Breast surgery under local anesthesia: second-stage implant exchange, nipple flap reconstruction, and breast augmentation.

Breast reconstruction can be performed safely with local anesthesia. Utilization of the star flap method in conjunction with tattooing successfully provides optimal aesthetic results without the need for an additional donor site. When tissue expander to silicon implant exchange is part of the operative plan, use of triple antibiotic irrigation as well as the Keller Funnel is recommended. Breast augmentation and breast augmentation-mastopexy can also be performed with good results under local anesthetic in a private operating room setting. All other operative conditions, including sterility and sound operative surgical techniques, should be the mainstay of any practice.

Cultured epithelial autografts for coverage of large burn wounds in eighty-eight patients: the Indiana University experience.

Since 1990, the authors have used a new technique for coverage of large burns, which begins with early tangential excision and coverage with cadaver allograft (A), followed by placement of cultured epithelial autograft (CEA) onto an allodermis base (CEA/A). They present their 18-year experience (1990-present) using CEA in 88 patients (20 children and 68 adults) with age range of 6 months to 73 years. A review of prospectively collected data was conducted on adult and pediatric patients grafted with CEA at the Indiana University Medical Center for definitive wound coverage (TBSA 28-98%). These patients were followed up for 3 to 90 months. Complications, take rates, and outpatient follow-ups were noted. The mean final take rate of CEA/A was 72.7%, and the overall patient survival rate was 91% (80 of 88 patients). Complications were classified as early and late, they included: (early) blistering and shearing (31%), pruritus and itching (4.7%), (late) CEA loss (2 patients, 2.3%), and wound contractures (66%). Contracture releases were performed on 32 patients (36%); of which, 18 were children (56%). Cultured keratinocytes provide an excellent alternative or adjunct to conventional split-thickness skin grafting in treating large burn wounds. A dedicated team of physicians, nurses, and therapists well rehearsed in CEA care are vital for success in keratinocyte grafting. The final graft take of 72.7% with a 91% overall survival rate gives much optimism for continuing to use CEA in critically burned patients.

Coverage of large pediatric wounds with cultured epithelial autografts in congenital nevi and burns: results and technique.

The use of cultured epithelial autografts (CEA) for the treatment of large burn wounds has gained popularity in recent years. This technique may circumvent the restrictions of limited donor site availability and hasten permanent wound coverage for large TBSA burns. The availability of a large amount of skin from a small donor site with the promise of permanent wound coverage suggests its use in other conditions such as giant congenital nevi (GCN) as well. The risk of malignant transformation of GCN to melanoma although somewhat controversial is significant enough to warrant early excision in childhood. Cultured keratinocytes may provide one-stage coverage of these large wounds, lessening the number of surgeries and the inherent staging problems of tissue expansion or autografting. A retrospective single institution review of was done for 29 children (20 burns and 9 patients with GCN) who underwent coverage of their large surface area wounds with CEA over an 18-year period. Excellent take rates were noted; 76.4% for burn patients and 66% for patients with GCN. Several strategies in preoperative, perioperative, and postoperative care have been standardized and have helped improve outcome. The keys to success with the CEA technique have been aggressive control of wound sepsis, surgical technique, specific use of topical antimicrobials, dressings, and the standardization of nursing and physiotherapy care. Although the cost of CEA is high, the benefits to patient care make this technique an appealing choice for large wound coverage in the pediatric population.

A comparison of outcomes between immediate and delayed repair of mandibular fractures.

Medical records of patients treated with surgical repair of mandible fractures by the otolaryngology and plastic surgery departments at a level 1 trauma centre were obtained and reviewed. Two study groups were compared: patients treated within 72 h of the injury and those treated after this time period. Patient demographics, time to repair, fracture types, substance abuse history, etiology, surgical management, complications and length of hospital stay were assessed. The complication rate was 41% (n=7) within the immediate group and 38% (n=6) within the delayed group (P=0.56). Complications were prevalent in patients with history of substance abuse in both groups. Complication rates did not increase when repair of mandible fractures was delayed beyond 72 h, while substance abuse was a factor in increasing complications rates. Outpatient triage with elective repair of isolated mandibular fractures appears to be more cost-effective than admission with inpatient management.

Facial neurothekeoma in a 10-year-old child.

Neurothekeoma is a rare and benign tumour that occurs most frequently on the head and neck. It is classified as a nerve sheath tumour and epidemiologically occurs in young adults. It is rare to find these tumours occurring in children. The following report describes a case of neurothekeoma in a young girl, its treatment and a review of the literature. Specific histological analysis may reveal atypical and aggressive features, which, in turn, affect resection and reconstructive options.

Pilot study examining the frequency of several gene polymorphisms in a morbidly obese population.

BACKGROUND: Obesity is a growing problem and is associated with numerous medical conditions. Several polymorphisms have been associated with lipid metabolism and obesity: PPAR-gamma2-Pro115Gln, PPARgamma2-Pro12Ala, beta3AR-Trp64Arg and SR-BI IVS5 C > T. We examined the frequency of these polymorphisms in patients with a BMI > 40 and compared them to individuals with a BMI < 30. Our hypothesis was that these polymorphisms would occur more frequently in the obese population. METHODS: This case-control study examined 126 individuals with a BMI > 40 in the McGill University Health Centre Bariatric Surgery Program and 102 individuals (controls) with a BMI < 30 attending a Lipid Clinic. DNA was extracted from whole blood by standard techniques. The polymorphisms were determined by polymerase chain reaction (PCR) and restriction genotyping. RESULTS: A significant difference between controls and the morbidly obese group was observed for 2 of 4 polymorphisms. The carrier frequency for PPARgamma2-Pro12Ala was 24.8% in the obese group and 12.9% in controls (odds ratio = 2.2; 95% CI = 1.1-4.4; P = 0.02). The carrier frequency for SR-BI IVS5 C > T was 22.8% in obese individuals versus 8.1% in controls (odds ratio = 3.5; 95% CI = 1.6-7.7; P = 0.002). There were no differences in frequency of diabetes in both obese (13/104) and control (9/126) groups (odds ratio = 1.86, 95% CI = 0.76 < O.R. < 4.54, P = 0.184). CONCLUSIONS: These results underscore the relationship between gene polymorphisms and obesity. Obese individuals may differ from non-obese individuals in the gene polymorphisms associated with metabolic control.