Eran Bar-Meir

Effects of vasopressor administration on the outcomes of microsurgical breast reconstruction.

The use of vasopressors during microsurgery is still debated. General anesthesia often induces hypotension, but microsurgeons are reluctant to use intraoperative vasopressors with the potential risks of vasoconstriction. A retrospective review was performed on 187 consecutive patients undergoing 258 deep inferior epigastric perforator flaps, free transverse rectus abdominis myocutaneous flap, and muscle-sparing free transverse rectus abdominis myocutaneous flap operations. A total of 102 patients (140 flaps) received intraoperative ephedrine and/or phenylephrine and 85 patients (118 flaps) did not. The administration of vasopressors did not affect the rates of reoperation, complete flap loss, partial flap loss, or fat necrosis. Patients receiving vasopressors had no differences in operative time, number of perforators, or number of rows of perforators harvested. There was no statistically significant association between dosage, timing, and complications. Although we do not recommend routine vasopressor use during microsurgery, administration does not seem to increase complications in microsurgical breast reconstruction.

Silicone gel breast implants and connective tissue disease-A comprehensive review

Silicone breast implants have been in use for breast reconstruction and breast augmentation for a long time. In the late 80s anecdotal reports describing a possible association between silicone-gel filled breast implants, and autoimmune diseases was accumulating. Due to the growing concern about the safety of silicone-gel implants, the Food and Drug administration (FDA) restricted their use to participants in controlled clinical trials, including women having reconstructive surgery. However, in recent years, large meta-analyses were unable to establish an association between silicone-gel breast implants and autoimmune disease. We review the current literature, emphasizing the most important epidemiologic studies.

Design and Impact of an Intraoperative Pathway: A New Operating Room Model for Team-Based Practice

BACKGROUND The concept of a team-based model for delivery of care has been critical at our institution for improving efficiency and safety. Despite these measures, difficulties continue to occur during lengthy operating room procedures. Using a novel team-based practice model, a multidisciplinary team was organized to improve efficiency in microsurgical breast reconstruction. We describe development of an intraoperative pathway for deep inferior epigastric perforator (DIEP) flap breast reconstruction and its impact on various outcomes. STUDY DESIGN We evaluated 150 patients who underwent DIEP flap breast reconstruction at Beth Israel Deaconess Medical Center from 2005 to 2008. Patient groups were subdivided into 50 unilateral and 50 bilateral procedures before the intraoperative pathway and 25 unilateral and 25 bilateral procedures after. Outcomes measured included operative time, complications, operating room and hospital costs, proper administration of prophylactic antibiotics and heparin, and staff satisfaction surveys. RESULTS Mean operative times decreased after pathway implementation in both unilateral (8.2 hours to 6.9 hours; p < 0.001) and bilateral groups (12.8 hours to 10.6 hours; p < 0.001) and complication rates were unchanged. Mean operating room costs decreased in the unilateral group by 10.2% (p = 0.018). Prophylactic heparin administration showed substantial improvements, although antibiotic administration and redosing of antibiotics trended upward. Staff surveys showed improved interdisciplinary communication, transition guidelines, and enhanced efficiency through standardization. CONCLUSIONS Implementation of an intraoperative pathway led to improvements in operative time, cost, quality measures, and staff satisfaction. Refinement of the pathway with team resolution of variances might continue to improve outcomes. Complex, multi-team procedures can derive benefits from standardization and intraoperative pathway development.

Nitrous oxide administered by the plastic surgeon for repair of facial lacerations in children in the emergency room.

Background: The purpose of this study was to investigate a means of providing pain relief during repair of facial lacerations in children in the emergency room. Methods: This study was conducted in the emergency room of a tertiary care, university-affiliated hospital. Fifty percent nitrous oxide was administered by the surgeon who sutured the laceration. A nurse monitored the child throughout the procedure. At the end of the procedure, pain scores were evaluated by the surgeon and nurse using the FLACC (face, legs, activity, cry, and consolability) scale, a structured observational-behavioral scale for measurement of pain. Results: Sixty patients between the ages of 1 and 16 years participated in the study. Of these, 15 were sutured using standard care (lidocaine infiltration), and 45 children received nitrous oxide in addition to lidocaine infiltration. Nitrous oxide was administered for an average of 11.9 ± 5.1 minutes (range, 4 to 30 minutes). Forty-three children recovered to preprocedure activity in less than 1 minute. Two children recovered in less than 3 minutes. Average FLACC scores during infiltration and suturing were significantly lower in the nitrous oxide group compared with controls (infiltration, 1.9 of 10 versus 9.7 of 10; suturing, 2 of 10 versus 8.8 of 10). Forceful restraining was necessary in all the controls, whereas in the nitrous oxide group mild force was required in only 15 percent. Seventy percent of the children receiving nitrous oxide had no side effects. Vomiting and nausea were the most common (17 percent), transient side effects. No respiratory or cardiovascular side effects occurred. Conclusions: Nitrous oxide can be safely administered by plastic surgeons while suturing facial lacerations in the emergency room. The fast onset and rapid recovery characteristics of nitrous oxide provide a convenient environment for performing short surgical procedures. This safe method for provision of analgesia and anxiolysis may be appealing to plastic surgeons for ambulatory procedures (e.g., suture removal, expander inflation, Botox injection, injection of various fillers) in pediatric and adult populations.

Guidelines for Treating Cardiac Manifestations of Organophosphates Poisoning with Special Emphasis on Long QT and Torsades De Pointes

Organophosphate poisoning may precipitate complex ventricular arrhythmias, a frequently overlooked and potentially lethal aspect of this condition. Acute effects consist of electrocardiographic ST-T segment changes and AV conduction disturbances of varying degrees, while long-lasting cardiac changes include QT prolongation, polymorphic tachycardia (“Torsades de Pointes”), and sudden cardiac death. Cardiac monitoring of organophosphate intoxicated patients for relatively long periods after the poisoning and early aggressive treatment of arrhythmias may be the clue to better survival. We present here a review of the literature with a focus on late cardiac arrhythmias (mainly “Torsades de pointes”), possible mechanisms, and treatment modalities, with special emphasis on postpoisoning monitoring for development of arrhythmias.

Ectopic PDX-1 expression directly reprograms human keratinocytes along pancreatic insulin-producing cells fate.

Background Cellular differentiation and lineage commitment have previously been considered irreversible processes. However, recent studies have indicated that differentiated adult cells can be reprogrammed to pluripotency and, in some cases, directly into alternate committed lineages. However, although pluripotent cells can be induced in numerous somatic cell sources, it was thought that inducing alternate committed lineages is primarily only possible in cells of developmentally related tissues. Here, we challenge this view and analyze whether direct adult cell reprogramming to alternate committed lineages can cross the boundaries of distinct developmental germ layers. Methodology/Principal Findings We ectopically expressed non-integrating pancreatic differentiation factors in ectoderm-derived human keratinocytes to determine whether these factors could directly induce endoderm-derived pancreatic lineage and β-cell-like function. We found that PDX-1 and to a lesser extent other pancreatic transcription factors, could rapidly and specifically activate pancreatic lineage and β-cell-like functional characteristics in ectoderm-derived human keratinocytes. Human keratinocytes transdifferentiated along the β cell lineage produced processed and secreted insulin in response to elevated glucose concentrations. Using irreversible lineage tracing for KRT-5 promoter activity, we present supporting evidence that insulin-positive cells induced by ectopic PDX-1 expression are generated in ectoderm derived keratinocytes. Conclusions/Significance These findings constitute the first demonstration of human ectoderm cells to endoderm derived pancreatic cells transdifferentiation. The study represents a proof of concept which suggests that transcription factors induced reprogramming is wider and more general developmental process than initially considered. These results expanded the arsenal of adult cells that can be used as a cell source for generating functional endocrine pancreatic cells. Directly reprogramming somatic cells into alternate desired tissues has important implications in developing patient-specific, regenerative medicine approaches.

Sociodemographics, referral patterns, and Internet use for decision-making in microsurgical breast reconstruction.

BACKGROUND Increasing numbers of patients are choosing to undergo microsurgical breast reconstruction. Currently, no information is available about the sociodemographic profile, referral patterns, or decision-making process of women who choose this reconstructive modality. METHODS All women who underwent breast reconstruction at a single institution between 2004 and 2007 were surveyed regarding demographic information, referral patterns, and decision-making processes. For data analysis, the cohort was separated by reconstructive method: nonmicrosurgical reconstruction (i.e., implant, latissimus, and pedicled transverse rectus abdominis musculocutaneous flaps) or microsurgical reconstruction (i.e., free transverse rectus abdominis musculocutaneous, deep inferior epigastric artery perforator, superficial inferior epigastric artery, and superior gluteal artery perforator flaps). RESULTS Overall, 332 women were surveyed, with a response rate of 77 percent. Patients who underwent microsurgical reconstruction were more likely to be 40 to 49 years old (p = 0.014), whereas nonmicrosurgical patients were clustered at the extremes of age. Microsurgery patients self-referred to a reconstructive surgeon, whereas other patients were sent by surgical oncologists (p < 0.001). The Internet was an important decision-making aid to help microsurgery patients identify their reconstructive modality (p < 0.001). Compared with nonmicrosurgical counterparts, microsurgery patients were independent decision-makers and more active in choosing their reconstructive procedure (p = 0.001). CONCLUSIONS Microsurgical breast reconstruction is highly sought after by a subset of patients with breast cancer. These patients are independent decision-makers in their health care choices. They use the Internet to learn about breast reconstruction techniques and are more likely to self-refer to a reconstructive surgeon. It remains unclear how many patients would choose microsurgical reconstruction if offered more widely or if awareness of the procedure were greater.

Safety of combining abdominoplasty and total abdominal hysterectomy : Fifteen cases and review of the literature

Combined surgeries eliminate the need for 2 anesthetics and 2 hospitalizations, the postoperative period of convalescence is no longer than for either procedure alone, and the total cost is reduced significantly. However, the safety of combining procedures is an unanswered question. We present 15 patients that underwent combined abdominoplasty with total abdominal hysterectomy from January 1992 to July 2002. A retrospective chart review was performed; surgical reports were analyzed, along with subsequent clinical follow-up notes. One patient had a wound infection that required hospitalization, drainage, and intravenous antibiotics. Four patients had minor complications. Patients’ satisfaction with the esthetic and functional results of combined procedures has been impressive. Our experience confirms the basic safety of the combined surgery when done on appropriately selected patients. These results are discussed in respect to the current literature.

Pedicled perforator flaps: a new principle in reconstructive surgery.

Background: In the evolution of flap physiology and reconstruction, there has been a trend of decreased donor-site morbidity. In this article, the chronology of flap reconstruction is discussed, with particular emphasis on the current state of nonmicrosurgical perforator based flaps. Methods: A literature search was conducted to study the evolution of flap physiology and reconstruction. Using this database, the authors describe the evolution of pedicled perforator flap reconstruction. Various examples of perforator-based flaps are discussed in this article. Results: The literature review identified examples of scenarios where pedicled perforator flaps from various regions of the body are viable options. Several clinical cases are presented with respect to each region. Conclusion: Pedicled perforator flaps are a new concept in nonmicrosurgical perforator flap reconstruction.

Combined Iliazarov and free flap for severe recurrent flexion-contracture release.

This article discusses the treatment of recurrent flexion-contracture of the knee after circumferential burns involving the entire limb. A two-team approach to surgery is used: the orthopedic team widely excises the scar tissue and releases tendons, muscles, and adjacent soft tissue that limit joint movement. The microsurgery team covers the exposed popliteal neurovascular elements with a latissimus dorsi free flap. However, full range of the knee is still limited by the short neurovascular bundle. Therefore, the orthopedic team applies a circular hinged Iliazarov external-fixator-frame to achieve gradual correction, until full range of the knee is achieved. Intensive physiotherapy and continuing use of extension splints for additional 6 months until the scars are deemed stable compliment the treatment regimen and prevent the recurrence of contractures. Between the years 2002 and 2003, we treated four patients (totaling five knee joints) with recurrent severe flexion-contractures after circumferential burns of the entire lower extremity. A significant limitation was caused by the abnormal scarring, which left the patients confined to a wheelchair. In all our patients, previous attempts to release the flexion-contracture failed. With the aforementioned technique, within 3 months after the procedure, all patients were able to walk. We encountered one major complication (ie, drop foot). At follow-up, all patients enjoyed a full range of motion and were able to walk. The strength of our approach comes from combining a free muscle flap with an Iliazarov external fixation and a detailed postoperative rehabilitation plan.