of 27) of implants surrounded by contracted capsules and on 18% (5 of 28) of those without capsular contracture (p less than 0.05). Only three implants tested positive using routine plating techniques. The predominant isolate was Staphylococcus epidermidis. The concept that capsular contracture is associated with subclinical infection of silicone implants is supported by this study. With changes in the microbiological technique, bacterial recovery and growth occurs at a frequency greater than previously thought.

Oxidative activity of polymorphonuclear leukocytes after thermal injury.

Since defects in polymorphonuclear neutrophil (PMN) function are associated with an increased risk of infection, we measured the metabolic response of neutrophils from 23 burn patients with a mean burn size of 52%. Neutrophils from burn patients had a different pattern of oxygen consumption than control cells; the rate of QO2 at rest was higher, while the magnitude of the respiratory burst was lower in patient than in control PMNs, depending on whether the cells were incubated in media or normal serum. The burn-induced changes in patient PMN metabolism seem to be due to circulating factors, at least in part, since the pattern of increased resting and decreased stimulated QO2 could be transferred to control cells by incubating them in burn serum. Thus, a thermal injury alters neutrophil metabolism as well as systemic metabolism.

Endotoxemia after burn injury: effect of early excision on circulating endotoxin levels.

Serial circulating endotoxin measurements (quantitative chromogenic limulus assay) were performed in sera from 19 burned patients to determine the profile of circulating serial circulating endotoxin after burn and the effect of early wound excision on serial circulating endotoxin level. Results indicate an early endotoxemia with the peak serial circulating endotoxin levels 7 to 12 hours and 4 days after burn. More importantly, the level of circulating serial circulating endotoxin can be diminished by early excision; late wound excision was associated with a transient increase of serial circulating endotoxin level. Early excision, therefore, may play a critical role in limiting endotoxemia after burn injury.

Complement activation and the toxicity of stroma-free hemoglobin solutions in primates.

The toxicity of hemoglobin solutions was studied in the context of their ability to activate serum complement (C). Three bovine polymerized hemoglobin solutions (BPHSs) with different degrees of purity were used for experiments in vitro and in vivo. BPHS-1 contained bacterial endotoxins (E) (5 EU/ml) and stromal phospholipids (PLs) (1.2 mg/dl), BPHS-2 contained only PLs (2.0 mg/dl), while BPHS-3 was completely free of both contaminants. C-activation was studied by the direct measurement of C3a, C4a, and C5a des Arg fragments, using commercially available RIA kits. During 1 hour of incubation with fresh monkey plasma, BPHS-1 and -2 activated both pathways of C, while BPHS-3 caused no activation of any factor. In vivo, Hb solutions were used to replace one-third of blood volume in three groups of six Coebus monkeys each, while fresh homologous plasma was used in a control group of four animals. Impure solutions activated the alternative pathway of C and caused significant reactions of the circulating blood (thrombocytopenia, leukopenia, and disseminated intravascular coagulation) associated with multiorgan dysfunction (cardiac arrhythmias, hypoxemia, reduction of renal clearance of endogenous creatinine, and elevation of liver enzyme SGPT). The pure solution neither activated C nor caused any reaction in the circulating blood. However, it caused a moderate degree of direct tissue injury, evidenced by transient reduction of creatinine clearance and elevation of SGPT. These observations suggest that impure and pure Hb solutions carry separate mechanisms of toxicity. Complement, activated by toxic impurities, plays an active role in the toxicity of impure solutions. C-activation in vitro could be used as a screening test of biocompatibility.