Ashley N. Amalfi

Acellular dermis-assisted prosthetic breast reconstruction versus complete submuscular coverage: a head-to-head comparison of outcomes.

Background: Complete submuscular tissue expander coverage affords the best protection against implant exposure but restricts lower pole expansion. Techniques using acellular dermis as a pectoralis muscle extension can allow for more rapid fill of the expander and better control of the inframammary fold. This study compares both techniques with regard to relevant outcomes. Methods: Results of 100 consecutive breast expander reconstructions performed by two surgeons between 2004 and 2007 were retrospectively reviewed. Patient demographics, expander coverage type, adjuvant treatment, length and characteristics of the expansion, and incidence and types of complications were analyzed. Results: One hundred women underwent breast reconstruction with 172 expanders, in 50 using complete submuscular placement and in 50 using partial subpectoral placement with acellular dermis. The patient groups were similar in terms of demographic data. Mean number of fills to complete reconstruction was 4.31 in the submuscular group and 1.72 in the acellular dermis group (p = 0.0001). Mean intraoperative fill volume was 130 cc in the submuscular group, compared with 412 cc per expander in the acellular dermis group (p = 0.0001). Fishers exact test demonstrated no significant difference in total complication rate between the two groups (14 percent versus 18 percent; p = 0.79). Conclusions: Acellular dermis allowed for a greater initial fill of saline. This potentially improves cosmetic outcome, as it better capitalizes on preserved mastectomy skin for reconstruction. The authors conclude that acellular dermis–assisted implant breast reconstruction has a safety profile no worse than that of complete submuscular coverage but offers the benefit of fewer expansions and the potential for more predictable secondary revisions.

Preferences in choosing between breast reconstruction options: a survey of female plastic surgeons.

Background: Female plastic surgeons are well suited to make a personal choice regarding breast reconstruction options, based on their knowledge of the actual procedures and first-hand experience with results. The authors surveyed this group to elicit their personal views on various modalities of breast reconstruction and to ascertain which types of reconstruction they would choose if faced with such a decision. Methods: All board-certified female plastic surgeons in the United States and Canada were surveyed by means of e-mail. This survey included questions regarding basic demographic and practice data. Respondents were requested to rank desired methods of reconstruction for themselves and to cite reasons for these choices. Results: A total of 435 surveys were sent: 350 were delivered (85 had invalid e-mail addresses), and 143 were returned (response rate, 41 percent). Overall, 66 percent of respondents chose implant-based reconstruction, 25 percent chose autologous reconstruction, and 9 percent chose no reconstruction. Respondents selecting autologous reconstruction cited cosmetic outcome as the most important factor considered in 47 percent of cases, compared with 14 percent of those choosing implant-based breast reconstruction (p = 0.0001). Invasiveness of the procedure/recovery time was cited as the most important factor by 83 percent of those surgeons opting for no breast reconstruction and by 51 percent of those choosing implant-based breast reconstruction (p = 0.0175). Conclusions: Board-certified female plastic surgeons exhibit a strong desire to pursue implant-based breast reconstruction over autologous reconstruction. When it was chosen, autologous reconstruction was felt to offer improved aesthetic outcomes. When making such a decision, patients can use female plastic surgeons as a resource for information, thus helping them to make an informed decision.

The Reconstruction of the Mutilated Hand

The challenging reconstructive treatment of defects in the upper extremity requires a sound working knowledge of a variety of flaps. As the hand surgeon weighs the pros and cons of each possible flap to obtain definitive closure, he or she must also integrate the priorities of function, contour, and stability as well as the anticipation of further reconstructive surgery in choosing the flap of choice. This review describes the various flaps available for closure of soft tissue defects of the upper extremity. The principles of management of wounds of the upper extremity is described to guide hand surgeons in the early treatment of massive wounds that will eventually need free tissue coverage. Currently used flaps include fasciocutaneous, fascial, musculocutaneous, muscle, and osteocutaneous flaps. Flap selection is based on the characteristics of the defect including size, shape, and location, the availability of donor sites, and the goals of reconstruction. Improved techniques of microsurgery and an ever increasing repertoire of flaps provide the framework for hand surgeons to offer the most appropriate flap based on donor site, thickness, amount of tissue needed, and composition. A discussion of the selection of ideal flaps for any given defect should enable the reconstructive hand surgeon to provide the most appropriate coverage of wounds to the hand and upper extremity.

Scar Contractures of the Hand

This article discusses scar contracture of the hand. It contains a brief outline of the anatomy of the hand and upper extremities and the types of injuries involved. Hand reconstruction, including examination, nonoperative treatment, surgery, excision and skin grafting, flaps, postoperative management, and complications, are covered.

Evidence-based medicine: Flexor tendon repair.

LEARNING OBJECTIVES After studying this article, the participant should be able to: (1) Describe and apply the current evidence-based treatment of acute flexor tendon injuries. (2) Compare and contrast the current postoperative therapy regimens following repair of flexor tendons. (3) Apply an evidence-based decision-making process for suture techniques of flexor tendon injuries. SUMMARY Flexor tendon repair remains a challenge for hand surgeons to reliably obtain excellent results. Surgical decisions should rely on the surgeons experience, outcome studies, and direct evidence. This review is a compilation of the evidence from the literature on optimizing outcomes for flexor tendon repair.

Cocaine-induced full-thickness tissue necrosis: a case series.

DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Fig. 1. A 60-year-old woman who underwent resection of a liposarcoma on the right shoulder. (Left) The location of the perforating branches of the tenth intercostal artery in the lateral part of the latissimus dorsi muscle was detected by color Doppler sonography. The divided latissimus dorsi flap was designed to include the perforator in the distal flap. (Right) Three months after primary closure of the donor site.

Cocaine-Induced Full Thickness Skin Necrosis

reSultS: Four patients (age 37-50) with cocaine-induced skin necrosis were identified between December 2010 and June 2011. All patients were cocaine users who suffered a prodrome of purpura which progressed to eschars and full-thickness necrosis within 4-6 weeks (Figure 1). Wounds involved the extremities, trunk and face. One patient eviscerated through abdominal necrosis overlying a ventral hernia. All patients demonstrated auto-antibodies including ANA, P-ANCA, lupus anticoagulant and rheumatoid factor. Histopathology revealed thromboses of dermal vessels with few inflammatory cells. Management included serial debridements, xenografting, and split-thickness skin grafting (Figure 2).