Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection.

SUMMARY: A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Evidence-based clinical practice guideline: Reconstruction after skin cancer resection.

A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection.

SUMMARY: A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Breast reconstruction using a staged nipple-sparing mastectomy following mastopexy or reduction.

BACKGROUND: To address those patients who do not meet anatomical criteria for nipple-sparing mastectomy, the authors use a staged approach: (1) mastopexy or breast reduction, (2) nipple-sparing mastectomy through the mastopexy incisions after a minimum of 3 to 4 weeks, and (3) the final reconstruction. METHODS: Fifteen patients underwent nipple-sparing mastectomy at Georgetown University Hospital between 2007 and 2010 after planned or unrelated mastopexy or reduction. An institutional review board-approved retrospective chart review recorded demographic information and outcomes such as skin necrosis and device failure. RESULTS: Fifteen patients (24 breasts) underwent nipple-sparing mastectomy after mastopexy or reduction with an average follow-up of 13 months. The staged procedure was planned in 10 patients [19 breasts (79 percent)] and unplanned, or coincidental, in five [five breasts (21 percent)]. The mastectomy was prophylactic in 17 breasts (71 percent) and therapeutic in seven (29 percent). Four of the 24 operated breasts (17 percent) experienced a complication. Two patients [two breasts (8 percent)] developed skin flap necrosis. Two patients [three breasts (13 percent)] developed minimal partial nipple-areola complex necrosis. One patient [one breast (4 percent)] had an expander explanted for infection related to skin flap necrosis. Fourteen patients [23 breasts (96 percent)] successfully recovered following nipple-sparing mastectomy and prior mastopexy or reduction without residual effects of nipple-areola complex or skin flap necrosis. CONCLUSIONS: The authors are comfortable offering the staged approach to nipple-sparing mastectomy to patients with moderately large or ptotic breasts. It may not be suitable for the very large or ptotic breast. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A head-to-head comparison of quality of life and aesthetic outcomes following immediate, staged-immediate, and delayed oncoplastic reduction mammaplasty.

BACKGROUND: Oncoplastic reduction mammaplasty offers patients breast conservation with the added benefit of functional improvement in symptoms related to macromastia. The reduction can be performed in the immediate setting with the lumpectomy, in a staged-immediate fashion after final pathology has been confirmed or in a delayed fashion after completion of both lumpectomy and radiation. This study compared quality of life and aesthetic outcomes for these different cohorts. METHODS: A retrospective review was carried out on 16 consecutive patients who had oncoplastic reduction mammaplasty by the senior author (M.Y.N.) between 2003 and 2009. Demographics, oncologic treatment and timing, and reduction techniques were recorded. Patients were asked to complete a questionnaire to assess quality of life and satisfaction. Preoperative and postoperative photographs were evaluated by 15 reviewers. RESULTS: Over a 7-year period, five patients had immediate, six had staged-immediate, and five had delayed reduction mammaplasty. Mean patient age was 52.5 years, and mean body mass index was 31.5. The average timing of reduction was 0, 49, and 734 days for the three groups. Positive margins occurred in two patients, leading to completion mastectomy. In addition, one patient in the staged-immediate group had a recurrence that led to completion mastectomy. Complications occurred in seven (44 percent) of 16 patients. Questionnaire response was 75 percent (12 of 16), showing positive scores in all groups but no statistical significance. Objective aesthetic evaluation also revealed significant improvements within groups comparing various preoperative to postoperative parameters. Importantly, aesthetic scores for the delayed group were consistently lower across all aspects but did not reach significance. CONCLUSION: Oncoplastic reduction mammaplasty can be safe and effective in carefully selected patients in the immediate, staged-immediate, and delayed settings.

Nipple-sparing mastectomy.

BACKGROUND: The debate over nipple-sparing mastectomy continues to evolve. Over the past several years, it has become more widely accepted, especially in the setting of prophylactic mastectomy, but its role in the treatment of breast cancer has only recently been reexamined. METHODS: Two indications for the procedure are discussed: prophylactic, for the high-risk patient; and the more controversial topic, therapeutic nipple-sparing mastectomy, for the patient with breast cancer. A review of the literature suggests that certain breast cancers may be amenable to retaining the nipple if they meet specific oncologic criteria: tumor size 3 cm or less, at least 2 cm from the nipple, not multicentric, and with clinically negative nodes. Moreover, newer technologies such as magnetic resonance imaging and preoperative mammotome biopsy may make the procedure even safer in this setting. Practical and technical aspects of the procedure are discussed, including patient selection. RESULTS: The accumulating data from multiple series of nipple-sparing mastectomy show that properly screened patients have a low risk of local cancer recurrence, that recurrences occur rarely in the nipple, and that recurrences in the nipple can be managed by removing the nipple. CONCLUSIONS: Despite continued controversy and the need for more long-term outcome data, nipple-sparing mastectomy is a procedure that is gaining increasing visibility and acceptance. Provided that certain oncologic and practical criteria are applied, it has the potential for allowing less invasive surgery and improved cosmetic outcomes without increased oncologic risk in appropriately selected patients.

Special considerations in the management of osteomyelitis defects (diabetes, the ischemic or dysvascular bed, and irradiation).

Although osteomyelitis is a difficult problem, certain conditions make it even more difficult to address. Diabetes, peripheral vascular disease, and radiation are all comorbidities that interfere with wound healing and therefore make the treatment of osteomyelitis challenging. In this article, we discuss these conditions, their pathophysiology, and highlight the special considerations in treating osteomyelitis in patients with these comorbidities.

Surgical algorithm for management of HIV lipodystrophy.

BACKGROUND: The accepted standard for treatment of human immunodeficiency virus disease, highly active antiviral therapy, may cause significant side effects, such as facial lipoatrophy and lipodystrophy. Facial wasting or a buffalo hump deformity may be pathognomonic for treated human immunodeficiency virus disease. In addition to facial wasting, cystic parotid degeneration may further distort the face. The authors outline the defects as a series of triangles defined by anatomical boundaries. METHODS: In a group of 27 patients, 17 were treated for buffalo hump (three isolated and 14 with associated facial wasting). Another 10 patients were treated for isolated facial wasting. RESULTS: The 14 patients who underwent liposuction of the buffalo hump with subsequent injection of the aspirate into the face had approximately 40 to 50 percent of the grafts survive. Recurrent or severely fibrous humps were treated with ultrasound-assisted liposuction. In six patients, autografts to the lypoatrophic face were utilized. Two patients undergoing gynecomastia reduction had successful grafting with the resected breast. Three patients with cystic degeneration of the parotid underwent superficial parotidectomy with rotation or grafting of the parotid into the defect, for a total of six individual procedures. CONCLUSION: The authors present an algorithm for treatment of buffalo hump and facial wasting deformities associated with human immunodeficiency virus lipodystrophy syndrome, with an emphasis on long-term results with autogenous tissue.