A prospective study of antibiotic efficacy in preventing infection in reduction mammaplasty.

BACKGROUND: The role of prophylactic antibiotics in reduction mammaplasty remains controversial. However, most surgeons choose to use antibiotics. In addition to cost and potential allergic reactions, unnecessary administration of antibiotics can suppress host natural flora and produce resistant organisms. METHODS: Fifty patients were sequentially assigned to one of three study limbs: (1) no antibiotics, (2) preoperative antibiotics only, or (3) preoperative and postoperative antibiotics. The study was designed to include approximately 17 patients in each group. Cephalosporin antibiotics were used unless there was any question of allergy, in which case an alternative antibiotic regimen was used. Preoperative data collected on patients included age, body mass index, history of diabetes mellitus, peripheral vascular disease, previous breast surgery, steroid therapy, and tobacco use. Operative data included specimen weight, operative time, estimated blood loss, prolonged intraoperative hypotension, adjunctive axillary and breast tail liposuction, and intraoperative breast tissue culture. RESULTS: The patient population in the three limbs of the study was similar. Thus, there was no significant difference among the groups insofar as the preoperative data were concerned (p > 0.20): age, body mass index, diabetes mellitus, peripheral vascular disease, previous breast surgery, and steroid or tobacco use. Furthermore, no significant difference (p > 0.12) was noted among intraoperative data in the three groups: specimen weight, operative time, estimated blood loss, prolonged hypotension, adjunctive breast liposuction, and positive bacterial culture from intraoperative breast tissue samples. Ninety percent of positive intraoperative breast tissue cultures revealed Staphylococcus epidermidis. Using strict criteria, the infection rate ranged from 19 to 20 percent. There was no significant difference (p > 0.91) in rate of infection among the three study limbs. There was, however, a significant reduction (p = 0.002) in delayed wound healing in the group that received preoperative antibiotics only. Among the studied risk factors for infection, only positive intraoperative culture of breast tissue was significant (p = 0.008) for development of infection. There was a significant association between delayed wound healing and infection (p = 0.003). CONCLUSIONS: This prospective study did not find that prophylactic antibiotics in reduction mammaplasty have an effect on infection; however, a single preoperative dose significantly improved wound healing.

Primary cleft nasal repair: the composite V-Y flap with extended mucosal tab.

A method of primary cleft lip nasal repair utilizing a medially based composite alar flap with a mucosal tab extension is presented. The procedure modifies, with a 5- to 6-mm mucosal tab extension, a previously described chondromucosal flap technique. Most cases were done concurrent with a modified Tennison lip repair. The flap consists of the lateral crus of the alar cartilage, together with its vestibular lining. The flap is advanced medially so the dome provides the tip support for the affected side of the nose. The goal is to restore symmetry, obviating the need for future major nasal surgery. Experience with this technique in 32 patients over 4 years is reported. Although encouraged by our results, it is anticipated significant percentage of patients will still benefit from secondary nasal surgery when their nasal growth is complete.

Efficacy of reconstituted and stored botulinum toxin type A: an electrophysiologic and visual study in the auricular muscle of the rabbit.

Once botulinum toxin type A is reconstituted, the manufacturer recommends that it be used in approximately 4 hours. As a result, a significant amount of this costly drug is often discarded because it is not completely used in the recommended period. The purpose of the present study was to compare fresh versus stored reconstituted botulinum toxin type A for (1) initial potency, (2) duration of action, and (3) bacterial colonization. Using a rabbit model, 20 New Zealand White rabbits were divided into four groups (I to IV). All rabbits had an injection of 2.5 U of reconstituted botulinum toxin into the right anterior auricular muscle. The first group was injected with botulinum toxin type A that was freshly reconstituted and served as the control. The second, third, and fourth groups were injected with botulinum toxin type A that had been reconstituted and stored for 2, 6, and 12 weeks, respectively, in a conventional freezer. Each rabbit had daily visual evaluation of the ear, with the position of auricle being graded from I to III. In addition, each rabbit had a nerve conduction study performed on the right anterior auricular muscle before injection and every 2 weeks after injection. Amplitude was chosen as the principal variable in the data analysis because it is the best predictor of physiologic changes at the muscle motor unit level. The endpoint of the study was defined as the time at which the nerve conduction studies and the visual inspections returned to baseline, preinjection levels. Botulinum toxin type A was also cultured before injection into each group.Overall, the nerve conduction data revealed a trend with a faster recovery (return to baseline) with the stored botulinum toxin. Groups IV and III returned to baseline first, followed by groups II and I. However, there was no significant difference among the groups at 2 and 4 weeks after injection, indicating that initial potency was unchanged. The differences between the groups became significant (p < 0.05) at 6 weeks and onward, suggesting that the duration was affected. Group I (fresh botulinum toxin) and group II (toxin stored for 2 weeks) had comparable outcomes and were not significantly different at any time period. Under visual inspection, the mean recovery time for each group was as follows: group IV, 5.4 weeks; group III, 7.0 weeks; group II, 6.75 weeks; and group I, 7.80 weeks. The results showed significance (p < 0.05) beginning after 3 weeks among some groups. Again, there was an overall quicker trend to return to baseline with the longer storage of the botulinum toxin (groups III and IV). These results support the authors' conduction study data, which suggest that the initial potency is not affected but the duration of action is. Again, groups I and II had comparable results. Microbiology cultures showed no growth of either aerobic or anaerobic bacteria at 7 days. In conclusion, using the rabbit model, it seems that reconstituted and stored botulinum toxin type A has the same initial potency but the duration of action is affected sometime after 2 weeks of storage. No bacterial contamination was associated with storing unpreserved reconstituted botulinum toxin type A for up to 12 weeks.

Nipple-areola reconstruction: satisfaction and clinical determinants.

After performing a chart review, the authors identified 120 patients who underwent breast cancer-related reconstruction. All charts were evaluated with regard to breast mound reconstruction type, nipple-areola reconstruction type, the interval between breast mound and nipple-areola reconstruction, the number of procedures needed to achieve nipple-areola reconstruction, patient history of radiation therapy, and complications. A questionnaire was then developed and mailed to all of the patients who underwent both breast mound and nipple/areola reconstruction (n = 105) to evaluate their level of satisfaction. Of the 43 patients who returned the questionnaire, 41 completed all portions correctly. The questionnaire evaluated patient satisfaction with breast mound reconstruction; patient satisfaction with nipple-areola reconstruction; what the patient disliked most about the nipple-areola reconstruction; and whether or not the patient would choose to have breast reconstruction again. Several parameters were then tested statistically against the reported patient satisfaction.A review of all patients who underwent breast reconstruction revealed that their breast mound reconstructions were done using either a TRAM flap (59 percent), a latissimus dorsi flap and an implant (19 percent), an expander followed by an implant (9 percent), an implant only (4 percent), or other means (9 percent). The nipple-areola was reconstructed in these patients with either a star flap (36 percent), nipple sharing (10 percent), a keyhole flap (9 percent), a skate flap (9 percent), an S-flap (8 percent), a full-thickness skin graft (6 percent), or by another means (22 percent). The number of procedures needed to achieve nipple-areola reconstruction was either one (in 66 percent of the patients), two (in 32 percent of the patients), or three or more (2 percent of the patients). Eleven percent of the patients experienced the complication of nipple necrosis. Satisfaction with breast mound reconstruction was reported by 81 percent of patients to be excellent/good, by 14 percent of patients to be fair, and by 5 percent of patients to be poor. Reported satisfaction with nipple-areola reconstruction was excellent/good for 64 percent of patients, fair for 22 percent of patients, and poor for 14 percent of patients. The factors patients disliked most about their nipple-areola reconstruction were, in descending order, lack of projection, color match, shape, size, texture, and position. Statistical analysis of the data revealed inferior patient satisfaction when there was a longer interval between breast mound and nipple areola reconstruction (p = 0.003). No significant difference was observed in nipple/areola reconstruction satisfaction ratings when compared with breast mound reconstruction type (p = 0.46), nipple-areola reconstruction type (p = 0.98), and history of radiation therapy (p = 0.23). There was also no significant difference when breast mound reconstruction was compared with technique (p = 0.51) and history of radiation therapy (p = 0.079). Overall, there was a greater satisfaction with breast mound reconstruction than with nipple-areola reconstruction (p = 0.0001).

End-stage cardiac failure in a morbidly obese patient treated by biliopancreatic diversion and cardiac transplantation.

A 57-year-old 132-kg female (BMI 48.6) with end-stage cardiac failure is presented. Because of a progressive cardiomyopathy, the patient required a heart transplant. However, before receiving the transplant, major weight loss was deemed to be mandatory. Supervised dieting had manifestly failed, and thus a highly effective weight-reducing operation, biliopancreatic diversion, was performed. This resulted in a weight loss of 50.4 kg in 9 months. She then underwent successful cardiac transplantation, and progressed well for several months. She then developed severe psychiatric depression, withheld her medications and developed a lethal acute rejection phenomenon.