"Reduction mammaplasty with superomedial pedicle technique: A literature review and retrospective analysis of 938 consecutive breast reductions".

BACKGROUND: The superomedial pedicle reduction mammaplasty has been noted in the literature to provide superior aesthetic results and longevity as well as shorter operative times. However, the inferior pedicle continues to be the most commonly utilized technique in the United States. There is a lack of large-volume outcome studies examining how the superomedial pedicle technique compares against more established reduction methods. METHODS: A retrospective review of 938 reduction mammaplasties was performed at a single institution over a 10-year period. A literature review of superomedial and inferior pedicle complication rates were performed. Study variables were compared against overall mean complication rates for the two techniques. Logistic regression, paired student T-Tests, and Chi-square analyses were used to calculate adjusted odds ratios and to compare continuous and categorical variables. RESULTS: Mean reduction weight was 730 g per breast, ranging from 100 to 4700 g. Overall complication rate was 16%, of which 10% were minor complications related to delayed wound healing. No cases of skin flap necrosis occurred. Increased complications were highly correlated with a BMI > 30, breast reduction weights > 831 g, and sternal notch to nipple distances > 35.5 cm. CONCLUSIONS: The superomedial pedicle reduction mammaplasty technique is safe and reliable with a complication rate lower than the inferior pedicle technique. Based on our findings we propose that residents should be exposed to this method of reduction mammaplasty as part of a compilation of techniques learned in residency and that practicing surgeons would benefit from becoming familiar with its applications.

Hemodynamic and metabolic efficacy of dopamine versus norepinephrine in a brain-dead swine model.

We tested the hypothesis that hepatosplanchnic and systemic hemodynamics are improved with equi-effective doses of dopamine (DA) versus norepinephrine (NE) in a brain-dead swine model. Pigs (n = 18) were anesthetized and ventilated. Brain death was induced by epidural balloon inflation, hypoventilation, and hypoxia. After 30 minutes, mechanical ventilation was restored without anesthesia. During 60 and until 480 minutes, half received DA (10 microg/kg/minute) and half received NE (0.1 microg/kg/minute) titrated to a mean arterial pressure (MAP) > 60 mm Hg with supplemental fluid to maintain a central venous pressure > 8 mm Hg. Hemodynamics, hepatic laser Doppler blood flow, and hepatic and gastric tissue oxygenation with near-infrared spectroscopy were continuously monitored. Serial blood samples were analyzed for blood gases and electrolytes, coagulation changes, and serum chemistries. Balloon inflation caused brain death and autonomic storm, and 8 of 18 were nonsurvivors. After 30 minutes, the MAP, mixed venous O(2) saturation, and partial pressure of arterial oxygen values decreased to 37 +/- 2 mm Hg, 38 +/- 4, and 49 +/- 8 mm Hg, respectively. Serum lactate increased to 5.4 +/- 0.7 mM. Among survivors (n = 10), MAP stabilized with either pressor. Urine output was maintained (>1 mL/kg/hour), but creatinine increased >30% with respect to the baseline. Tachyphylaxis developed with NE but not with DA (P < 0.05). Cardiac index was higher with DA versus NE (P < 0.05). There were no differences in stroke volume, metabolic indices, or liver blood flow. Liver tissue O(2) was higher with DA versus NE at 8 hours (P < 0.05). Coagulation tests and liver enzymes were similar with NE versus DA (P > 0.05). In conclusion, after brain death, cardiac index and hepatic oxygenation were significantly improved with equi-effective doses of DA versus NE.

Cerebrovascular resuscitation after polytrauma and fluid restriction.

BACKGROUND: There are few reproducible models of blast injury, so it is difficult to evaluate new or existing therapies. We developed a clinically relevant polytrauma model to test the hypothesis that cerebrovascular resuscitation is optimized when intravenous fluid is restricted. STUDY DESIGN: Anesthetized swine (42+/-5 kg, n=35) received blasts to the head and bilateral chests with captive bolt guns, followed by hypoventilation (4 breaths/min; FiO(2)=0.21). After 30 minutes, resuscitation was divided into phases to simulate typical prehospital, emergency room, and ICU care. For 30 to 45 minutes, group 1, the control group (n=5), received 1L of normal saline (NS). For 45 to 120 minutes, additional NS was titrated to mean arterial pressure (MAP) > 60 mmHg. After 120 minutes, mannitol (1g/kg) and phenylephrine were administered to manage cerebral perfusion pressure (CPP) > 70 mmHg, plus additional NS was given to maintain central venous pressure (CVP) > 12 mmHg. In group 2 (n=5), MAP and CPP targets were the same, but the CVP target was>8 mmHg. Group 3 (n=5) received 1 L of NS followed only by CPP management. Group 4 (n=5) received Hextend (Abbott Laboratories), instead of NS, to the same MAP and CPP targets as group 2. RESULTS: Polytrauma caused 13 deaths in the 35 animals. In survivors, at 30 minutes, MAP was 60 to 65 mmHg, heart rate was >100 beats/min, PaO(2) was < 50 mmHg, and lactate was>5 mmol/L. In two experiments, no fluid or pressor was administered; the tachycardia and hypotension persisted. The first liter of intravenous fluid partially corrected these variables, and also partially corrected mixed venous O(2), gastric and portal venous O(2), cardiac output, renal blood flow, and urine output. Additional NS (total of 36+/-1 mL/kg/h and 17+/-6 mL/kg/h, in groups 1 and 2, respectively) correlated with increased intracranial pressure to 38+/-4 mmHg (group 1) and 26+/-4 mmHg (group 2) versus 22+/-4 mmHg in group 3 (who received 5+/-1 mL/kg/h). CPP was maintained only after mannitol and phenylephrine. By 5 hours, brain tissue PO(2) was>20 mmHg in groups 1 and 2, but only 6+/-1 mmHg in group 3. In contrast, minimal Hextend (6+/-3 mL/kg/h) was needed; the corrections in MAP and CPP were immediate and sustained, intracranial pressure was lower (14+/-2 mmHg), and brain tissue PO(2) was> 20 mmHg. Neuropathologic changes were consistent with traumatic brain injury, but there were no statistically significant differences between groups. CONCLUSIONS: After polytrauma and resuscitation to standard MAP and CPP targets with mannitol and pressor therapy, we concluded that intracranial hypertension was attenuated and brain oxygenation was maintained with intravenous fluid restriction; cerebrovascular resuscitation was optimized with Hextend versus NS; and longer term studies are needed to determine neuropathologic consequences.

Prolongation of skin graft survival by exogenous ubiquitin.

Recently, it was shown that exogenous ubiquitin has anti-inflammatory actions in vivo and that the ubiquitin-decapeptide 50-59 has immunosuppressive effects similar to cyclosporine. Immunosuppressive effects of the native ubiquitin molecule and its therapeutic potential in transplantation are unknown. We tested the hypothesis that ubiquitin inhibits alloreactivity and increases allograft survival in a murine model of skin transplantation in fully mismatched strain combinations (C3H/HEJ-DBA2). Ubiquitin dose-dependently inhibited mixed leukocyte reaction in C3H/HEJ splenocytes in vitro. Intraperitoneal ubiquitin administration (25 microg/h for 14 days) was well-tolerated, dose-dependently increased ubiquitin serum concentrations and median allograft survival from 10 days (with albumin; control) to 17 days in DBA2 mice (survival ratio: 1.7, 95% confidence interval: 1.266-2.134; P=0.0005). The in vivo effects in this study combined with our previous work strongly indicate that ubiquitin is a potent immune modulator with broad therapeutic potential. Ubiquitin treatment could be a novel strategy to improve immunosuppressive regimens in transplantation.

Simulation training for a mass casualty incident: two-year experience at the Army Trauma Training Center.

BACKGROUND: Civilian and military mass casualty incidents (MCI) are an unfortunate reality in the 21st century, but there are few situational training exercises (STX) to prepare for them. To fill this gap, we developed a MCI STX for U.S. Army Forward Surgical Teams (FST) in conjunction with the U.S. Army Trauma Training Center. METHODS: After a standardized briefing, each FST has 60 minutes to unpack, setup, and organize a standard equipment cache into an emergency room, operating room, and intensive care unit. In an adjacent room, five anesthetized swine are prepared with standardized, combat-relevant injuries. The number and acuity of the total casualties are unknown to the FST and arrive in waves and without warning. A realistic combat environment is simulated by creating resource limitations, power outages, security breaches, and other stressors. The STX concludes when all casualties have died or are successfully treated. FSTs complete a teamwork self-assessment card, while staff and FST surgeons evaluate organization, resource allocation, communication, treatment, and overall performance. Feedback from each FST can be incorporated into an updated design for the next STX. RESULTS: From 2003-2005, 16 FSTs have completed the STX. All FSTs have had collapses in situational triage, primary/ secondary surveys, and/or ATLS principles (basic ABCs), resulting in approximately 20% preventable deaths. CONCLUSIONS: We concluded (1) a MCI can overwhelm even combat- experienced FSTs; (2) adherence to basic principles of emergency trauma care by all FST members is essential to effectively and efficiently respond to this MCI; (3) by prospectively identifying deficiencies, future military or civilian performance during an actual MCI may be improved; and (4) this MCI STX could provide a template for similar programs to develop, train, and evaluate civilian surgical disaster response teams.

Hepatectomy enables prolonged survival in select patients with isolated noncolorectal liver metastasis.

OBJECTIVE: This study was done to determine the benefit of undergoing liver resection for noncolorectal metastasis. METHODS: A single-institution retrospective review of all patients (n = 95) who underwent hepatic resection for a noncolorectal liver metastasis from 1990 to 2005 was performed. Primary outcomes measure was months of patient survival after liver resection. RESULTS: Median patient age was 58 years (range 19 to 83 years). There were 37 men (38.9%) and 58 women (61.1%). The 30-day postoperative mortality rate was 2.1%, and postoperative complications developed in 15.8% of patients. Mean hospital stay was 7 days (range 4 to 25 days). Median time of survival from date of liver resection was 36 months, and 5-year survival rate was 34.9%. Primary tumor sites were identified as foregut or gastrointestinal in 16.8% and nongastrointestinal in 83.2%. Patients with a nonforegut primary tumor had a median survival time twice as long as those with foregut primaries (49 months versus 20 months, p < 0.001). Multiple liver metastases were an independent prognostic factor for worse outcomes with a hazard ratio of 3.3 (p = 0.007). No treatment-dependent variables (initial treatment modality, extent of liver resection, margins, complications) were found on multivariable analysis to be important prognostic factors. CONCLUSIONS: In select patients with any of a variety of malignancies metastatic to the liver, prolonged survival can result from liver resection, especially in those with a single, resectable tumor from a nongastrointestinal primary site.

Ubiquitin reduces fluid shifts after traumatic brain injury.

BACKGROUND: Ubiquitin has well-described intracellular properties. Recent data also suggest pleiotropic effects of extracellular ubiquitin, including induction of apoptosis, regulation of immune functions, and therapeutic potential during fluid resuscitation from severe trauma. However, the actions of exogenous ubiquitin after traumatic brain injury (TBI) are unknown. METHODS: Series 1: Thirty-five minutes after TBI and hemorrhage, 1.5 mg ubiquitin/kg (n = 5) or albumin (n = 5) intravenous was followed by fluid resuscitation to maintain mean arterial and cerebral perfusion pressure. Series 2: Ubiquitin (n = 5) or vehicle (n = 6) was administered after TBI only. Ubiquitin was measured with enzyme-linked immunosorbent assay in serum, urine (series 1), and cerebrospinal fluid (series 2) for 300 minutes. RESULTS: Series 1: After intravenous bolus, serum ubiquitin peaked at t = 45 minutes with a half-life of 54 minutes. Recovery in urine was 10%. With albumin versus ubiquitin, 85% more resuscitation fluid was required to stabilize systemic and cerebral hemodynamics (P < .05 for t = 150 to 300 minutes), but hematocrit was similar. With albumin there were progressive increases in intracranial pressure, peak inspiratory pressure, and decreases in oxygenation. All were significantly attenuated by ubiquitin (all P < .05 vs albumin). Series 2: Intravenous ubiquitin altered cerebrospinal fluid ubiquitin with an increased time to peak (t = 88 +/- 13 min vs 45 +/- 7 min, P < .05) and area under the concentration-time curve (82 +/- 22 vs 23 +/- 11 microg/min(1)/mL(-1), P < .05). CONCLUSIONS: After TBI, intravenous ubiquitin crossed the blood-brain barrier and significantly reduced third spacing of fluid into the brain and lung during resuscitation.

Management of giant congenital nevi with artificial skin substitutes in children.

Giant congenital nevi are one of several skin conditions in the pediatric patient population whose treatment leaves the patient with large skin defects. The giant congenital nevus is a rare pigmented skin lesion that covers large skin areas or affects any major or difficult-to-treat region of the body, such as the face. Congenital nevi should be excised fully because of the increased risk for malignant transformation to melanoma, as well as cosmetic considerations. However, after excision patients are left with large wounds that are difficult to close. Traditionally these defects have been repaired with split-thickness skin grafts, full-thickness skin grafts, the use of tissue expanders, and a variety of flaps. However, each of these methods has its disadvantages and thus cannot be used in all cases. Recently, new methods have been developed for the closure of large skin defects in pediatric patients with the use of artificial skin substitutes. Advantages include coverage of large wounds, decrease or elimination of donor site pain and morbidity, and decreased scarring and wound contractures. The authors present these experiences through two case reports.