C. Scott Hultman

Acute and Persistent Postoperative Pain after Breast Surgery

OBJECTIVES This studys primary aim was to determine levels of acute and persistent postoperative pain and the incidence of severe postoperative pain after mastectomy. A secondary aim was to examine factors associated with postoperative pain. DESIGN A retrospective cohort study of 196 female breast surgery subjects was conducted. Data were collected on: numerical rating scale (NRS) pain scores in the Post Anesthesia Care Unit (PACU) and at 1 month and 6-12 months postoperative; age; race; insurance; obesity; radiotherapy; chemotherapy; hypertension; anesthesia care time; and intraoperative and PACU opioid use. Severe postoperative pain was defined as NAS > or = 5. Data were analyzed using chi square, Fishers exact test or analysis of variance, with alpha = 0.05. RESULTS PACU pain and the incidence of severe PACU pain increased with surgical complexity (P < 0.005). PACU pain scores averaged 4.71 +/- 0.24 and 57.7% of subjects experienced severe pain. Postoperative pain scores at 1 or 6-12 months did not vary by surgical complexity and averaged 2.21 +/- 0.32 and 0.74 +/- 0.22, respectively. Severe postoperative pain was experienced by 22.1% of subjects at 1 month and 8.2% of subjects at 6-12 months. Older age and systolic hypertension were associated with less PACU pain. Non-White race, obesity, and high PACU opioid use were associated with greater postoperative pain at 1 month. Non-White people also had greater postoperative pain at 6-12 months. CONCLUSIONS The results suggest that nearly 60% of breast surgery patients experience severe acute postoperative pain, with severe pain persisting for 6-12 months in almost 10% of patients.

Skin-sparing mastectomy flap complications after breast reconstruction: Review of incidence, management, and outcome

This study assesses the incidence and outcome of skin-sparing mastectomy (SSM) flap complications after breast reconstruction. The authors performed a retrospective review of 37 consecutive patients undergoing SSM and immediate breast reconstruction, focusing on preoperative demographics, management of complications, and early outcome. Univariate analysis comparing patients with and without complications was performed using Students t-test and chi-square analysis. From July 2000 to December 2001, 37 patients (mean age 48.1, range 24–71 y) underwent SSM and breast reconstruction (unilateral 20, bilateral 17) via TRAM flaps (n = 18), latissimus flaps (n = 13), and expander/implants (n = 6). SSM flap complications occurred in nine patients (24.3%) and included mild (n = 2), moderate (n = 5), and severe (n = 2) skin loss, resulting in four cases of dehiscence, five reoperations, and no delay in postoperative adjuvant therapy (required in six patients). Previous irradiation (n = 5, p = 0.045) and diabetes (n = 3, p = 0.001) were associated with SSM flap complications, but age, smoking, previous breast cancer, and type of reconstruction were not. Patients with SSM flap loss had a higher body mass index (BMI) than those without complications (30.0 vs. 24.3;p = 0.025). Skin flap complications after SSM and breast reconstruction are not uncommon but did not delay the initiation of adjuvant chemotherapy or radiotherapy, despite the need for reoperation. Patients with elevated BMI, diabetes, and previous irradiation may be at increased risk for SSM flap complications.

Utility of the omentum in the reconstruction of complex extraperitoneal wounds and defects: Donor-site complications in 135 patients from 1975 to 2000

ObjectiveTo examine donor-site complications after omental harvest for the reconstruction of extraperitoneal wounds and defects. Summary Background DataThe omentum, with its immunologic and angiogenic properties, is a versatile organ with well-documented utility in the reconstruction of complex wounds and defects. However, the need for laparotomy and the potential for intraabdominal complications have been cited as relative contraindications to the use of the omentum as a reconstructive flap. Further, few series have assessed long-term results, and no reports have focused on donor-site complications. MethodsPatients who underwent reconstruction of extraperitoneal defects with the omentum at a single university healthcare system were identified by searching discharge databases and office records. Charts were reviewed to determine patient demographics, surgical indications and technique, postoperative complications, and outpatient follow-up. Patients with donor-site complications were compared with patients who had no complications using the Student t test and chi-square analysis. Statistical significance was defined at P < .05. ResultsFrom 1975 to 2000, the authors successfully harvested 135 omental flaps (64 pedicled, 71 free transfer) for reconstruction of the following defects: scalp (n = 16), intracranial (n = 1), orbitofacial (n = 33), neck (n = 8), upper extremity (n = 7), lower extremity (n = 4), intrathoracic (n = 3), sternal (n = 34), breast (n = 3), chest wall (n = 18), abdominal wall (n = 1), and perineal (n = 7). Donor-site complications in 25 patients (18.5%) included abdominal wall infection (n = 9), fascial dehiscence (n = 8), symptomatic hernia (n = 8), unplanned reexploration (n = 6), postoperative ileus (n = 3), gastrointestinal hemorrhage (n = 2), delayed splenic rupture (n = 1), gastric outlet obstruction (n = 1), and late partial small bowel obstruction (n = 1). Factors associated with increased donor-site complications included the use of pedicled flaps (compared with free tissue transfer), mediastinitis, advanced age, and pulmonary failure. Of note, 53 patients had undergone previous abdominal surgery; of these, 26 patients required extensive adhesiolysis and 4 patients sustained enterotomies. Eleven patients (8.1%) had partial flap loss and three patients (2.2%) had total flap loss. Mean length of stay was 28 days. Average follow-up was 2.4 years. The death rate was 5.9%. ConclusionsThe omentum can be safely harvested and reliably used to reconstruct a diverse range of extraperitoneal wounds and defects. Donor-site complications can be significant but are usually limited to abdominal wall infection and hernia. Risk factors associated with complications include the use of pedicled flaps, mediastinitis, and pulmonary failure. This low rate of donor-site complications strongly supports the use of the omentum in the reconstruction of complex wounds and defects.

Thoracic reconstruction with the omentum: Indications, complications, and results

This study provides a retrospective analysis of 60 patients who underwent thoracic reconstruction with the omentum. Patients were identified by searching several databases to determine demographics, indications for surgery, operative technique, and postoperative course, including donor and recipient site morbidity. From January 1975 to May 2000, the authors harvested and transferred the omentum successfully (57 pedicled, 3 free) in 60 patients (mean age, 60 years; age range, 21–86 years) for sternal wound infections (N = 34), chest wall resections (N = 17), pectus deformities (N = 2), intrathoracic defects (N = 4), and breast reconstruction (N = 3). The omentum was used as a primary flap in 39 patients and as a salvage flap in 21 patients. Average operative time was 3.9 hours and average hospital stay was 34.3 days. Partial flap loss occurred in 7 patients, with no total flap failures. Morbidity included six abdominal wound infections and seven epigastric hernias. Mortality was 11.7%. The omentum can be harvested safely and used reliably to reconstruct varying thoracic wounds and defects. Specific indications from this series include osteoradionecrosis, chest wall tumors, massive sternal wounds, and refractory mediastinitis.

Allogeneic fibroblasts used to grow cultured epidermal autografts persist in vivo and sensitize the graft recipient for accelerated second-set rejection

INTRODUCTION Cultured epidermal autografts (CEAs) have been used for wound coverage in patients with massive burns and other skin defects. However, CEAs often display late breakdown, which may be immunologically mediated and initiated by persistent foreign fibroblasts used as a feeder layer to optimize keratinocyte growth. This study investigates whether these fibroblasts, previously shown to persist in vitro, survive after grafting and induce host sensitization to alloantigen. METHODS CEAs from CBA donors (H-2k) were grown on allogeneic NIH 3T3 (H-2q) or syngeneic LTK (H-2k) fibroblasts, which were removed by trypsinization 7 days later. CBA mice (n = 85) were flank-grafted with NIH allografts (positive control), CEA/3T3s, CEA/LTKs, or CBA autografts (negative control). Hosts were challenged with second set NIH tail allografts 3 weeks later. Median graft survival was compared between groups by Wilcoxon rank and chi 2 analysis. Additional CBA mice (n = 15) received CEAs that were biopsied 0, 4, and 8 days after grafting. The presence of allogeneic fibroblasts was determined by Western immunoblotting, using KL295, a monoclonal antibody that recognizes H-2q (but not H-2k) class II histocompatibility antigens. RESULTS Allogeneic fibroblasts persisted after grafting but decreased over time, as determined by alloantigen expression on Western immunoblots. Accelerated tail graft rejection occurred in hosts primed by NIH allografts (9 days, p < 0.05), as well as by CEAs growth with an allogeneic (10 days, p < 0.05) but not a syngeneic feeder layer (12 days, NS). Mice receiving flank autografts rejected second set tail allografts at 12 days. CONCLUSIONS Immunogenic fibroblasts used to grow CEAs survive in vivo and sensitize the graft recipient for accelerated second-set rejection. These persistent cells may initiate an inflammatory response that may result in late graft breakdown and limit the utility of CEAs grown with a foreign fibroblast feeder layer.

Hypertrophic burn scar management: what does the evidence show? A systematic review of randomized controlled trials.

IntroductionHypertrophic scars (HTS) are a source of morbidity for burn survivors and can present with a range of lifestyle-limiting problems. These include pruritus, pain, burning, stiffness, and contractures. Many solutions have been developed, but few have been studied in the form of a prospective, randomized control trial (RCT). Given the importance these RCTs carry in shaping the treatment of burn patients, we sought to systematically and critically review this portion of the burn literature. MethodsPubMed was used to perform 2 separate searches with limits that included Humans, English, and Randomized Controlled Trial. A keyword search using “hypertrophic,” “Scar,” “burn,” and “treatment” was cross-referenced with a MeSH subject-heading search using “Cicatrix, Hypertrophic” AND “Burn.” Studies were then reviewed and excluded if they did not address management of burn HTS in the non-acute setting. ResultsTwo literature searches resulted in a total of 32 articles. Twelve articles were excluded because they were not relevant to the topic (n = 10) or could not be obtained (n = 2). The remaining 20 articles contained 882 patients treated for hypertrophic scars. Breakdown based on topics included laser therapy (58 patients, 2 articles), silicone gel (204 patients, 7 articles), compression garment (236 patients, 4 articles), silicone + pressure (226 patients, 3 articles), topical emollients (58 patients, 2 articles), systemic therapy (62 patients, 1 article), intralesional therapy (18 patients, 1 article), and surgical treatment (20 patients, 1 article). While some articles had favorable conclusions (laser, emollients, surgical, and intralesional therapy) or unfavorable conclusions (systemic therapy), there were conflicting results on silicone and/or compression. ConclusionsDespite hypertrophic scars being a common occurrence in burn survivors, both the number of studies and consensus for treatment are limited. Efforts to perform larger, adequately powered RCTs are needed, specifically in the areas of silicone, compression garments, and combination therapy.

Shine on: Review of Laser- and Light-Based Therapies for the Treatment of Burn Scars

Restoration of form and function after burn injury remains challenging, but emerging laser and pulsed light technologies now offer hope for patients with hypertrophic scars, which may be associated with persistent hyperemia, chronic folliculitis, intense pruritis, and neuropathic pain. In addition to impairing body image, these scars may limit functional recovery, compromise activities of daily living, and prevent return to work. Three different platforms are now poised to alter our reconstructive algorithm: (1) vascular-specific pulsed dye laser (PDL) to reduce hyperemia, (2) ablative fractional CO2 laser to improve texture and pliability of the burn scar, and (3) intense pulsed light (IPL) to correct burn scar dyschromia and alleviate chronic folliculitis. In this paper, we will provide an overview of our work in this area, which includes a systematic review, a retrospective analysis of our preliminary experience, and interim data from our on-going, prospective, before-after cohort trial. We will demonstrate that laser- and light-based therapies can be combined with each other safely to yield superior results, often at lower cost, by reducing the need for reconstructive surgery. Modulating the burn scar, through minimally invasive modalities, may replace conventional methods of burn scar excision and yield outcomes not previously possible or conceivable.

Surgical management of HIV-associated lipodystrophy: role of ultrasonic-assisted liposuction and suction-assisted lipectomy in the treatment of lipohypertrophy.

Purpose:HIV-associated lipodystrophy is a frequent consequence of highly active antiretroviral therapy and has been associated with several metabolic disorders (increased triglycerides, hypercholesterolemia, insulin resistance) as well as altered fat distribution, including lipohypertrophy (neck, trunk, breasts) and lipoatrophy (nasolabial fold, cheek, extremities). Medical treatment of fat redistribution is usually ineffective. We evaluated the efficacy and safety of the surgical management of HIV lipodystrophy. Methods:We performed a retrospective review of 12 consecutive patients (3 female, 9 male; mean age, 44.4 years; mean CD4+ cell count, 554/mm3; mean body mass index, 28.9 kg/m2; mean triglycerides, 421 mg/dL; no active opportunistic infections; mean duration of HIV infection, 11.4 years) who underwent surgical management of HIV lipodystrophy at a university hospital from 2001 to 2006. Results:Surgical intervention included a combination of ultrasonic-assisted liposuction (UAL) and suction-assisted lipectomy (SAL) of the anterior neck (7 patients), posterior neck (10 patients), and trunk (2 patients); direct excision of mastoid fat pads (1 patient); direct excision of thigh lipomata (1 patient); facelift/necklift (1 patient); browlift (1 patient); fat injections (1 patient); and blepharoplasty (2 patients). Mean lipoaspirate volume was 701 mL (range, 270–1400 mL). Complications and sequelae included seroma (1 patient), ecchymosis (1 patient), need for revision (2 patients), and recurrence (3 patients) but did not include nerve injury, fat necrosis, skin loss, or infection. Although all patients reported improvement in form and function, UAL/SAL of the anterior neck had limited efficacy in 3 of 7 patients. UAL/SAL of the cervicodorsal fat pad was initially successful in 10 of 10 patients, but 3 patients developed partial late (>1 year) recurrence, all associated with weight gain. Mean follow up was 30 months (range, 1–66 months). Conclusions:Despite the potential for recurrence, surgical management of HIV-associated lipodystrophy is efficacious with minimal morbidity. UAL/SAL is particularly beneficial in reducing the cervicodorsal fat pad, whereas facelift and necklift may be necessary to adequately address anterior neck lipohypertrophy.

Salvage of infected spinal hardware with paraspinous muscle flaps : Anatomic considerations with clinical correlation

Purpose:Infected spinal stabilization devices represent a significant reconstructive challenge by threatening spinal stability and increasing the risk of neurologic complications. This study provides an anatomic and clinical investigation of posterior midline trunk reconstruction using paraspinous muscle flaps as the primary method of repair. Methods:We retrospectively analyzed a series of 25 consecutive patients (mean age, 57.2 years; range, 32–78 years) with complex spinal wounds, reconstructed with paraspinous muscle flaps, at a single university healthcare system. To help define the versatility of these muscle flaps, we also performed cadaveric dissections with lead oxide injections in 10 specimens, with an emphasis on regional blood supply, flap width, and arc of rotation. Results:From 1994 to 2000, we successfully reconstructed 25 patients with complex spinal wounds, using 49 paraspinous muscle flaps as the primary method of reconstruction. Hardware present in 22 patients was replaced or retained in 17 cases. Long-term spinal fusion with preservation of neurologic status was observed in all patients, with no cases of dehiscence or reinfection. Wound complications included cerebrospinal fluid leak (1), skin necrosis (1), sinus tracts (3), and seroma (2). Mean length of stay was 24 days (range, 8–57 days). One postoperative death occurred. Paraspinous dissections and injections confirmed a segmental type IV blood supply with medial and lateral perforators, arising from intercostal vessels superiorly and lumbar and sacral vessels inferiorly. Flap width was 8 cm at the sacral base, 5 cm at the level of the inferior scapular angle, and 2.5 cm at the first thoracic vertebra. Conclusions:Paraspinous muscle flaps can be used as the primary reconstructive option to cover and preserve spinal hardware, control local infection, and enable long-term spinal stabilization. Cadaveric dissections confirmed the usefulness of paraspinous flaps, which can be based upon lateral or medial perforators and can be safely mobilized to reliably reconstruct complex spinal wounds.

Early, complete burn wound excision partially restores cytotoxic T lymphocyte function.

BACKGROUND Cytotoxic lymphocytes (CTLs) are an important component of immune function, involved in antigen recognition and resistance to viral infection. Burn injury suppresses cell-mediated immunity, induces allograft tolerance, and increases the risk of viral infection, but the mechanisms are not well understood. This study analyzes the effect of burn size and burn wound excision on CTL activity. METHODS Anesthetized CBA mice (n = 12) received a 0%, 20%, or 40% body surface area contact burn. Additional mice (n = 16) received a 40% burn that was totally, partially, or not excised 72 hours after burn. Excised areas were covered with normal, syngeneic skin. Two weeks later harvested splenocytes were cocultured with allogeneic stimulators. CTL activity was determined by a 51Cr release assay, in which CTL effectors were tested on allogeneic, radiolabeled targets. Dilution curves of CTL activity were compared by ANOVA: RESULTS Both 20% and 40% burns significantly inhibited CTL activity (p < 0.05). Total but not partial excision of a 40% burn restored CTL activity (p < 0.01). Both total and partial wound excision also improved survival (p < 0.05). CONCLUSIONS Burn injury inhibits CTL activity in a size-dependent manner, and total wound excision significantly improves both CTL function and survival after injury. This study suggests a mechanism for the immunosuppressive effects of burn injury and provides an immunologic rationale for early, complete burn wound excision.