Benjamin E. Cohen

Nipple-areola reconstruction: satisfaction and clinical determinants.

&NA; After performing a chart review, the authors identified 120 patients who underwent breast cancer‐related reconstruction. All charts were evaluated with regard to breast mound reconstruction type, nipple‐areola reconstruction type, the interval between breast mound and nipple‐areola reconstruction, the number of procedures needed to achieve nipple‐areola reconstruction, patient history of radiation therapy, and complications. A questionnaire was then developed and mailed to all of the patients who underwent both breast mound and nipple/areola reconstruction (n = 105) to evaluate their level of satisfaction. Of the 43 patients who returned the questionnaire, 41 completed all portions correctly. The questionnaire evaluated patient satisfaction with breast mound reconstruction; patient satisfaction with nipple‐areola reconstruction; what the patient disliked most about the nippleareola reconstruction; and whether or not the patient would choose to have breast reconstruction again. Several parameters were then tested statistically against the reported patient satisfaction. A review of all patients who underwent breast reconstruction revealed that their breast mound reconstructions were done using either a TRAM flap (59 percent), a latissimus dorsi flap and an implant (19 percent), an expander followed by an implant (9 percent), an implant only (4 percent), or other means (9 percent). The nippleareola was reconstructed in these patients with either a star flap (36 percent), nipple sharing (10 percent), a keyhole flap (9 percent), a skate flap (9 percent), an S‐flap (8 percent), a full‐thickness skin graft (6 percent), or by another means (22 percent). The number of procedures needed to achieve nipple‐areola reconstruction was either one (in 66 percent of the patients), two (in 32 percent of the patients), or three or more (2 percent of the patients). Eleven percent of the patients experienced the complication of nipple necrosis. Satisfaction with breast mound reconstruction was reported by 81 percent of patients to be excellent/good, by 14 percent of patients to be fair, and by 5 percent of patients to be poor. Reported satisfaction with nippleareola reconstruction was excellent/good for 64 percent of patients, fair for 22 percent of patients, and poor for 14 percent of patients. The factors patients disliked most about their nipple‐areola reconstruction were, in descending order, lack of projection, color match, shape, size, texture, and position. Statistical analysis of the data revealed inferior patient satisfaction when there was a longer interval between breast mound and nipple areola reconstruction (p = 0.003). No significant difference was observed in nipple/areola reconstruction satisfaction ratings when compared with breast mound reconstruction type (p = 0.46), nipple‐areola reconstruction type (p = 0.98), and history of radiation therapy (p = 0.23). There was also no significant difference when breast mound reconstruction was compared with technique (p = 0.51) and history of radiation therapy (p = 0.079). Overall, there was a greater satisfaction with breast mound reconstruction than with nipple‐areola reconstruction (p = 0.0001). (Plast. Reconstr. Surg. 110: 457, 2002.)

An innervated cross-finger flap for fingertip reconstruction

An innervated cross-finger flap for treatment of severe fingertip injuries is described. With this method, the dorsal skin over the middle phalanx, together with its sensory nerve, is transferred as a compound skin-nerve flap. A neurorrhaphy is performed between this nerve and the cut end of the digital nerve at the injury site. Seven of eight patients (88 percent) treated with this method (mean follow-up time 14.4 months) achieved measurable two-point discrimination. The average for those who did was 4.8 mm. A group of patients with similar injuries treated with standard cross-finger flaps exhibited slower sensory return that progressed to a lower level. In this group (mean follow-up time 16.3 months), three of six (50 percent) achieved measurable two-point discrimination with a mean value of 9 mm.

Preventing seroma in the latissimus dorsi flap donor site with fibrin sealant.

Donor site seroma continues to be the most common complication of latissimus dorsi flap reconstruction. Numerous preventive methods and treatments have been described. The use of fibrin sealant in the donor site before closure may be an effective means of seroma prevention. The authors evaluated the efficacy of fibrin sealant in conjunction with closed suction drainage in a series of 17 latissimus flap donor sites. They also determined their approximate institutional seroma rate with a retrospective chart review of 20 donor sites. The fibrin sealant patients had a seroma rate of 11.8% compared with a rate of 35% among the untreated patients (P = 0.047). This compares favorably with seroma rates as high as 79% described in the literature. In conclusion, the use of fibrin sealant in the latissimus flap donor site appears to be effective in preventing seroma.

Reversal of dopamine extravasation injury with topical nitroglycerin ointment

We treated a neonate with two sites of ischemia caused by dopamine extravasation. Standard treatment called for local infiltration of phentolamine, an alpha blocker. Instead, we applied 2% topical nitroglycerin ointment and the ischemia was totally reversed.

A prospective study of antibiotic efficacy in preventing infection in reduction mammaplasty.

Background: The role of prophylactic antibiotics in reduction mammaplasty remains controversial. However, most surgeons choose to use antibiotics. In addition to cost and potential allergic reactions, unnecessary administration of antibiotics can suppress host natural flora and produce resistant organisms. Methods: Fifty patients were sequentially assigned to one of three study limbs: (1) no antibiotics, (2) preoperative antibiotics only, or (3) preoperative and postoperative antibiotics. The study was designed to include approximately 17 patients in each group. Cephalosporin antibiotics were used unless there was any question of allergy, in which case an alternative antibiotic regimen was used. Preoperative data collected on patients included age, body mass index, history of diabetes mellitus, peripheral vascular disease, previous breast surgery, steroid therapy, and tobacco use. Operative data included specimen weight, operative time, estimated blood loss, prolonged intraoperative hypotension, adjunctive axillary and breast tail liposuction, and intraoperative breast tissue culture. Results: The patient population in the three limbs of the study was similar. Thus, there was no significant difference among the groups insofar as the preoperative data were concerned (p > 0.20): age, body mass index, diabetes mellitus, peripheral vascular disease, previous breast surgery, and steroid or tobacco use. Furthermore, no significant difference (p > 0.12) was noted among intraoperative data in the three groups: specimen weight, operative time, estimated blood loss, prolonged hypotension, adjunctive breast liposuction, and positive bacterial culture from intraoperative breast tissue samples. Ninety percent of positive intraoperative breast tissue cultures revealed Staphylococcus epidermidis. Using strict criteria, the infection rate ranged from 19 to 20 percent. There was no significant difference (p > 0.91) in rate of infection among the three study limbs. There was, however, a significant reduction (p = 0.002) in delayed wound healing in the group that received preoperative antibiotics only. Among the studied risk factors for infection, only positive intraoperative culture of breast tissue was significant (p = 0.008) for development of infection. There was a significant association between delayed wound healing and infection (p = 0.003). Conclusions: This prospective study did not find that prophylactic antibiotics in reduction mammaplasty have an effect on infection; however, a single preoperative dose significantly improved wound healing.

Efficacy of reconstituted and stored botulinum toxin type A: an electrophysiologic and visual study in the auricular muscle of the rabbit.

Once botulinum toxin type A is reconstituted, the manufacturer recommends that it be used in approximately 4 hours. As a result, a significant amount of this costly drug is often discarded because it is not completely used in the recommended period. The purpose of the present study was to compare fresh versus stored reconstituted botulinum toxin type A for (1) initial potency, (2) duration of action, and (3) bacterial colonization. Using a rabbit model, 20 New Zealand White rabbits were divided into four groups (I to IV). All rabbits had an injection of 2.5 U of reconstituted botulinum toxin into the right anterior auricular muscle. The first group was injected with botulinum toxin type A that was freshly reconstituted and served as the control. The second, third, and fourth groups were injected with botulinum toxin type A that had been reconstituted and stored for 2, 6, and 12 weeks, respectively, in a conventional freezer. Each rabbit had daily visual evaluation of the ear, with the position of auricle being graded from I to III. In addition, each rabbit had a nerve conduction study performed on the right anterior auricular muscle before injection and every 2 weeks after injection. Amplitude was chosen as the principal variable in the data analysis because it is the best predictor of physiologic changes at the muscle motor unit level. The endpoint of the study was defined as the time at which the nerve conduction studies and the visual inspections returned to baseline, preinjection levels. Botulinum toxin type A was also cultured before injection into each group. Overall, the nerve conduction data revealed a trend with a faster recovery (return to baseline) with the stored botulinum toxin. Groups IV and III returned to baseline first, followed by groups II and I. However, there was no significant difference among the groups at 2 and 4 weeks after injection, indicating that initial potency was unchanged. The differences between the groups became significant (p < 0.05) at 6 weeks and onward, suggesting that the duration was affected. Group I (fresh botulinum toxin) and group II (toxin stored for 2 weeks) had comparable outcomes and were not significantly different at any time period. Under visual inspection, the mean recovery time for each group was as follows: group IV, 5.4 weeks; group III, 7.0 weeks; group II, 6.75 weeks; and group I, 7.80 weeks. The results showed significance (p < 0.05) beginning after 3 weeks among some groups. Again, there was an overall quicker trend to return to baseline with the longer storage of the botulinum toxin (groups III and IV). These results support the authors’ conduction study data, which suggest that the initial potency is not affected but the duration of action is. Again, groups I and II had comparable results. Microbiology cultures showed no growth of either aerobic or anaerobic bacteria at 7 days. In conclusion, using the rabbit model, it seems that reconstituted and stored botulinum toxin type A has the same initial potency but the duration of action is affected sometime after 2 weeks of storage. No bacterial contamination was associated with storing unpreserved reconstituted botulinum toxin type A for up to 12 weeks.

Efficacy of a local anesthetic pain pump in abdominoplasty

Background: Recently, pain infusion pumps for postoperative pain control have gained popularity in many surgical specialties. This investigation was designed to evaluate the efficacy of a local anesthetic pain infusion pump in management of postoperative pain in abdominoplasty patients. Methods: A retrospective study of 38 abdominoplasty patients with local anesthetic pain pumps and 35 abdominoplasty patients without pain pumps was performed. Pain pumps were loaded with 0.25% or 0.5% bupivacaine and infused at a constant rate of 4 ml/hour. All patients were admitted postoperatively and started on a narcotic patient-controlled analgesia. Postoperative patient-controlled analgesia narcotic use and pain scores were recorded every 2 hours by the nursing staff. For the first 24 hours of postoperative hospital stay, pain medication, pain scores, and antiemetic use were determined from the patients’ charts. Hospital stay was also reviewed. Results: In the pain pump group, there was a small but not statistically significant reduction in pain medication use (2.65 versus 3.04 pain units) (p = 0.34). Interestingly, pain scores were higher in the pain pump group but not significantly (2.73 versus 2.31) (p = 0.17). There was no statistically significant difference in the use of antiemetics (0.8 versus 0.6) (p = 0.60). Hospital length of stay averaged 2.2 days in the pain pump group and 2.5 days in the group without pain pumps (p = 0.09). Conclusions: The postoperative use of pain pumps in abdominoplasty patients does not significantly improve pain management. Further investigation into this application of the pain pump is necessary before recommending their routine use in abdominoplasty patients.

Survival of transferred intestinal segments after vascular pedicle interruption

Rat intestinal segments with intact vascular pedicles were transferred from the abdominal cavity into the subcutaneous space. After 30 days, the vascular pedicle was severed. The intestinal segments, now completely dependent on wound neovascularization, survived completely. We conclude that early survival of intestinal transfers requires perfusion through the vascular pedicle. With time in a favorable bed, new vessel ingrowth from the recipient wound into the intestinal segment provides adequate circulation so that the vascular pedicle can be safely divided with no ill effect or at most a minor mucosal slough which quickly heals. Further clinical opportunities are necessary to determine the time course for these phenomena in humans.

Analysis of risks and aesthetics in a consecutive series of tissue expansion breast reconstructions

A consecutive series of 73 patients underwent tissue expansion for breast reconstruction between 1980 and 1986. The cases were reviewed, and preoperative risk factors, postoperative complications, and aesthetic results were assessed. Cigarette smoking correlated with a higher incidence of complications and unfavorable results. Similar correlations were found among patients with histories of significant medical disorders or alcohol abuse, although patient numbers were small in these categories. Subpectoral and suprapectoral placement of expanders yielded similar complication rates and aesthetic results. Surgical techniques contributing to improved aesthetic results are described.

Simultaneous bilateral breast reconstruction using latissimus dorsi myocutaneous flaps: a retrospective review of an institutional experience.

&NA; A single institutions experience in the simultaneous reconstruction of both breasts using bilateral latissimus dorsi myocutaneous flaps is presented. The procedure was performed on 24 patients by the attending staff of the department of plastic surgery at St. Joseph Hospital in Houston, Texas, between 1979 and 1999. Of the 24 patients reviewed, six had immediate reconstructions, 13 had delayed primary reconstructions, and five had secondary reconstructions of failed or unsatisfactory primary procedures. In the group with delayed reconstructions, the average time between mastectomy and reconstruction was 46.4 months, with a range from 7 days to 21 years. The operative method, results, and outcomes of our experience in these patients is presented. (Plast. Reconstr. Surg. 108: 1174, 2001.)