Addressing the Potential Need for Coronary Artery Bypass Grafting After Free Tissue Transfer for Breast Reconstruction: An Algorithmic Approach.

The number one cause of death in American women is heart disease. Studies have clearly shown the superiority of internal mammary artery (IMA) grafts for coronary revascularization over other conduits or intracoronary techniques. Our goal was to design an algorithm for recipient vessel selection in patients undergoing free tissue transfer breast reconstruction.A review of the literature was performed to identify potential evidence to contribute to a best-practice guideline. The lack of high-level evidence led us to create a guideline based on a workgroup consensus, expert opinion, cadaveric studies, and case reports.As we operate on older patient populations, the need for IMA use for coronary artery bypass grafting (CABG) after autologous breast reconstruction may arise more frequently. We discuss the current literature regarding recipient vessel choices and level of recipient vessel harvest in free flap breast reconstruction to help continually evolve the practices of our specialty to the potential future needs of our patients. We also present a best-practice decision algorithm for vessel selection and harvest, as well as a sample case of CABG using the left IMA 35 days after previous autologous breast reconstruction using the left IMA.As the number of patients we operate on who may later require their IMA for CABG increases, so too must our understanding of the implications of our selection of recipient vessels for free autologous breast reconstruction.

Desmoid tumor of the hand: a case report.

SUMMARY: Extra-abdominal desmoid tumors are extremely rare in the hand. These tumors do not metastasize; however, they are potentially locally invasive and have extremely high local recurrence rates after surgical excision with reports of up to 78% recurrence, specifically in the hand. We describe the first case of a desmoid tumor originating from the extensor mechanism of a digit and discuss our treatment approach. In addition, a literature review performed shows a male predominance of desmoid tumors in the hand in the 30- to 50-year-old age group. Current evidence supports aggressive early wide surgical excision and reconstruction to preserve function.

The Fort Hood Massacre: Lessons learned from a high profile mass casualty.

BACKGROUND: On November 5, 2009, an army psychiatrist at Fort Hood in Killeen, TX, allegedly opened fire at the largest US military base in the world, killing 13 and wounding 32. METHODS: Data from debriefing sessions, news media, and area hospitals were reviewed. RESULTS: Ten patients were initially transferred to the regional Level I trauma center. The remainder of the shooting victims were triaged to two other local regional hospitals. National news networks broadcasted the Level I trauma center's referral phone line which resulted in more than 1,300 calls. The resulting difficulties in communication led to the transfer of two victims (one critical) to a regional hospital without a trauma designation. CONCLUSIONS: Triage at the scene was compromised by a lack of a secure environment, leading to undertriage of several patients. Overload of routine communication pathways compounded the problem, suggesting redundancy is crucial. LEVEL OF EVIDENCE: Prognostic study, level V.

A prospective evaluation of U-clips for arterial microvascular anastomoses.

BACKGROUND: The nitinol U-clip (Medtronic, Inc.; Minneapolis, MN, USA) is similar to conventional suturing but eliminates knot tying, thereby decreasing ischemia time. This study is the first clinical trial of this new technology for arterial microsurgical anastomoses in free tissue transfer. METHODS: We performed a prospective clinical trial of nitinol U-clips for 25 consecutive arterial microsurgical anastomoses. Standard microsurgical techniques and instruments were used, and the primary outcome was free flap survival. The secondary outcomes were ischemia time, operating room (OR) time, number of clips used, and recipient/donor-site complications. Significant recipient/donor-site complications were defined as those requiring re-operation. Descriptive statistics were used and minimum follow-up was 3 months. RESULTS: All anastomoses were successful (25/25). The most common etiology of the defect was cancer resection (92%), and 44% of the recipient vessels had been irradiated prior to surgery. Mean ischemia time was 29 minutes (range 12 to 54 minutes), and mean OR time was 7.4 hours. On average, seven U-clips were used per arterial anastomosis (range 5 to 12). At 3-month follow-up, there was a 100% flap survival rate with no significant recipient-site or donor-site complications. CONCLUSION: This study suggests that the nitinol U-clip provides rapid, reproducible microvascular arterial anastomoses.

True pancreaticoduodenal aneurysms with celiac stenosis or occlusion.

BACKGROUND: Pancreaticoduodenal artery (PDA) aneurysms are rare, representing only 2% of all visceral artery aneurysms. True PDA aneurysms associated with celiac stenosis or occlusion make up an even smaller subset of this group. No relationship between aneurysm size and the likelihood of rupture of PDA aneurysms is apparent. PDA aneurysm rupture is associated with a mortality rate upwards of 50%; therefore, accepted practice is treatment upon diagnosis. There is debate in the literature on whether the treatment of coexisting celiac axis stenosis is necessary for the prevention of recurrence. DATA SOURCES: Literature relating to PDA aneurysms associated with celiac stenosis or occlusion was identified by performing a PubMed keyword search. References from identified articles were also assessed for relevance. The current literature was then reviewed and summarized. CONCLUSIONS: Characteristics of this patient population are identified. Based on current evidence, our best practice recommendation for the treatment of coexisting celiac axis stenosis is provided.

Preoperative pregnancy testing.

BACKGROUND: In up to 2% of all pregnancies, the need for general anesthesia in a nonobstetrical surgery arises. Surgery on a pregnant woman may have significant implications for the fetus, patient, physician and hospital. On review of the plastic surgery literature, the authors were unable to find current guidelines or recommendations for preoperative pregnancy testing in the plastic surgery patient population. METHODS: Literature regarding maternal and fetal risk during anesthesia and surgery, as well as preoperative pregnancy testing was identified by performing a PubMed, OVID and MEDLINE key word search. The current literature was subsequently reviewed and summarized. RESULTS: A report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation allows physicians and hospitals to implement their own policies and practices with regard to preoperative pregnancy testing. The overall frequency of an incidentally found positive preoperative pregnancy test ranges from 0.34% to 2.4%. DISCUSSION: Various studies have reported increased rates of spontaneous abortions, congenital anomalies, such as neural tube defects, and low and very low birth weight infants born to mothers exposed to anesthesia and surgery during pregnancy. Because the accepted practice is to postpone elective surgery during pregnancy, identifying these patients before surgery is critical. CONCLUSIONS: Based on the current evidence, the authors' best practice recommendation for preoperative pregnancy testing is provided.

HISTORIQUE: Dans jusqu'à 2 % de toutes les grossesses surgit la nécessité d'une anesthésie générale en vue d'une opération non obstétricale. L'opération d'une femme enceinte peut avoir des conséquences importantes pour le fœtus, la patiente, le médecin et l'hôpital. À l'analyse de la documentation en chirurgie plastique, les auteurs n'ont pu trouver de lignes directrices ou recommandations à jour sur les tests de grossesse préopératoires auprès de la population de patientes subissant une chirurgie. MÉTHODOLOGIE: Les auteurs ont colligé la documentation scientifique à l'égard du risque pour la mère et le fœtus pendant l'anesthésie et des tests de grossesse préopératoires au moyen d'une recherche par mots clés dans PubMed, OVID et MEDLINE. Ils l'ont ensuite analysée et résumée. RÉSULTATS: Un rapport du groupe de travail sur l'évaluation préanesthésique de l'American Society of Anesthesiologists permet aux médecins et aux hôpitaux d'adopter leurs propres politiques et pratiques relativement aux tests de grossesse préopératoires. La fréquence globale de tests de grossesse préopératoires dont les résultats positifs sont fortuits oscille entre 0,34 % et 2,4 %. EXPOSÉ: Diverses études font état d'une augmentation du taux d'avortements spontanés, d'anomalies congénitales, telles qu'une anomalie du tube neural, et de petit poids ou d'extrême petit poids de naissance chez les nourrissons nés de mères exposées à l'anesthésie et à la chirurgie pendant la grossesse. Puisqu'en cas de grossesse, la pratique acceptée consiste à reporter les chirurgies non urgentes, il est essentiel de repérer ces patientes avant l'opération. CONCLUSIONS: D'après les données probantes actuelles, les auteurs présentent leurs recommandations de pratique exemplaire à l'égard des tests de grossesse avant une opération.

Acute macroglossia in the pediatric patient: worth a look.

Macroglossia is defined as an enlarged tongue that in the resting position protrudes beyond the alveolar ridge or teeth. Macroglossia may be a chronic, indolent phenomenon or may be acute. We present a case of acute traumatic macroglossia in a pediatric patient following accidental self-application of an orthodontic elastic band. The 5-year-old patient presented with swelling of the anterior portion of the tongue unassociated with upper airway obstruction. The diagnosis was delayed until the patient was in the operating room under general anesthesia for repair of a presumed traumatic laceration, 3 weeks after her initial presentation. A thorough history may not reveal the cause of acute macroglossia. Examination under sedation may be necessary to establish a definitive diagnosis.

Breast augmentation: A geographical comparison.

OBJECTIVE: To describe and compare physical characteristics and implant details of women undergoing primary cosmetic breast augmentation in different geographical locations. METHODS: Three cohorts of 100 consecutive breast augmentation cases in university settings were retrospectively reviewed for patient demographic and implant information in Kelowna (British Columbia), Loma Linda (California, USA) and Temple (Texas, USA). Statistical analysis was performed with a Kruskal-Wallis test without normality assumption (P<0.05 was considered to be significant). Pearson correlation coefficients were also determined for body mass index (BMI) versus implant volume at each of the sites. RESULTS: The three group medians were significantly different for weight, BMI and implant volume. Kelowna's average patient was 33 years of age, had a BMI of 20.8 kg/m(2) and an implant volume of 389 mL. Loma Linda's average patient was 32 years of age, had a BMI of 21.6 kg/m(2) and an implant volume of 385 mL. Temple's average patient was 36 years of age, had a BMI of 22.6 kg/m(2) and an implant volume of 335 mL. Pearson correlations for BMI versus implant volume were statistically significant in the Loma Linda and Temple groups. CONCLUSION: Patients from different geographical locations undergoing breast augmentation were similar in age, height and parity, but varied in weight, BMI and implant volume. A positive linear correlation between BMI and implant volume was found in the American cohorts.

Taser and Taser associated injuries: a case series.

Taser devices were introduced in 1974 and are increasingly used by law enforcement agencies. Taser use theoretically reduces the risk of injury and death by decreasing the use of lethal force. We report a spectrum of injuries sustained by four patients subdued with Taser devices. Injuries identified in our review included: 1) a basilar skull fracture, right subarachnoid hemorrhage, and left-sided epidural hemorrhage necessitating craniotomy; 2) a concussion, facial laceration, comminuted nasal fracture, and orbital floor fracture; 3) penetration of the outer table and cortex of the cranium by a Taser probe with seizure-like activity reported by the officer when the Taser was activated; and 4) a forehead hematoma and laceration. The Taser operator's manual states that these devices are designed to incapacitate a target from a safe distance without causing death or permanent injury. However, individuals may be exposed to the potential for significant injury. These devices represent a new mechanism for potential injury. Trauma surgeons and law enforcement agencies should be aware of the potential danger of significant head injuries as a result of loss of neuromuscular control.