An outcome study of breast reconstruction: presurgical identification of risk factors for complications.

BACKGROUND: Breast reconstruction following mastectomy has been shown to have a salutary effect on the overall psychological well-being of women being treated for breast cancer. Unfortunately, however, not every patient is an ideal candidate for reconstruction. Complications stemming from reconstructive surgery can cause significant morbidity, the most important of which may be the delay of subsequent adjuvant antineoplastic therapies, and therefore may not be in the best interests of the patient. METHODS: A retrospective study was performed on a consecutive series of 123 breast reconstructions in 98 patients, performed by one of two plastic surgeons, in a university setting over a 5-year period, for all surgical outcomes. Specifically, wound-healing complications, infections, and reoperations leading to the potential delay of subsequent chemotherapy or radiotherapy were recorded, and possible risk factors leading to these were sought. RESULTS: Three presurgical risk factors were found to have a statistically significant influence on the development of complications following breast reconstruction. These were: (1) increasing obesity, defined by the body mass index, (2) an active or recent (<5 year) history of cigarette smoking, and (3) a history of previous radiation exposure. Odds ratios were used to describe the magnitude of the effect of each factor for the development of complications. An ordinal regression analysis was used to create a nomogram based on this information that can be used to calculate any individual patient's presurgical risk for developing major complications following breast reconstruction, based on the presence of these factors. CONCLUSIONS: It is possible, based on the presence of specific presurgical risk factors, to predict the probability of developing major complications following breast reconstruction. This information can be useful to the referring physician and plastic surgeon alike in determining which patients are the best candidates for breast reconstruction and which type of reconstruction would be best suited for each individual patient.

Surgical approach to posterior skull deformity.

The incidence of occipital skull flattening in infants has recently increased, partly as a result of widespread supine positioning to prevent sudden infant death syndrome. The authors discuss the causes and differential diagnosis of posterior skull deformity in this subpopulation of patients and describe their technique for surgical correction of the condition.

Comparison of propofol and methohexital continuous infusion techniques for conscious sedation.

PURPOSE: Methohexital and propofol have been shown to be effective agents for continuous intravenous infusion to produce conscious sedation during oral surgical procedures. The current study was conducted to compare these techniques for intraoperative cardiopulmonary stability, patient cooperation, amnesia, comfort, recovery time, and postoperative nausea and vomiting. METHODS: Seventy ASA Class I or Class II patients between the ages of 18 and 40 years, scheduled for surgical extraction of impacted third molars, were entered into the study. Thirty-five patients were assigned to group A (methohexital) and 35 were assigned to group B (propofol). Intravenous sedation was accomplished using premedication with 1.5 microg/kg of fentanyl and 0.05 mg/kg of midazolam followed by the continuous infusion of methohexital or propofol at a rate of 50 microg/kg/min. The infusion was then titrated to 100 microg/kg/min to accomplish a level of sedation in which the eyes were closed and the patients were responsive to verbal commands. Subjects were monitored for variability of heart rate, blood pressure, oxygen saturation, amnesia, comfort, cooperation, nausea and vomiting, and recovery time based on cognitive, perceptual, and psychomotor tests. RESULTS: There was no statistical difference between the two medication groups except for heart rate, which was found to increase by 11 beats/min for group A and only three beats/min in group B. CONCLUSION: A continuous infusion technique using either methohexital or propofol (50 to 100 microg/kg/min) was found to be safe and effective, with no clinically significant differences in cooperation, cardiopulmonary stability, recovery time, amnesia, comfort, and the incidence of nausea or vomiting. However, the cost-effectiveness of methohexital is superior to that of propofol.

The influence of craniofacial structure on obstructive sleep apnea in young adults.

PURPOSE: This study compares craniofacial measurements of lateral cephalometric radiographs of young obstructive sleep apnea patients with those of nonapneic snorers and controls. PATIENTS AND METHODS: Forty-eight patients (BM=28.0+/-3.8) with obstructive sleep apnea, 25 patients (BMI=26.3+/-3.5) with nonapneic snoring, and 54 controls (BMI=24.8+/-2.7) were evaluated. All subjects were between 18 and 40 years of age. Nineteen lateral cephalometric measurements were performed by a single investigator blinded to the results of the polysomnograms. RESULTS: Univariate logistic regression analysis of the 19 variables showed significantly increased midfacial height (ANS-N), narrowed middle airway space (MAS), steep mandibular plane angle (FMA), elongated pharynx (PNS-Eb), and inferiorly positioned hyoid bone (PNS-H, MP-H) in the obstructive sleep apnea group. The nonapneic snoring group showed only a tendency toward maxillary and mandibular retrognathia (SNA and SNB). No significant differences were found for cranial base angle (S-N-Ba), PAS, inferior airway space, maxillary unit length (ANS-PNS) mandibular unit length (Cd-Gn), tongue height (Tng-Ht), soft palate length (PNS-P), and palatal vault height (Ocl-Pal 6). The OSA group was also found to have multiple sites of abnormality of both the upper and lower pharynx, with 58% of the patients having two or more abnormal values (1 standard deviation from the mean) as opposed to 40% of the nonapneic snoring group. CONCLUSIONS: Highly significant craniofacial abnormalities were found in the upper and lower pharynx in young obstructive sleep apnea patients. Most of these patients (58%) had abnormalities in both the upper and lower pharynx, suggesting that palatal surgery alone may be an inadequate treatment. This information may define future investigations needed to determine how to more effectively treat this subgroup of young obstructive sleep apnea patients.

Management of avulsive injuries of the nasal bones: review of the literature and three case reports.

Blunt contusions, lacerations, and avulsion-type trauma are the most often reported nasal injuries sustained in motor vehicle accidents. The nasal skeleton and soft tissues are frequently involved and may require surgical repair of the injuries. The primary reconstruction often requires the use of autogenous grafts, and secondary revision surgery may be necessary. The treatment may require a multidisciplinary surgical team or a single surgeon who knows how to manage the injury. Optimally, the reconstruction of nasal bone avulsions is performed primarily, using autogenous graft materials. This article presents reconstruction of the nasal deformities in 3 patients involved in motor vehicle accidents. The authors describe and evaluate the various graft materials and surgical techniques utilized. The advantages and disadvantages of autogenous and alloplastic materials are discussed. Studies with more patients and long-term follow-up are required for a definitive evaluation.

Changes in facial movement after maxillary osteotomies.

PURPOSE: Determine changes in facial movement while smiling after maxillary Le Fort I osteotomies. MATERIALS AND METHODS: Twenty patients (ages 15 to 38) treatment-planned for maxillary Le Fort I osteotomies were divided into two groups. Group A consisted of 10 patients who underwent superior and/or posterior positioning of the maxilla. Group B consisted of 10 patients who underwent anterior and/ or inferior repositioning of the maxilla. All patients underwent preoperative and postoperative (3 to 8 months) videographic analysis of a maximal closed mouth smile by the Johnson Maximal Static Response Assay, evaluating four landmarks around the mouth and nose (alar base--A, cheilion--C, labrale superioris--Ls, and intermediate between cheilion and labrale superioris--Im). RESULTS: Group A was noted to have a statistically significant decrease in movement of the face at points C and Im. No significant change was seen for points Ls and A. Group B was noted to have a statistically significant increase in movement of the face at point A, C, and Im. Point Ls was also found to increase, however not significantly. CONCLUSION: Surgical repositioning of the maxilla anteriorly and/or inferiorly lengthens the facial musculature resulting in an increase in facial movement while smiling. Likewise surgically repositioning the maxilla superiorly and/or posteriorly reduces the length of the facial musculature, resulting in a decrease in facial movement while smiling.

Methohexital infusion technique for conscious sedation.

PURPOSE: The purpose of this study was to evaluate a methohexital infusion technique for conscious sedation in oral surgical procedures. Patients were evaluated for recall, comfort, recovery, and surgeon's estimate of cooperation. MATERIALS AND METHODS: Twenty adult (mean age, 29 years) ASA I or II patients requiring various dentoalveolar procedures were entered into the study. Administration of 1.5 micrograms/kg fentanyl and 1 mg midazolam were given until sedation was achieved. An infusion of methohexital was started using 50 micrograms/kg/min and increased as needed to 75 micrograms/kg/min. Postoperatively, visual analog scales were used to evaluate the efficacy of the technique. RESULTS: The average total amount of methohexital infused was 257 mg for an average surgical time of 88 minutes. Recovery times were short and uneventful. Patients were cleared for discharge in under 35 minutes. No cardiac or respiratory side effects were noted other than a mild increase ( < 15%) in heart rate. Shivering and hiccoughing were noted in two and four cases, respectively. Recall of surgical events reported by patients was low and patient cooperation was high as reported by surgeons. CONCLUSION: The continuous infusion of methohexital for conscious sedation has been shown to be safe, effective, inexpensive, and well accepted by patients and surgeons.

Comprehensive Health Effects Testing Program for Denver's Potable Water Reuse Demonstration Project.

The Comprehensive Health Effects Testing Program for the Denver Water Department's Potable Water Reuse Demonstration Project is designed to evaluate the relative health effects of highly treated reclaimed water derived from secondary wastewater compared to Denver's present high-quality drinking water. The 1 million gallon per day (1 mgd) demonstration plant provides water to be evaluated in the studies treating unchlorinated secondary treated wastewater with the following additional processes: high pH lime clarification, recarbonation, filtration, ultraviolet irradiation, activated carbon adsorption, reverse osmosis, air stripping, ozonation, and chloramination. An additional sample is obtained from the identical treatment process substituting ultrafiltration for reverse osmosis. The toxicology tests to evaluate the possible long-term health effects are chronic toxicity and oncogenicity studies in Fischer 344 rats and B6C3F1 mice and reproductive/teratology in Sprague-Dawley rats. The results of these evaluations will be correlated with microbiological, chemical, and physical test results to establish the relative quality of reclaimed water compared to all established health standards as well as Denver's pristine drinking water.

A new simplified cryosurgical instrument: the Foster Froster.

The authors report in detail the development of a simplified, yet highly efficient cryosurgical instrument. It is lightweight, portable, inexpensive, and easy to use. Studies show it to be comparable in most instances to a popular contemporary unit. Its chief drawback appears to be that it cannot serve as a liquid nitrogen reservoir for extended periods, although it can be used for multiple procedures without re-filling.