Cemile Nurdan Ozturk

Breast reconstruction with abdominal-based free flaps in high body mass index population: postoperative complications and impact of weight loss.

AbstractObesity, which is becoming endemic in the United States, causes a significant challenge for reconstructive surgeons. This study evaluates postoperative complications and impact of weight loss in the high body mass index (BMI) population undergoing breast reconstruction with abdominal free flaps. A retrospective review of 182 consecutive patients was performed. Patients were divided into groups according to their BMI at the time of surgery (preoperative BMI) and presence of weight loss, and data were compared among groups. Multivariate analysis of effect of preoperative BMI on complications revealed that overall flap (P = 0.008) and donor (P = 0.016) complication rates were significantly higher in the obese group. Analysis of preoperative weight loss did not yield a statistically significant reduction in flap (P = 0.5161) or donor (P = 0.8034) complication rates. Univariate analysis showed that higher preoperative BMI is associated with higher risk of systemic complications (P = 0.027). It is important to inform patients preoperatively that weight loss, although beneficial for ease of procedure and quality of life, does not diminish their increased risk of complications. Body mass index during surgery is the most important predictor of complications.

An Analysis of Current Techniques Used for Intraoperative Flap Evaluation.

BackgroundOver the last decade, microsurgeons have used a greater variety of more complex flaps. At the same time, microsurgeons have also become more interested in technology, such as indocyanine green (ICG) angiography, dynamic infrared thermography (DIRT), and photospectrometry, for preoperative planning and postoperative monitoring. These technologies are now migrating into the operating room, and are used to optimize flap design and to identify areas of hypoperfusion or problems with the anastomoses. Although relatively more has been published about ICG angiography, information is generally lacking about the intraoperative role of these techniques. MethodsA systematic analysis of articles discussing intraoperative ICG angiography, DIRT, and photospectrometry was performed to better define the sensitivity, specificity, expected outcomes, and potential complications associated with these techniques. ResultsFor intraoperative ICG angiography, the sensitivity was 90.9% (95% CI: 77.5–100) and the accuracy was 98.6% (95% CI: 97.6–99.7). The sensitivity of DIRT was 33% (95% CI: 11.3–64.6), the specificity was 100% (95% CI: 84.9–100), and the accuracy was 80% (95% CI: 71.2–89.7). The sensitivity of intraoperative photospectrometry was 92% (95% CI: 72.4–98.6), the specificity was 100% (95% CI: 98.8–100), and the accuracy was also 100% (95% CI: 98.7–100). ConclusionThese technologies for intraoperative perfusion assessment have the potential to provide objective data that may improve decisions about flap design and the quality of microvascular anastomoses. However, more work is needed to clearly document their value.

Free vascularized lymph node transfer for treatment of lymphedema: A systematic evidence based review.

BACKGROUND Free vascularized lymph node transfer (VLNT) is a relatively novel technique for treatment of lymphedema. The purpose of this systematic review was to evaluate the current evidence on VLNT and to determine if there is objective data concerning improved outcomes. METHODS A literature search of PubMed, EMBASE and CENTRAL electronic databases was conducted to identify articles written in the English language on VLNT for treatment of lymphedema. Publications were selected according to inclusion criteria. Papers reporting adjunct techniques and those that did not describe outcomes were excluded. Data including patient demographics, surgical technique, complications and outcomes were extracted. A quality score was calculated for each article. RESULTS Eighteen studies were included with an overall study population of 305 patients. Mean quality score of articles was 5.3 with levels of evidence range from II to IV. Among 182 patients who underwent limb circumference assessment, 165 (91%) showed postoperative improvement. Reduction of limb volume was noted in 98 of 114 (86%) patients. Ninety two patients underwent lymphoscintigraphy/lymphangiography and 55 (60%) demonstrated moderate or significant improvement of flow. Patient satisfaction was questioned in 105 patients and with exception of 7 patients, all reported a high satisfaction level with significant relief in symptoms and improved quality of life. Publications also reported a reduction in infectious episodes. CONCLUSION VLNT appears to provide improvement in lymphedema. More studies with standardized methods for reporting outcomes and uniform patient selection are needed to evaluate this technique thoroughly.

Achieving patient satisfaction in abdominally based free flap breast reconstruction: correlation with body mass index subgroups and weight loss.

Background: The goal of this study was to evaluate the relationship between body mass index, preoperative weight loss, and patient satisfaction in breast reconstruction with abdominally based free flaps. Methods: A custom survey with overall, breast, and abdomen questions was sent to patients who underwent abdominally based free flap breast reconstruction over the past 4 years. Clinical data were collected for patients who returned surveys. Data analysis was performed based on body mass index and percentage weight loss before surgery. Results: One hundred seventy-nine surveys were sent. Ninety-two patients (51.4 percent) responded. Normal weight patients versus overweight patients did not have statistically significant differences in any satisfaction scores. Overweight patients had higher overall satisfaction (p = 0.01), breast-specific satisfaction (p = 0.01), and abdomen-specific satisfaction (p = 0.02) compared with obese patients. Normal weight patients had higher breast-specific satisfaction (p = 0.05) and abdomen-specific satisfaction (p = 0.03) scores compared with obese patients. Patients with significant preoperative weight loss were more satisfied with feeling of breasts in clothes (p = 0.01), social appearance (p = 0.05), and current abdominal appearance (p = 0.01) compared with patients with moderate preoperative weight loss. Overall, breast- and abdomen-specific satisfaction scores decreased with increase in pannus thickness. Conclusions: Patient satisfaction with abdominally based free flap breast reconstruction was highest in patients with normal body mass index and lowest in obese patients. Overweight or obese patients should be encouraged to participate in healthy weight loss programs to achieve improved postoperative satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Skin sterility after application of a vapocoolant spray.

BACKGROUND Refrigerant sprays have been widely used to reduce pain in the office setting. However, more recently, their use has been limited by both concern regarding flammability and questions of bacterial contamination. OBJECTIVE We investigated the microbiological effect of 1,1,1,3,3 pentafluoropropane and 1,1,1,2-tetrafluoroethane when sprayed after povidone–iodine application in 50 volunteers. MATERIALS AND METHODS In 50 volunteers, 3 cultures were taken (1) at time 0 before antiseptic application, (2) after povidone–iodine topical antiseptic, and (3) after spraying with vapocoolant. Cultures at 3 time intervals were analyzed in a blinded fashion, and Gram stains obtained when cultures were positive. RESULTS Bacterial growth was found in 98% of cultures taken before antiseptic was applied (Group 1), in 28 cultures (56%) after povidone–iodine was applied, and in 24 cultures (48%) after spraying with vapocoolant. There was a statistically significant difference found between Group 1 (no antiseptic) and both Group 2 (after antiseptic but before vapocoolant) and Group 3 (after vapocoolant) (p < .001). CONCLUSION The topical antiseptic povidone–iodine significantly reduces skin colonization when compared with unprepared skin (p < .001). The vapocoolant 1,1,1,3,3 pentafluoropropane and 1,1,1,2-tetrafluoroethane is sprayed on skin prepared with povidone–iodine; there is no statistically significant increase in bacterial colonization.

Treatment of Foot Degloving Injury With Aid of Negative Pressure Wound Therapy and Dermal Regeneration Template.

Degloving injury of the foot continues to be a challenging condition to treat. Despite current advancements in reconstructive options, most of these injuries can result in amputations, causing physical and emotional impairment. Few reports have been published on the management of these complex traumatic injuries. Typical reconstruction options have included skin grafting and reattachment of the avulsed skin. Many treating physicians have encountered challenging issues in predicting tissue viability, knowing the extent of the injury, and making a logical decision for limb salvage procedures. The present report provides an algorithm of our approach in managing degloving injuries. A case of foot degloving injury, treated by serial surgical operations with the dominant aim of salvaging the avulsed tissue, is presented. The avulsed portion of the foot, with no identifiable vessels for microsurgical reattachment, was defatted and used as a full-thickness skin graft. Negative pressure wound therapy and a dermal regeneration template were used as adjunct techniques to help obtain good soft tissue coverage. The traditional treatment methods for degloving injuries and the applications of new wound care technologies are discussed.

Radiation Wounds and Their Management: Reconstructive Options

The following chapter focuses on the wounds and unstable scars caused by radiation injury and their reconstructive management. The radiation wounds are challenging to treat and oftentimes would require radical debridement of the involved soft tissues and the bone, if necessary. Mainstay of reconstruction relies on bringing healthy, well-vascularized soft tissue from areas outside the zone of radiation injury. In addition, previously irradiated tissues are at risk for wound healing complications. Prophylactic flaps could be performed to reduce the risk, should a need to operate on irradiated tissues without any evidence of wound arise. Reconstructive options include regional flaps or free tissue transfers which are demonstrated with typical case examples in this chapter.

Abstract: Breast Implant Infection Can be Successfully Treated with Nonsurgical Therapy

METHODS: A single-center, retrospective analysis of all patients who underwent implant-based breast reconstruction at Mount Sinai Hospital was performed. All patients who developed an implant infection and then underwent capsulectomy with implant exchange and STIMULAN beads impregnated with antibiotics were included. Patient demographics, medical history, operative complications, and surgical outcomes were reviewed.

Reconstruction of Face and Scalp Defects with Local Flaps

With increasing incidence of cutaneous malignancies of the face and scalp, the need for reconstructive surgery is steadily increasing. Aesthetics is a major requirement of facial defect reconstruction. Because of the reliability, convenience, and aesthetic outcome, local flaps are often the reconstructive choice for facial and scalp skin defects.

Breast Reconstruction with Abdominal-Based Free Flaps in High Body Mass Index Population

Obesity, becoming endemic in the US, is a significant challenge for plastic surgeons. Risk factors associated with high body mass index (BMI) are well documented. For this reason, extra caution is required when performing breast reconstruction with free abdominal flaps in this population. In select patients, such as those presenting for delayed breast reconstruction or those who undergo immediate breast reconstruction with expanders, the free flap procedure can be delayed until after reduction in BMI is obtained. Weight loss prior to surgery facilitates the surgical procedure, improves patient’s quality of life and increases postoperative satisfaction.