Autologous Breast Reconstruction in a Patient With End-Stage Renal Disease and Systemic Lupus Erythematosus.

Background: Patients with end-stage renal disease (ESRD) secondary to systemic lupus erythematosus (SLE) have historically been deterred from free flap breast reconstruction due to perceived complication risks. Numerous studies examining patients with ESRD have cited free flap complications, including increased incidences of infection and wound breakdown, with some surgeons suggesting ESRD is an independent risk factor for flap failure.15 Due to perceived risks, autologous breast reconstruction has not been extensively explored as an option in patients with ESRD on hemodialysis with comorbid connective tissue/autoimmune disorders, such as SLE. To the authors' knowledge, there are currently no published reports of successful free flap breast reconstruction in patients with ESRD due to SLE. Methods: This case report describes a patient requiring hemodialysis for ESRD caused by SLE who underwent left mastectomy and immediate autologous breast reconstruction. Deep inferior epigastric perforator flap technique was employed. Conclusions: This successful case report suggests the use of free flaps is a feasible option that should be considered for oncologic breast reconstruction in patients with ESRD secondary to SLE who require hemodialysis. The authors believe that further investigation is warranted to evaluate the safety of autologous breast reconstruction as an option for patients with either comorbidity. While ESRD and SLE are not explicit contraindications to free flap reconstruction, careful patient selection and appropriate indication is paramount for immediate surgical and long-term reconstructive success.

Sweet Syndrome After Bilateral Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Case Report.

We describe a case of Sweet's Syndrome after bilateral deep inferior epigastric perforator flap breast reconstruction in a patient with ductal carcinoma of the left breast.

Use of antibiotic beads to salvage infected breast implants.

PURPOSE: When an implant becomes infected, implant salvage is often performed where the implant is removed, capsulectomy is performed, and a new implant is inserted. The patient is discharged with a PICC line and 6-8 weeks of intravenous (IV) antibiotics. This method has variable success and subjects the patient to long-term systemic antibiotics. In the 1960s, the use of antibiotic-impregnated beads for the treatment of chronic osteomyelitis was described. These beads deliver antibiotic directly to the site of the infection, thereby eliminating the complications of systemic IV antibiotics. This study aimed to present a case series illustrating the use of STIMULAN calcium sulfate beads loaded with vancomycin and tobramycin to increase the rate of salvage of the infected implant and forgo IV antibiotics. METHODS: A retrospective analysis was performed of patients who were treated at Mount Sinai Hospital for implant infection with salvage and antibiotic beads. RESULTS: Twelve patients were identified, 10 of whom had breast cancer. Comorbidities included hypertension, smoking, and immunocompromised status. Infections were noted anywhere from 5 days to 8 years postoperatively. Salvage was successful in 9 out of the 12 infected implants using antibiotic bead therapy without home IV antibiotics. CONCLUSIONS: The use of antibiotic beads is promising for salvaging infected breast implants without IV antibiotics. Seventy-five percent of the implants were successfully salvaged. Of the three patients who had unsalvageable implants, one was infected with antibiotic-resistant Rhodococcus that was refractory to bead therapy and one was noncompliant with postoperative instructions.

Use of both antegrade and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction.

BACKGROUND: Autologous abdominal tissue transfer is a well-established method of breast reconstruction. The deep inferior epigastric perforator (DIEP) flap has the additional benefit of minimal donor site morbidity as it spares the muscle and fascia. Conventional DIEP flaps may not provide adequate volume in cases where the patient is thin, has midline abdominal scars, and/or has a large volume of tissue to replace. One solution is to use a bipedicled DIEP flap, incorporating all the available abdominal tissue. Bipedicled DIEP flaps have been described in a number of different configurations. The literature appears to favor intra-flap anastomosis, with a minimal exposition of two recipient vessels. It has been demonstrated that both the antegrade internal mammary artery (aIMA) and retrograde internal mammary artery (rIMA) are adequate recipient vessels. Here, the authors present a single-center experience with bipedicled DIEP flaps to both the aIMA and rIMA, showing their feasibility and safety. METHODS: A retrospective review of patients who underwent unilateral breast reconstruction using bipedicled DIEP flaps was performed to assess outcomes. RESULTS: A total of 20 patients who underwent unilateral breast reconstruction using a bipedicled DIEP flap were selected for this study. All of them were previously diagnosed with cancer. There were zero flap failure and zero instance of abdominal hernia or issue with abdominal wall functionality following the surgeries. CONCLUSIONS: The series of surgeries described in this study resulted in successful breast reconstruction in 20 women using a bipedicled DIEP flap. The results show that this approach allows for reconstruction in places where a conventional DIEP does not provide adequate volume, achieved safely, and does not increase morbidity. The bipedicled DIEP flap is a viable option for large-volume autologous breast reconstruction, providing ample tissue for successful reconstruction while also allowing for shorter recovery and limited donor site morbidity.

The Use of a Hyaluronic Acid-Carboxymethylcellulose Membrane as an Adhesion Barrier during Nipple Delay before Nipple-preserving Mastectomy.

The desire for nipple-preserving mastectomies has increased over the past decade as studies have proven that the procedure has comparable oncologic risk as a traditional mastectomy in both therapeutic and prophylactic cases. Partial or complete nipple necrosis is a well-known complication of this procedure with rates in the literature ranging between 1% and 9%. In high-risk patients, surgeons are performing a delay procedure before the mastectomy to help improve nipple vascularity and decrease necrosis rates. We present a technique of using a short-lasting bioresorbable hyaluronate-carboxymethylcellulose membrane (Seprafilm; Genzyme, Cambridge, Mass.) during the delay procedure as an interpositional sheet, which prevents adhesion of the anterior breast skin from the underlying gland to both block revascularization to improve nipple perfusion and prevent the need for redissection of the previously created plane during the final mastectomy.

Immediate bone grafting and plating of the radial osteocutaneous free flap donor site.

BACKGROUND: The primary shortcoming of the osteocutaneous radial forearm flap (ORFF) in head and neck reconstruction is the high incidence of fracture at the donor site. Although several prophylactic measures are reported, combined plating with iliac crest bone graft (ICBG) of the donor site has not been previously described. Outcomes and rationale for this method of radius reconstruction are described. METHODS: Retrospective review of a prospectively maintained database identified 23 consecutive patients who underwent head and neck reconstruction using an ORFF. Flap features, method of donor-site reconstruction, and complications were evaluated. RESULTS: The initial 7 patients from the series had no intervention at the radius donor site. The next 7 patients had ICBG only, whereas the final 9 patients had both plating and ICBG placed at the donor site. The mean cross-sectional diameter and length of radius bone harvested was 30% by 7 cm, 33% by 8 cm, and 53% by 9 cm for the 3 groups, respectively. Fracture rates for the 3 groups were 29%, 14%, and 0%. There were no iliac crest donor-site complications. CONCLUSIONS: Plating combined with ICBG is a safe and effective method for radius donor-site reconstruction. This technique maximizes both early and late strength of the radius while allowing for harvest of greater segments of bone. Decreased donor-site morbidity combined with more bone available for use in oromandibular reconstruction may tip the risk-benefit scale in favor of more widespread ORFF use.

Minimally invasive correction of inverted nipples: a safe and simple technique for reliable, sustainable projection.

Numerous techniques have been described for the correction of inverted nipples; their diversity supports the lack of a consistently reliable method. Dermoglandular flaps, open suture, and suction techniques have all been described to combat the "corrected" nipple's propensity to collapse. We present a minimally invasive parenchymal release and percutaneous suture technique that provides sustainable long-term correction of inverted nipples. Thirty-one patients with 58 inverted nipples were treated. The technique, performed under local anesthesia, employs lysis of the foreshortened subareolar fibro-ductal tissue to achieve resting eversion of the nipple using an 18-gauge needle. Through the same needle-access site, a purse-string suture is then placed, exiting the areolar skin and re-entering through the same stitch point every 3 to 5 mm around the circumference of the new nipple-base. An absorbable suture closes the access site over the knot, and 2 crossed absorbable mattress sutures are placed beneath the nipple to complete the correction. Of 27 patients with bilateral and 4 with unilateral, nipple inversion, durable correction was achieved in 1 procedure in 45 of 58 nipples (78%). There were 13 recurrences, of which 11 (19%) were successfully treated under local anesthesia with a second purse-string suture, and 2 (3%) required a third procedure under local anesthesia. There were no late reinversions. There were no cases of infection, nipple ischemia, or other complications. Occasional recurrences are corrected very simply under local anesthesia. Percutaneous release of nipple inversion followed by purse-string suture support performed through "needle-only" access points is a simple, safe, and reliable technique, and should be considered for the correction of inverted nipples.

Incidence of vertebral artery thrombosis in cervical spine trauma: correlation with severity of spinal cord injury.

BACKGROUND AND PURPOSE: The incidence of blunt traumatic vertebral artery dissection/thrombosis varies widely in published trauma series and is associated with spinal trauma. The purpose of this study was to determine the frequency of traumatic vertebral artery thrombosis (VAT) in cervically injured patients by using routine MR angiography (MRA) and MR imaging and identify associations with the severity of neurologic injury. METHODS: A retrospective review of 1283 patients with nonpenetrating cervical spine fractures with or without an associated spinal cord injury (SCI) was performed. Imaging consisted of routine cervical MR imaging and 2D time-of-flight MRA of the neck. The cervical injury level, neurologic level of injury, and American Spinal Injury Association (ASIA) grade were recorded. RESULTS: In this study, 632 patients met the inclusion criteria, 83 (13%) of whom had VAT on the admission MR imaging/MRA. Fifty-nine percent (49/83) of VAT patients had an associated SCI. VAT was significantly more common in motor-complete patients (ASIA A and B, 20%) than in neurologically intact (ASIA E, 11%) cervical spine-injured patients (P = .019). VAT incidence was not significantly different between motor-incomplete (ASIA C and D, 10%) and neurologically intact (ASIA E, 11%) cervical spine-injured patients (P = .840). CONCLUSION: The absence of neurologic symptoms in a patient with cervical spine fracture does not preclude VAT. VAT associated with cervical spinal injury occurs with similar frequency in both neurologically intact (ASIA E) and motor-incomplete patients (ASIA C and D) but is significantly more common in motor-complete SCI (ASIA A and B).