Autologous breast reconstruction using the immediately lipofilled extended latissimus dorsi flap.

BACKGROUND: The latissimus dorsi flap is a popular choice for autologous breast reconstruction. To dramatically improve volume, we report our experience of using the immediately lipofilled extended latissimus dorsi (ELD) flap and show it as a valid option for autologous breast reconstruction. METHODS: Patients undergoing the procedure between December 2013 and June 2016 were included. Demographic, clinical and operative factors were analysed, together with in-hospital morbidity and duration of postoperative hospital stay. RESULTS: A total of 71 ELD flaps with immediate lipofilling were performed. Forty-five reconstructions were immediate and the remaining 26 delayed. Median (range) volume of autologous fat injected immediately was 171 ml (40-630 ml). Contralateral reductions were performed in 25 patients with the median reduction volume 185 g (89-683 g). Median duration of admission was 6.5 (3-18) days and patients were followed up for 12 months (1-37). Three total flap failures occurred and had to be excised (4%). One haematoma occurred requiring drainage (1%). Signs of infection requiring intravenous antibiotics occurred in five patients (7%). In 5 patients wound dehiscence occurred, and only two of these required resuturing (3%). In total, 7 patients developed a seroma requiring repeated drainage (10%). Three reconstructions experienced mild mastectomy flap necrosis with no needing reoperation (4%). CONCLUSIONS: Our experience represents the largest series to date and shows that in carefully selected patients the technique is safe, can avoid the requirement for implants, and has the potential to streamline the reconstructive journey.

Quality of life in patients with amyotrophic lateral sclerosis: perceptions, coping resources, and illness characteristics.

OBJECTIVE: To assess and compare quality of life (QOL) for two groups of patients with amyotrophic lateral sclerosis (ALS): (1) those reporting a more positive quality of life and (2) those reporting a more negative quality of life. METHODS: One hundred patients with ALS participated in this cross-sectional, descriptive study conducted in an ALS clinic. Quality of life was graded in two ways: (1) a global question about present QOL, giving four choices (life could not be better, usually good, sometimes good, and not good) which the researchers divided into two groups: the more positive QOL and the more negative QOL and (2) patients' responses to a 25-item internally generated open-ended survey. The Appel ALS Rating Scale measured objective data for physical strength and functioning. RESULTS: One hundred patients (68 men and 32 women) with a mean age of 58.2 (range, 29-82) years participated in the study. The average disease duration was 1.9 (range, 0.08-15) years. Patients who reported the more positive QOL were younger, had a shorter disease duration, and experienced less disease severity (p < 0.05). Those endorsing the more positive QOL reported more adequate finances and less stress over disease characteristics (p < 0.05). CONCLUSIONS: Illness characteristics do influence QOL for patients with ALS, but they are not the only concerns. When measuring QOL in patients with ALS, the unique features of the psychosocial factors, personality traits, and spiritual factors, in addition to disease symptoms, need to be identified and discussed with patients and families throughout the illness.

Wheelchair use by patients with amyotrophic lateral sclerosis: a survey of user characteristics and selection preferences.

OBJECTIVES: To determine wheelchair types and features that are most beneficial to patients with amyotrophic lateral sclerosis (ALS), to ascertain at what stage of disease and disability patients benefit from wheelchair use, and to pinpoint the differences in patient characteristics between the users of manual and motorized wheelchairs. DESIGN: Internally generated questionnaire. SETTING: A neuromuscular clinic. PATIENTS: Forty-two patients (28 men, 14 women) with ALS who used wheelchairs and whose mean age was 53.9 years (range, 32-75yr). MAIN OUTCOME MEASURE: Wheelchair users completed a 39-item survey. RESULTS: At the time of the survey, the patients' mean Appel ALS rating scale total score was 84.5 (range, 48-138), indicating moderate disability. Forty-one patients reported that wheelchairs permitted them greater interaction in their communities; 33 were "very satisfied" with the positive impact of wheelchair use on their activity levels. Most users did not work and needed caregiver assistance for activities of daily living. The most desirable wheelchair features provide extra comfort (supports for the head, neck, trunk, extremities) and have improved maneuverability (lightweight frame, smaller wheelbase). Undesirable features are low sling backs and sling seats, nonremovable static leg rests, and large frames. No significant differences were reported between manual wheelchair users and motorized wheelchair users in terms of overall disease symptom severity, arm and leg strength, and bulbar function. However, motorized wheelchairs offer patients a greater sense of independence and an improved sense of well-being. CONCLUSION: Information obtained directly from wheelchair users with ALS provided first-hand experience concerning the most and least desirable features of wheelchairs and may help other ALS patients make informed decisions when purchasing a wheelchair.

Rehabilitation parameters in total knee replacement patients undergoing epidural vs. conventional analgesia.

Epidural analgesia for total knee replacement (TKR) surgery has been proposed as a means of enhancing patient comfort, thereby expediting rehabilitation and reducing hospital stay. This study was done to determine differences in rehabilitation parameters of range of motion and mobility in patients receiving epidural vs. conventional (intravenous) analgesia following TKR surgery. Chart reviews were done of 52 patients who underwent consecutive unilateral TKR, with 26 patients in each analgesia group. There were 21 males and 31 females, ages 24-88 years (median 65), with diagnoses of osteoarthritis (45), rheumatoid arthritis (4), and other (3). The surgeon, procedure, type of prosthesis, and physical therapy protocol were the same for all subjects. Demographics, range of motion, distance walked, assistance required for gait and transfers, assistive device, and exercise competence data were studied at the first postoperative day and at time of discharge. No significant difference was found in the length of stay at the p < .05 level. Significant differences at the first postoperative day favored the epidural group: in knee flexion range--median difference was 0.26 rad [95% confidence interval (CI): 0.09-0.52, p < .05] ie., 15 degrees (95% CI: 5-30); in total range of motion--median difference was 0.30 rad (95% CI: 0.09-0.58, p < .05), ie., 17 degrees (95% CI: 5-33); and in assistance required for gait and transfers (p < .05). At discharge, the epidural group required significantly less assistance (p < .05). There was a trend toward greater walking distance in the epidural group, who walked a median of 15.2 m farther than the conventional analgesia group.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact tolerances of the rigidly fixated maxillofacial skeleton.

A study was designed to determine how soon an athlete who undergoes rigid fixation of a facial fracture can return to full competition. The impact resistance of a rigidly fixated malar complex fracture was studied and compared with that of an intact malar complex. Twelve fresh human cadaver heads were used. A custom-designed impact device was used to deliver a blow of a specific energy to each intact malar complex. The subsequent fractures were rigidly fixated at three points using titanium miniplates and screws. A second impact of identical energy was delivered. The forces generated and the subsequent displacement of hard and soft tissues were recorded after each impact. It was concluded from this study that an impact to a rigidly fixated malar complex fracture produced less force and greater displacement of hard and soft tissues than an impact of identical energy to an intact malar complex. The potential for sustaining more severe maxillofacial injuries after an initial facial fracture should be seriously considered. The results suggest that sufficient time should be allowed for the bony healing of a facial fracture to occur, even after rigid fixation, before an athlete can resume full contact activities.

Carbon dioxide laser treatment of laryngeal stenosis.

Six patients ranging from 3 to 67 years of age were treated for acquired laryngeal stenosis. Five of these patients were considered failures from conventional surgical techniques including multiple open endolaryngeal procedures and repeated dilations. Using the carbon dioxide laser, the various obstructing lesions were excised microendoscopically and injected with interstitial steroids. After one to six procedures, all of these patients now have adequate airways and serviceable voices.

Carcinoma in thyroglossal duct remnants.

Two cases of carcinoma arising in thyroglossal duct remnants are reported to add to the previously documented 78 cases in the literature. This rare lesion, which occurs is less than 1% of thyroglossal duct abnormalities, pathologically and clinically is similar to primary tumors arising in the thyroid gland. Papillary adenocarcinomas constitute 75-85% of all cases reported and most are confined to the duct remnant itself with metastasis being infrequently recorded. Therapy consists of wide excision of the tumor-bearing tissue (Sistrunk procedure) in those cases localized to the duct remnant itself. In instances where metastasis or additional lesions are detected in the thyroid gland, thyroid ablation and neck dissections are indicated. Additional modalities such as suppressive thyroid therapy, radioactive iodine, and external radiation have been employed. Distant metastasis is rare and the long-term prognosis is very favorable.