Christopher Tokin

Oncologic Safety of Skin-Sparing and Nipple-Sparing Mastectomy: A Discussion and Review of the Literature

Breast conservation therapy has been the cornerstone of the surgical treatment of breast cancer for the last 20 years; however, recently, the use of mastectomy has been increasing. Mastectomy is one of the most frequently performed breast operations, and with novel surgical techniques, preservation of the skin envelope and/or the nipple-areolar complex is commonly performed. The goal of this paper is to review the literature on skin-sparing mastectomy and nipple-sparing mastectomy and to evaluate the oncologic safety of these techniques. In addition, this paper will discuss the oncologic importance of margin status and type of mastectomy as it pertains to risk of local recurrence and relative need for adjuvant therapy.

Incidence of oral clefts among different ethnicities in the state of California.

IntroductionSeveral population-based epidemiologic studies have been conducted to evaluate the incidence of oral clefts in different ethnicities in the United States and other countries. The largest studies were performed in white (non-Hispanic) subjects. The highest incidence rates have been reported in Asians and Native Americans. Material and MethodsWe performed a retrospective longitudinal analysis of the California Office of Statewide Health Planning and Development patient discharge database from 1995 to 2010. We identified the yearly number of live births and the number of patients diagnosed with cleft palate or cleft lip with or without palate. We also stratified the number of live births and the incidence of clefts based on ethnic backgrounds. We studied the trend in the incidence rates among different ethnicities in the period between 1995 and 2010. We identified and analyzed data from 3 main groups of patients: those with any cleft disease (AC), isolated cleft palate (CP), and cleft lip with or without cleft palate (CLP). ResultsOur database shows a total number of 8,043,393 live births included in the study. The calculated incidence rates for the white (Non-Hispanic) population are 16.2 with AC, 7.6 with CP, and 8.67 with CLP. Rates for the Hispanic population are 12.26 with AC, 4.79 with CP, and 7.5 with CLP. Rates for Asian/Pacific Islanders are 11.57 with AC, 4.9 with CP, and 6.68 with CLP. Rates for the African American population are 8.9 with AC, 4.1 with CP, and 6.7 with CLP. Rates for the Native American population are 8.15 with AC, 2.1 with CP, and 6 with CLP. We also noticed a declining trend in the incidence rates of AC, CP, and CLP over the period of the study between 1995 and 2010. DiscussionOur results suggest different incidence rates among different ethnicities. We found the highest rates for any oral cleft, isolated cleft palate, and cleft lip with and without palate in the white (non-Hispanic) population. The declining incidence rates during the period of the study (15 years) could be attributed to environmental, demographic, or gene pool factors. However, further studies are needed to investigate this finding.

A comparison of cell-enriched fat transfer to conventional fat grafting after aesthetic procedures using a patient satisfaction survey.

IntroductionThe role of regenerative cells in adult human fat is still unfolding. At present, limited clinical studies comparing patient satisfaction with cell-enriched fat transfer (CEFT) to conventional autologous fat transfer (AFT) for aesthetic indications have been performed. Herein, we present our data obtained from patient satisfaction questionnaires. MethodsPatients undergoing fat grafting received AFT or CEFT. Study participants were surveyed for overall satisfaction, symmetry, deformity, scarring, and pigmentation. Hospital charts were reviewed for complications, and patient survey responses between the groups were compared. ResultsBetween January 2009 and September 2011, 36 patients had 6-months follow-up and were mailed surveys. Of these, 17 (12 CEFT and 5 AFT) returned completed Patient Satisfaction Rating surveys. At a median follow-up time of 10.7 months, the overall mean satisfaction rate was 5.2 of 6 (5.3 vs 5.0 for CEFT and AFT, respectively, P = 0.42). There were no significant differences about deformity (5.1 vs 4.7, P = 0.50), symmetry (4.5 vs 5.0, P = 0.48), or scarring (5.3 vs 4.5, P = 0.23). However, pigmentation was improved in the CEFT vs the AFT groups (P < 0.001). No patients in the AFT group noted skin pigmentation improvement, whereas 7 of 12 receiving CEFT noted improvement in skin pigmentation. ConclusionsCell-enriched fat transfer to the face and body of aesthetic patients produces high satisfaction rates. Our preliminary data demonstrates similar satisfaction with regard to symmetry, scarring, and deformity in patients treated with CEFT versus AFT, without any complications. Unexpectedly, a clinical and statistical improvement in pigmentation was seen for patients treated with CEFT over AFT. Further studies need to be done to better understand this phenomenon.

The pedicled myocutaneous flap as a choice reconstructive technique for immediate adjuvant brachytherapy in sarcoma treatment

Successful treatment of soft-tissue sarcomas is highly dependent on total tumour resection coupled with adjuvant radiation therapy to achieve local control and decrease recurrence. Reconstruction of soft-tissue defects after resection aims to cover vital structures, while providing enough stable tissue to withstand adjuvant brachytherapy treatment. In the present study, pedicled myocutaneous flaps were used as a vital adjunct in the treatment of soft-tissue sarcoma, and our experience with 2 such patients is described. The flaps served to reconstruct large three-dimensional defects while providing stable coverage over brachytherapy hardware to allow for delivery of radiation in the immediate postoperative period. Pedicled locoregional myocutaneous flaps provide a safe, easy, and reliable reconstructive technique in the treatment of soft-tissue sarcoma.

Statewide multicenter analysis of the incidence of secondary surgeries after isolated cleft palate repair.

IntroductionPrevious smaller studies have reported a wide range, 15% to 45%, of secondary palate surgery. The goal of this study was to report the true incidence of secondary surgery derived from a large statewide database as well as study the timing and risk factors for secondary surgery. MethodsRetrospective longitudinal analysis was performed of the 1995 to 2010 California Office of Statewide Health Planning and Development patient discharge database, which allows patients to be followed up over time. Patients were included in the study if they had an isolated palate diagnosis in addition to a primary repair code and excluded if they ever carried a cleft lip diagnosis or repair code. ResultsA total of 2616 isolated cleft palate patients were identified with a median follow-up of 8.0 years. At 16 years, the overall rate of second surgery was 13.6% with complete cleft palate patients having a higher rate of second surgery (15.92%) than the incomplete cleft palate patients (12.36%). The risk of second surgery over time showed a bimodal distribution; the first peak was seen in the first postoperative year and the second peak was seen 3 to 5 years postoperative. On multivariate regression, the only independent risk factor of a secondary surgery was uninsured status (HR, 4.55 [1.64–12.64]), whereas incomplete cleft palate (HR, 0.68 [0.46–0.98]) and Hispanic ethnicity (HR, 0.68 [0.50–0.94]) were found to be protective for secondary surgery with the rest of the covariates not showing significant association. ConclusionsThe incidence rate of secondary surgery (13.6%) at 16 years was less than reported in the literature. Patients who had a complete cleft palate repaired showed a higher incidence rate compared with those who had an incomplete cleft repaired, likely correlating with the complexity and invasiveness of the primary surgery. The first risk peak at which secondary surgeries were performed reflects the short-term complications that needed to be addressed within the first postoperative year. The second peak reflects the longer-term complications diagnosed at the age at which children reach speech milestones.

Breast cancer presenting within or adjacent to the breast implant capsule: a case series and clinical recommendations.

Introduction Since the advent of silicone breast implants in the 1970s forever changing the field of breast reconstruction, now, over 1 million American women have breast implants. The development of a capsule around the implant is a part of the body’s immune response to a surgically implanted foreign object. Composed mostly of collagen fibers, microscopically, it also appears to be a highly vascular structure. While breast cancer occurring in or adjacent to the implant capsule has anecdotally been described, it is a rare event and not well documented in the literature. We report a series of cases where we iscovered carcinoma and carcinoma in situ of the breast within or mmediately adjacent to the implant capsule, and suggest that its ascular nature may predispose tumor seeding to the capsule at rates igher than previously believed, as well as demonstrate clinical evience of an interesting aspect of tumor biology. We also suggest that his unusual presentation may require more extensive surgery, and

Are Risks of Adverse Outcomes Following Outpatient Cosmetic Procedures Additive When Procedures Are Combined

Methods: Retrospective longitudinal analysis was performed of the 2005-2010 California Office of Statewide Health Planning and Development (OSHPD) Ambulatory Surgery Database, which contains data for ambulatory surgery centers licensed by the California Department of Public Health. Patients were included if they had undergone an abdominoplasty or any other procedure that was identified as frequently performed concurrently with abdominoplasty liposuction, breast procedures, face procedures, thighlift/brachioplasty, and hernia repair. Patients’ subsequent in-patient admissions and emergency department visits were identified from the respective OSHPD databases, capturing all admissions to non-military hospitals in the state. Outcomes analyzed were the one-year venous thromboembolism (VTE) rate, 30-day readmission rate, 30-day emergency department visit rate, and 30-day mortality. All outcomes were analyzed for patients undergoing an isolated procedure and two concurrent procedures.