Patient Characteristics Associated with Free Nipple Graft Reduction Mammoplasty.

PURPOSE: Surgical approaches for reduction mammoplasty most commonly incorporate a parenchymal vascular pedicle. For patients with larger breasts where pedicle viability may be compromised due to excessive length, the free nipple graft (FNG) technique provides a safe alternative. Criteria for whether a patient should undergo a FNG remains controversial due to variable reports in the literature with small sample sizes and inherent surgeon-dependent bias. To address this, we sought to investigate perioperative factors associated with performing FNGs at our institution in order to better elucidate specific indications for this surgery. METHODS: A retrospective chart review was performed for 323 patients who underwent a reduction mammoplasty from August 2009 to July 2019 at Keck Hospital and LAC+USC Medical Center. Data regarding patient demographics, comorbidities, pre-operative breast characteristics, and post-operative complications were extracted. Student's t-test, Fisher's exact test, and logistic regression were performed in R. RESULTS: Of 323 patients, 15 received an FNG. Independent variables analyzed included: age, body mass index (BMI), obesity, smoking, diabetes, hypertension, surgical indication, sternal notch-to-nipple length, nipple-to-inframammary fold length, and weight of breast specimens removed. BMI, obesity, gigantomastia, and weight of specimen resected were significantly associated with use of the FNG (p < 0.001, p < 0.05, p < 0.0001, p < 0.0001, respectively). Regression analysis revealed that patients who had an average of more than 1500 g of tissue removed from each breast were 1.41 (95% CI: 1.17-1.71, p<0.001) times more likely to undergo an FNG procedure than those who had less than 1500 g of tissue removed. Demographic data and breast characteristics, such as notch-to-nipple length and nipple-to-inframammary fold length, were not significantly associated. CONCLUSION: Total weight of the breast specimens removed and BMI were significantly associated with the FNG technique. Removing more than 1500 g gof total breast tissue was also significantly correlated. These findings may guide surgeons during the decision-making process of when to use an FNG.

National Outcomes after Pressure Ulcer Closure: Inspiring Surgery.

Over two million Americans receive treatment for pressure ulcers (PUs) annually, but national surgical outcomes are not well described. This study investigated rates and risk factors of postoperative complications in patients with PU. The 2011 and 2012 American College of Surgeons-National Surgical Quality Improvement Project database was queried and PU patients undergoing flap closure were identified. Descriptive statistics and multivariate regression analysis was used and reported as odds ratios (ORs) if (P < 0.05). Of 1196 patients identified with a primary diagnosis of PU, 327 (27%) underwent flap closure. Emergency interventions were performed in seven patients who were excluded from analysis. Characteristics were average age 53.3 (±17); 65 per cent male; 41 per cent with grossly contaminated or infected wounds; 29 per cent frail; and 16 per cent with an American Society of Anesthesiologists score of four or five. Myocutaneous or fasciocutaneous flaps were performed in 82 per cent of patients, local skin rearrangements in 17 per cent, and free flap in one patient. Complications were low with 1.9 per cent recurrence and 4.7 per cent reoperation rates. Higher American Society of Anesthesiologists was independently associated with mortality (odds ratio = 6.6) and steroid use correlated with flap failure (odds ratio = 15). No differences in complication profiles were identified based on technique, frailty, or contamination. Surgical closure can be considered reasonable in all patients fit for anesthesia.

Microsurgical Lower Extremity Reconstruction in the Subacute Period: A Safe Alternative.

BACKGROUND: Microsurgical reconstruction of the lower extremity is an integral part of the limb salvage algorithm. Success is defined by a pain-free functional extremity, with a healed fracture and sufficient durable soft tissue coverage. Although early flap coverage of lower extremity fractures is an important goal, it is not always feasible because of multiple factors. Between the years 2000 and 2010, approximately 50% of patients at Los Angeles County and University of Southern California Medical Center requiring microsurgical reconstruction did not receive soft tissue coverage until more than 15 days postinjury secondary to primary trauma, physiologic instability, patient comorbidities, or orthopedic and plastic surgery operative backlog. The objective of our study was to evaluate outcomes in patients who underwent microsurgical reconstruction of the lower extremity, in relation to the timing of reconstruction. METHODS: A retrospective chart review was performed for patients requiring immediate lower extremity reconstruction from January 2000 to December 2009 at LAC + USC. RESULTS: Fifty-one patients were identified in this study. The most common mechanisms of injury were motorcycle, motor vehicle, and fall accidents. Eighty-six percent of injuries were open and 74% were comminuted. The distal 1/3 of the tibia, including the tibial pilon, was the most common location of injury. When comparing patients reconstructed in less than 15 days versus greater than or equal to 15 days, there was no significant difference in rates of flap failure, osteomyelitis, bony union, or ambulation. CONCLUSION: Microsurgical reconstruction of the lower extremity in the subacute period is a safe alternative.

Locomotor biomechanics after total sacrectomy: a case report.

STUDY DESIGN: Biomechanical analysis of locomotion after total sacrectomy in a single patient case. OBJECTIVE: To describe the biomechanics of locomotion after successful total sacrectomy and spinopelvic reconstruction. SUMMARY OF BACKGROUND DATA: Total sacrectomy is a complex surgery that has significant consequences for mobility after surgery due to loss of lower lumbar and sacral innervation to the lower extremities, and the anatomic dissociation of the spine from the pelvis. There is no existing literature quantifying locomotor biomechanics after total sacrectomy. METHODS: A 22-year-old female with a sacral osteosarcoma underwent an en bloc sacrectomy with L3 to pelvis instrumented fusion. Neuromuscular function was tested 1 year after surgery using monopolar needle electromyography. Three-dimensional motion capture and surface electromyography were used to quantify spatiotemporal characteristics of locomotion and lower extremity kinematics, kinetics, and muscle function during locomotion at 6 months and 1 year after surgery. RESULTS: Electrodiagnostic testing suggested partial preservation and reinnervation of S1 nerve root function on the right, resulting in greater than expected activity in the hamstrings, gluteus maximus, and triceps surae postsurgically. Unexpectedly on the left, there was residual activity in the hamstrings, despite the loss of sacral innervation and the sciatic nerve. At 1 year after surgery, the patient was able to walk independently. Kinematic and kinetic impairments and compensations were most evident in the sagittal and coronal planes. CONCLUSION: Excellent locomotor outcomes are possible after total sacrectomy.

Assessment of three-dimensional high-definition visualization technology to perform microvascular anastomosis.

BACKGROUND AND AIM: Traditional visualization techniques in microsurgery require strict positioning in order to maintain the field of visualization. However, static posturing over time may lead to musculoskeletal strain and injury. Three-dimensional high-definition (3DHD) visualization technology may be a useful adjunct to limiting static posturing and improving ergonomics in microsurgery. In this study, we aimed to investigate the benefits of using the 3DHD technology over traditional techniques. METHODS: A total of 14 volunteers consisting of novice and experienced microsurgeons performed femoral anastomoses on male Sprague-Dawley retired breeder rats using traditional techniques as well as the 3DHD technology and compared the two techniques. Participants subsequently completed a questionnaire regarding their preference in terms of operational parameters, ergonomics, overall quality, and educational benefits. Efficiency was also evaluated by mean times to complete the anastomosis with each technique. RESULTS: A total of 27 anastomoses were performed, 14 of 14 using the traditional microscope and 13 of 14 using the 3DHD technology. Preference toward the traditional modality was noted with respect to the parameters of precision, field adjustments, zoom and focus, depth perception, and overall quality. The 3DHD technique was preferred for improved stamina and less back and eye strain. Participants believed that the 3DHD technique was the better method for learning microsurgery. Longer mean time of anastomosis completion was noted in participants utilizing the 3DHD technique. CONCLUSIONS: The 3DHD technology may prove to be valuable in improving proper ergonomics in microsurgery. In addition, it may be useful in medical education when applied to the learning of new microsurgical skills. More studies are warranted to determine its efficacy and safety in a clinical setting.

Breast reconstruction satisfaction rates at a large county hospital.

BACKGROUND: It has been previously reported that the indigent patient population is less likely to seek breast reconstruction. It has also been reported that lower income women who do chose to undergo reconstruction are less satisfied with the results. This study assesses the level of breast reconstruction satisfaction in women treated at Los Angeles County Medical Center (LAC). For those women with lower satisfaction, we seek to identify the root source of this dissatisfaction. METHODS: Patients who underwent breast reconstruction at LAC from 2007 to 2012 were identified by Current Procedural Terminology codes. Eligible participants were administered the BREAST-Q postreconstruction module. Demographic data were obtained from the patient and/or their medical records. RESULTS: A total of 65 patients completed the surveys. The satisfaction scores for the appearance of the breast were 61 (24) and satisfaction with overall outcome was 80 (26). The occurrence of major complications was associated with lower satisfaction scores with respect to the appearance of the breast (P<0.0001) and overall outcome (P=0.02). In addition, patients with delayed reconstruction were also noted to be more satisfied with respect to appearance of the breast (P=0.03). CONCLUSIONS: Despite suggestions that the indigent and the underserved patient population are less satisfied with the results of their breast reconstruction procedures, patients at LAC demonstrated comparable satisfaction levels to other published reports. The occurrence of major complications and immediate reconstruction were significantly associated with lower levels of satisfaction.

Determination of a perfusion threshold in experimental perforator flap surgery using indocyanine green angiography.

Indocyanine green (ICG) angiography has been used in the evaluation of flap perfusion but the viability threshold has not been elucidated. In this study, we determined the threshold by comparing perfusion, using ICG imaging (SPY imaging system, LifeCell Corporation), to clinical evidence of nonviability in rat abdominal perforator flaps. Abdominal flaps, based on a single perforator, were elevated and re-inset in Sprague-Dawley rats. ICG imaging and clinical assessments were conducted preoperatively, as well as 0, 24, and 48 hours postoperatively. SPY-Q software allowed standardization of the perforator's perfusion for comparison purposes. A total of 278 random percentage measurements were made from postoperative day 0 giving a mean (SE) percentage perfusion of 26.8% (1.6%) and 59.1% (1.3%), respectively, for necrosis and survival (P<0.05). We demonstrate that ICG angiography can be readily analyzed in a perforator flap environment allowing a determination of the perfusion threshold.

Oncoplastic approaches to breast conservation.

When a woman is diagnosed with breast cancer many aspects of her physical, emotional, and sexual wholeness are threatened. The quickly expanding field of oncoplastic breast surgery aims to enhance the physician commitment to restore the patient's image and self-assurance. By combining a multidisciplinary approach to diagnosis and treatment with oncoplastic surgery, successful results in the eyes of the patient and physician are significantly more likely to occur. As a way to aid oncoplastic teams in determining which approach is most suitable for their patient's tumor size, tumor location, body habitus, and desired cosmetic outcome we present a review of several oncoplastic surgical approaches. For resections located anywhere in the breast, the radial ellipse segmentectomy incision and circumareolar approach for segmental resection are discussed. For resections in the upper or central breast, crescent mastopexy, the batwing incision, the hemibatwing incision, donut mastopexy, B-flap resection, and the central quadrantectomy are reviewed. For lesions of the lower breast, the triangle incision, inframammary incision, and reduction mastopexy are discussed. Surgeons who are interested in adding oncoplastic breast conserving therapies to their skill sets are encouraged to implement these surgical techniques where applicable and to seek out breast fellowships or enhanced training when appropriate.

Preventing postsurgical dissatisfaction syndrome after rhinoplasty with propranolol: a pilot study.

BACKGROUND: Rhinoplasty patients are commonly anxious about their result when the splint is removed. A small group of them, however, are overtly unhappy with their appearance despite objectively satisfactory early results, cannot be reassured about their favorable long-term prognosis, and remain dissatisfied despite objectively satisfactory end results. The authors have termed this symptom complex "postsurgical dissatisfaction syndrome." In these patients, it seems that persistence of the original negative image of their appearance at the time of splint removal fails to yield to an improved self-image as healing progresses. METHODS: The authors theorized that the syndrome is analogous to the persistence of negative emotional memories seen in posttraumatic stress disorder. In trauma-exposed patients, the beta-adrenergic blocker propranolol, when given within a few hours of the traumatic event, may reduce the subsequent emotional strength of the traumatic memory. The authors hypothesized that giving propranolol to postrhinoplasty patients with the above early symptomatology would reduce the likelihood of postsurgical dissatisfaction syndrome. RESULTS: A retrospective review of 1000 consecutive rhinoplasty patients identified 11 with early symptomatology. Of these 11 (not taking propranolol), nine (82 percent) developed postsurgical dissatisfaction syndrome. In addition, a prospective study was performed of nine additional patients with the same early symptomatology who were immediately treated with propranolol. In contrast, only three developed postsurgical dissatisfaction syndrome (p < 0.04). Results of a randomized, double-blind, placebo-controlled study of 50 additional postrhinoplasty patients suggests that propranolol's effect is not due to anxiolysis. CONCLUSIONS: Propranolol given immediately after splint removal in anxious, unhappy cosmetic surgery patients may prevent postsurgical dissatisfaction syndrome. A double-blind study appears warranted.

Optimal dose of enoxaparin in critically ill trauma and surgical patients.

BACKGROUND: Low-molecular-weight heparin is effective for prevention of venous thromboembolism. The efficacy of daily dosing in critically ill patients is unknown. METHODS: Seventeen critically ill patients on 40 mg of enoxaparin subcutaneously daily were studied. Anti-Xa activity was measured 4 hours after the third dose and before the fourth dose. Adverse events were recorded. RESULTS: Mean peak anti-Xa activity was 0.19 +/- 0.09 International Units/mL and mean trough was 0.044 +/- 0.04 International Units/mL. The recommended target range is 0.1 to 0.2 International Units/mL. The trough was below therapeutic levels in all but two patients. One thrombosis occurred in a patient despite a therapeutic trough. CONCLUSION: Daily dosing of enoxaparin is inadequate for critically ill patients and should be abandoned. Further studies using twice daily dosing are needed. Patients with renal insufficiency may require an increased interval of administration (daily dosing). Anti-Xa levels may not correlate with the risk of thromboembolic complications. Patients with renal insufficiency and morbid obesity may require alternative dosing and monitoring of anti-Xa levels.

Early enteral nutrition does not decrease hypermetabolism associated with burn injury.

BACKGROUND: A prospective, randomized study was performed to compare the effects of early versus late enteral feeding on postburn metabolism. METHODS: Burn patients were randomized to receive enteral feedings either within 24 hours (early) or 7 days (late) of injury. Basal energy expenditure (BEE) was calculated from Harris-Benedict equations and resting energy expenditure (REE) was obtained from indirect calorimetry. The average daily energy expenditure (DEE) was expressed as REE/BEE. RESULTS: Average age, burn size, infections, and length of stay were similar between groups. Mortality between groups was similar (early, 28%; late, 38%) and not significantly influenced by inhalation injury. When controlled for percentage of total body surface area burn, inhalation injury, and age, the early group had an increased rather than decreased DEE, with a mean DEE calorie 0.17 more than the late group (p = 0.07). CONCLUSION: Early enteral feeding does not decrease the average energy expenditure associated with burn injury.

Real-time monitoring of keratin 5 expression during burn re-epithelialization.

BACKGROUND: Keratin is a major protein produced during epithelialization following burn injury and is a useful marker for assessing wound healing. Transgenic mice expressing enhanced green fluorescent protein (EGFP) driven by the keratin 5 (K5) promoter (K5GFP mice) were used to monitor keratin expression, and thus, re-epithelialization of burn wounds. MATERIALS AND METHODS: K5GFP transgenic mice were created using conventional techniques, with PCR and Southern blot confirmation of transgene incorporation, followed by selection of the line with the most intense and consistent basal epithelial EGFP expression. Epi-fluorescent microscopy of 24 K5GFP mouse flanks and 10 negative littermate controls was used to characterize EGFP intensity, before wounding and serially for 30 days after administration of a standardized burn wound and excision. Biopsy sections of K5GFP and negative control mice were stained with K5 antibody and imaged with confocal microscopy to characterize the distribution of EGFP and K5 at baseline and after injury and to examine the correlation between K5 expression and EGFP expression during healing. RESULTS: Green fluorescence intensity increased at the advancing wound margin of burned K5GFP mice, reaching a maximum between days 12 and 15 post-burn and then decreasing as healing completed. K5 and EGFP expression increased in parallel in burned K5GFP mice as demonstrated by confocal microscopy. CONCLUSION: EGFP expression correlated with K5 expression during wound healing and therefore serves as a good marker of re-epithelialization. This transgenic model allows noninvasive, real-time assessment of in vivo K5 expression and will be useful in the study of wound healing.

Elective plastic surgical procedures in adolescence.

Adolescent patients are seeking plastic surgery to correct deformities or perceived deformities in increasing numbers. It is essential for the physician to understand the influence of perceived body image irregularity that motivates patients of all ages to request plastic surgery. The increased demand for plastic surgical procedures among young patients is caused partially to increased media exposure to the available procedures offered by plastic surgeons. A successful aesthetic procedure can have a positive influence on a mature, well-motivated teenager, while surgery on a psychologically unstable adolescent can be damaging to the patient. The American Society for Aesthetic Plastic Surgery has developed guidelines for the appropriate selection of teenagers for aesthetic plastic surgery [26]. First, the physician must "assess physical maturity, because operating on a feature that has not yet fully developed could interfere with growth or negate the benefits of surgery in later years." Second, the physician should explore emotional maturity and expectations of the teenager. The teenager should understand the goals and limitations of the proposed surgery and have realistic expectations. Third, only board certified plastic surgeons who operate in accredited facilities should perform these procedures, to ensure the safety of the teenager and the quality of the procedure. Finally, teenagers and their parents should understand the risks of surgery, postoperative restrictions on activity, and typical recovery times. The referring physician and surgeon must be aware of the positive or negative effects that plastic surgery can have on the life of a teenager and be able to select patients who have the motivation, maturity, psychosocial, and emotional attributes that will lead to patient satisfaction.