Breast Tissue Expanders with Magnetic Ports: Clinical Experience at 1.5 T.

BACKGROUND: The purpose of this study was to evaluate breast tissue expanders with magnetic ports for safety in patients undergoing abdominal/pelvic magnetic resonance angiography before autologous breast reconstruction. METHODS: Magnetic resonance angiography of the abdomen and pelvis at 1.5 T was performed in 71 patients in prone position with tissue expanders with magnetic ports labeled "MR Unsafe" from July of 2012 to May of 2014. Patients were monitored during magnetic resonance angiography for tissue expander-related symptoms, and the chest wall tissue adjacent to the tissue expander was examined for injury at the time of tissue expander removal for breast reconstruction. Retrospective review of these patients' clinical records was performed. T2-weighted fast spin echo, steady-state free precession and gadolinium-enhanced spoiled gradient echo sequences were assessed for image artifacts. RESULTS: No patient had tissue expander or magnetic port migration during the magnetic resonance examination and none reported pain during scanning. On tissue expander removal (71 patients, 112 implants), the surgeons reported no evidence of tissue damage, and there were no operative complications at those sites of breast reconstruction. CONCLUSION: Magnetic resonance angiography of the abdomen and pelvis in patients with certain breast tissue expanders containing magnetic ports can be performed safely at 1.5 T for pre-autologous flap breast reconstruction perforator vessel mapping. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Nasal Sculpting: Calculated and Predictable Tip Elevation With Cephalic Trim.

BACKGROUND: Rhinoplasty techniques to affect nasal tip rotation are well described. Cephalic alar trim is a powerful method for achieving tip elevation. Previous studies and texts provide aesthetic guidelines for nasolabial angles. Often, surgeon experience determines the degree of lower lateral cartilage resection to achieve optimal results. This study analyzes the change in tip elevation with measured resections of the lower lateral cartilages. This can aid the surgeon in accurately predicting the effect of cephalic alar trim on tip elevation. METHODS: Ten fresh cadaveric dissections were performed to determine the change in nasolabial angles after cephalic trim of the lower lateral cartilage. Closed rhinoplasty technique was performed using marginal and intercartilaginous incisions to expose the lower lateral cartilage. Caliper measurements of the lower lateral cartilage were recorded. Serial cephalic trim was performed in 25% increments. True lateral photographs were obtained before and after each serial excision. Nasolabial angle measurements were obtained using a digital goniometer for digital photo analysis. RESULTS: Four female and 6 male cadavers were evaluated. The mean initial nasolabial angle was 106° ± 2°. The mean lower lateral cartilage width was 9.45 ± 1.38 mm. Serial 25% reductions in lower lateral cartilage height resulted in a mean total nasolabial angle change of 7.4°, 12.9°, and 19.6°, respectively. The mean incremental change in the nasolabial angle was 6.47° ± 1.25°. CONCLUSION: The nasolabial angle is an essential aesthetic feature. Cephalic trim is a key maneuver in affecting the nasolabial angle. A 25% lower lateral cartilage cephalic trim correlates with an average change in the nasolabial angle of 6.47°. Knowledge of the cephalic trim to nasolabial angle relationship aids in achieving desired tip elevation.

Synchronous squamous cell carcinoma in multiple digits.

Cancers of the perionychium are relatively rare occurrences and are often related to chronic inflammation associated with trauma, infection, exposure to ultraviolet radiation, or other carcinogens. Squamous cell carcinoma is the most common tumor reported of the nail bed. Synchronous squamous cell carcinomas of the perionychium have been rarely reported. We present a case of a 46-year-old woman with synchronous squamous cell carcinomas involving both hands and multiple digits. Treatment modalities include chemotherapeutics, Mohs surgery, and amputation. Early diagnosis of squamous cell carcinoma of the nail bed provides the greatest chance to preserve maximal function of the hand. Onychomycosis may be the presenting symptom of a patient with squamous cell carcinoma and may also be a predisposing factor in patients with occupational risk factors. Suspicion of this disease process can help the clinician establish the diagnosis via biopsy and provide optimal care for these patients.

Safe treatment of trigger thumb with longitudinal anatomic landmarks.

OBJECTIVE: Stenosing tenosynovitis of the thumb flexor tendon sheath is also known as trigger thumb. It is an inflammatory process that involves the flexor tendon sheath at the A1 pulley. Successful percutaneous or open treatment of trigger thumb depends on the ability of the clinician to properly predict the location of the A1 pulley. Longitudinal anatomic landmarks can facilitate safe treatment for the trigger thumb while circumventing injury to the neurovascular bundles. METHODS: Fourteen fresh cadaveric hands were dissected to identify surface landmarks corresponding to the oblique course of the flexor pollicis longus tendon at the level of the A1 pulley. RESULTS: The longitudinal landmarks for the A1 pulley of the thumb are the palpable hook of the hamate and the midline of the thumb interphalangeal (IP) crease. Other bony prominences, such as the pisiform bone did not serve as effective landmarks while the thumb was in an abducted position. CONCLUSION: we encourage the use longitudinal anatomic landmarks to predict the location of the thumb A1 pulley. The hook of the hamate and the midline at the palmar interphalangeal crease are reliable landmarks for safe release of the A1 pulley while avoiding inadvertent injury to adjacent structures.

Salvage of exposed implantable cardiac electrical devices and lead systems with pocket change and local flap coverage.

Erosion and exposure of pacemaker (PPM) and implantable cardiac defibrillator (ICD) devices are potentially dire complications, which have classically required the removal of the entire generator and lead systems. This study evaluates a series of cases wherein debridement, irrigation, pocket change, and local flap coverage were used for the successful salvage of indwelling leads after exposure and infection of implantable cardiac defibrillator devices. Patients with skin erosion, infection, and/or exposure of prepectoral infraclavicular cardiac defibrillator devices were treated over a 23-month period between June 2004 and April 2006. The surgical technique involved wide excision of the exposure site with a rhombic incision pattern, followed by removal of the generator unit and complete debridement of the peridevice capsule. Subclavian atrioventricular (AV) leads were preserved. The pocket was irrigated with antibiotic solution. A new pocket plane was selected and developed, and a new generator unit was implanted. A rhombic flap was developed and transposed to achieve tension-free closure over closed suction drains. Data were reviewed retrospectively. Six patients were treated, all male, mean age 66 years (range, 50 to 83 years). All patients presented with "new" exposure of the implantable generator within 48 hours. None demonstrated gross purulence, sepsis, or endocarditis. Initial gram stain was negative for bacteria in all cases, 1 (17%) grew sensitive Staphylococcus epidermidis species. Mean follow-up is 22 months (range, 8 to 31 months). One patient (17%) developed a hematoma, successfully treated by aspiration. Five patients (83%) were treated successfully, with no wound dehiscence, generator or lead exposure, or recurrence of infection. One patient (17%) developed drainage and exposure at a separate site (AV lead) at 10 months postoperative and required generator and lead explantation and site change to the contralateral anterior chest wall. In conclusion, in the absence of sepsis or gross infection, skin excision, pocket change, generator change with lead preservation, closed-suction drainage, and flap coverage for tension-free closure should be considered in the treatment of early ICD and PPM exposure.

Multilayer reconstruction of abdominal wall defects with acellular dermal allograft (AlloDerm) and component separation.

Multiple techniques have been employed for the repair of abdominal incisional hernias with varying rates of success. Primary fascial apposition and prosthetic implantation have been associated with high rates of secondary recurrence, infection, and other complications, often due to insufficient alleviation of tension and implant intolerance. This study evaluates the repair of incisional and recurrent abdominal hernias with multilayered acellular dermal allograft (AlloDerm; LifeCell Corporation, Branchburg, NJ) and musculofascial separation. Patients with incisional or recurrent abdominal hernias were treated between January 2003 and March 2004. The surgical technique involved musculofascial release of the external oblique, followed by a double-layer implantation of dermal allograft. The primary allograft layer was placed as an "underlay" interposition, sutured under moderate tension beneath the fascial edges of the defect. When minimal tension remained, the native fascial margins of the defect were directly repaired. A second allograft layer was then placed and sutured to the superficial aspect of the ventral fascia to complete the repair. Data were reviewed retrospectively. Sixteen patients were treated. There were 10 males and 6 females, mean age 56 years (range 44--72 years). Fifteen patients (94%) had previous hernia repair procedures, and 6 patients (38%) had undergone 2 or more previous procedures. Nine patients (56%) were treated with hernia site infections or prosthetic exposure. Mean follow-up is 16 months (range 9 to 23 months). There were 2 seromas (13%). One patient (6%) developed a wound dehiscence with allograft exposure that healed by secondary intention. There were no recurrences. By minimizing tension and providing a durable biocompatible matrix for support, component separation with bilaminar acellular dermal allograft should be considered for the repair of complex and recurrent ventral hernias.