Daniel H. Stewart

Breast reduction as an alternative treatment option for early breast cancer in women with macromastia.

Macromastia has been considered a relative contraindication to breast conservation therapy because of difficulties with postoperative radiation therapy and cosmesis. This study evaluates the feasibility of the inferior pedicle reduction mammaplasty as a component of breast conservation therapy for patients with early breast cancer. A retrospective review identified 6 patients with macromastia receiving oncologic treatment of breast cancer and simultaneous breast reduction. Mean age was 43.5 +/- 8.7 (mean +/- SD) years, and all breast cancers were stage I or II, averaging 2.3 +/- 1.5 cm in size. All patients underwent a Wise-pattern inferior pedicle breast reduction after cancer extirpation and received postoperative radiation as part of their treatment. They were evaluated for postoperative complications, esthetic outcome of the breasts, and local recurrence. Patients in this series were followed for an average of 30.3 months, with no significant postoperative complications and recurrences. Breast reduction incisions healed primarily and adjuvant radiation was completed without a delay. All patients were pleased with the esthetic result and had improvement of their symptoms related to macromastia. Thus, we believe that breast reduction is a reasonable and safe option for early breast cancer patients with macromastia who desire breast conservation therapy. Our combined oncologic and reconstructive approach may improve the outcome of this group of patients with early breast cancers.

Impedance plethysmography: a new method for continuous muscle perfusion monitoring.

Vigilant postoperative monitoring of the buried muscle flap is critical after free transfer because early diagnosis of vascular insufficiency is essential to allow prompt correction. We have identified a monitoring method utilizing needle electrodes and impedance plethysmography that gives a beat-to-beat representation of muscular perfusion. In 25 New Zealand White rabbits the gastrocnemius muscle was isolated on its vascular pedicle, and two intramuscular needle electrodes were placed. The instantaneous impedance changes of the muscle (corresponding to the pulsatile volume changes of perfusion) were measured and recorded. Using this representation of perfusion, an independent judge was able to correctly diagnose muscular ischemia 100 percent of the time (n = 25). Further, the judge was able to correctly distinguish the ischemia as arterial (n = 10) or venous (n = 10) in origin 100 percent of the time. Additionally, we monitored muscle perfusion transcutaneously in five free muscle flaps and demonstrated a reliable impedance signal that correlated with perfusion.

Modern surgical treatment of complex facial fractures: a 6-year review.

Open reduction and internal fixation (ORIF) with refined titanium plates and screws have revolutionized the surgical treatment of complex facial fractures, but its outcome remains relatively unknown. The purpose of this study is to review the results of modern surgical treatment of complex facial fractures involving at least two of the three zones of the face. From 1996 to 2002, 54 consecutive patients (41 males, 13 females; age 5-74 years) with complex facial fractures were treated by the plastic surgery service in our institution. All patients had their fractures repaired within 10 days after injury. ORIF of the fractures was performed through standard surgical approaches for the upper, middle, or lower face in a preferred sequence. Multiple rigid fixations were completed with current titanium plates and screws. Postoperative functional problems, residual cosmetic deformities, and reoperations for any complications in each patient were evaluated. All patients have been followed for up to 5 years. Overall, of the 54 consecutive patients in this study, 8 (14.8%) patients had postoperative functional problems, and 7 (13.0%) developed variable postoperative cosmetic deformities. Only nine (16.7%) patients underwent a subsequent reoperation for correction of the functional or cosmetic concern. Thus, we believe that modern surgical treatment of complex facial fractures by way of open treatment and rigid fixation with refined titanium plates and screws has resulted in overall good to excellent outcomes and a relatively low postoperative complication rate.

Is reversed venous flow safe in free-flap transfer? A dilemma with the radial forearm flap.

The distally based radial artery forearm flap has become our workhorse flap for hand and finger coverage, relying on reversed or retrograde venous outflow through the venae comitantes. Free-flap transfer, however, has been used by us only with antegrade venous anastomoses. This study was intended to determine if a single retrograde venous anastomosis would be adequate for flap viability. Six groups of saphenous flaps were developed in New Zealand White rabbits. In situ flaps compared antegrade with retrograde venous outflow in groups 1 and 2. Microvascular venous anastomoses with antegrade or retrograde outflow were compared in groups 3 and 4. Free-flap transfer with antegrade or retrograde venous outflow was compared in groups 5 and 6. No significant difference in survival was found between groups 1 and 2. A significant difference in survival (p = 0.025) was found between groups 3 and 4, but technical differences make these groups incomparable. Significantly better survival (p = 0.014, chi-squared test) was found in group 5 with antegrade outflow versus group 6 with retrograde outflow.

360-Degree Evaluations of Plastic Surgery Resident Accreditation Council for Graduate Medical Education Competencies: Experience Using a Short Form

Background: The Accreditation Council for Graduate Medical Education has asked training programs to develop methods to evaluate resident performance, using competencies essential for outcomes. Methods: A two-page form was completed by 12 surgeons and 28 nurses and clinical staff directly involved in plastic surgery patient care (n = 40), evaluating University of Kentucky plastic surgery residents at each level of training (n = 6). There were eight groups of health care professionals among the 40. Six Accreditation Council for Graduate Medical Education competencies were rated, with technical/operative skills added as a subset of patient care. Hierarchical cluster analysis was used to determine similarity of rating profiles of the rating groups; Kruskal-Wallis analysis of variance delineated the way in which the participants used the competencies to make their selections by asking them whether they would choose the resident for future surgical care. Results: Rating profiles revealed two clusters of raters. In one cluster were nurses assigned to an ambulatory surgery center, faculty, residents, and an intern (the surgeons’ cluster; n = 15); in the second cluster were other nurses and clinical staff (nurses’ cluster; n = 25). The nurses’ cluster was found to rate residents more positively, and the surgeons’ cluster more often cited areas for improvement. Specific competencies deemed important to each group were identified. Conclusions: Resident performance is rated differently by health care professionals, in two distinct groups. Based on this clustered arrangement, the resident is able quarterly to enjoy two, independent, formative assessments, potentially over 6 years of integrated training.

“oxytocin Hand”: Extravasation and Vascular Compromise after Obstetrical Pitocin

Sir:Oxytocin [produced commercially as oxytocin (Pitocin; Allscripts Healthcare Solutions, Chicago, Ill.) and Syntocinon (Sandoz Pharmaceuticals Corp., East Hanover, N.J.)] and vasopressin are well known for their effects on human reproduction (tetanic uterine contraction) and on sodium excretion (a

Flap pedicle vena comitant as a vein graft donor source

A vena comitant segment harvested from a flaps pedicle can be used as an interpositional vein graft in selected microvascular cases. When a vascular pedicle includes paired venae comitantes, one of these can prove suitable for use as a vein graft while still allowing for venous outflow of the flap. An additional operative site and procedure to harvest a vein graft can be avoided if a vena comitant segment can be used. We present eight cases in which pedicle vena comitant segments were used as interpositional vein grafts. In six cases, vena comitant grafts were used to supercharge or augment venous outflow in transverse rectus abdominis myocutaneous (TRAM) flaps used for breast reconstruction. A vena comitant graft was used to revise the venous anastomosis in one deep inferior epigastric perforator (DIEP) flap. The arterial anastomosis was revised with a vena comitant graft in a gracilis muscle free flap. Our experience demonstrates the viability and utility of using the flap pedicles vena comitant as a source of vein graft in selected cases.

Symptomatic Nonsyndromic Pancarpal Coalition: Report of a Rare Case and Review of the Literature

Carpal coalition, the union of 2 or more carpal bones, can be congenital or acquired. Congenital, nonsyndromic carpal coalition usually presents in otherwise healthy individuals. The most common coalition is between the lunate and the triquetrum, followed by the capitate and the hamate. Pancarpal coalition, or coalition of all or most of the bones of the carpus, is an extremely rare finding and usually occurs as part of a syndrome. We present a nonsyndromic case of this rare entity, in a 28-year-old woman of West African descent, with symptoms of left hand and wrist pain. Our literature review revealed only 1 other reported case of isolated, nonsyndromic symptomatic pancarpal coalition.