Jeffrey A. Ascherman

Implant reconstruction in breast cancer patients treated with radiation therapy

Background: Implant reconstruction in breast cancer patients treated with radiation therapy is controversial. Prior studies are limited by older prosthetic devices, reconstructive techniques, and radiation therapy protocols. Methods: A retrospective review was performed of patients who underwent tissue expansion and implant breast reconstruction performed by a single surgeon after mastectomy for breast cancer from 1996 to 2003. Complications and aesthetic results were compared between patients who received radiation therapy and those who did not. Results: A total of 104 patients (123 breasts) who underwent mastectomy and implant breast reconstruction were included in the study. Twenty-seven patients (27 breasts) received either premastectomy or postmastectomy radiation therapy for breast cancer. All patients who received radiation therapy did so before completion of their implant reconstruction. Complications ultimately requiring prosthetic device removal or replacement, as well as total complications (those requiring prosthetic removal or replacement and those not requiring prosthetic removal or replacement), were more frequent in breasts that received radiation than breasts that did not (18.5 percent versus 4.2 percent for complications requiring prosthetic removal or replacement, p ≤ 0.025, and 40.7 percent versus 16.7 percent for total complications, p ≤ 0.01). Breast symmetry was significantly better in patients who did not receive radiation compared with those who did (p < 0.01). Conclusions: Implant breast reconstruction in patients who receive radiation therapy is possible but associated with more frequent complications and decreased aesthetic results. However, the present results compare favorably to those reported in prior studies. Improved results in the present study may be attributable to the use of newer prostheses, staged breast reconstruction with initial tissue expansion, total muscular coverage of the implant, and modern radiation therapy protocols.

Single-stage Management of 74 Consecutive Sternal Wound Complications with Pectoralis Major Myocutaneous Advancement Flaps

The optimal management of sternal wound complications remains controversial. Since 1985, we have utilized a combination of immediate, aggressive debridement with simultaneous repair using bilateral pectoralis major myo-cutaneous advancement flaps, regardless of the degree of infection. As compared with the use of distant pedicled muscle flaps or pectoralis major turnover flaps, the management of complicated sternal wounds with immediate pectoralis major myocutaneous advancement flaps provides an effective yet simpler, quicker method of management with improved aesthetic results. In addition, basing the pectoralis major myocutaneous flaps on the thoracoacromial arteries eliminates the need for intact internal mammary arteries, valuable since the latter are increasingly used for coronary grafts.Seventy-four consecutive patients, 17 (23 percent) of whom were immunosuppressed heart transplant recipients, have been managed with this procedure. There were no intraoperative deaths. The 30-day perioperative mortality rate was 9 percent (7 of 74), with only 1 death related to persistent sepsis. The morbidity rate was 39 percent, with the most common complication being seroma managed by needle aspiration (18 of 74, 24 percent). The aesthetic and functional results have been uniformly excellent. (Plast. Reconstr. Surg. 93: 1433, 1994.)

PORCN mutations in focal dermal hypoplasia: coping with lethality.

The X‐linked dominant trait focal dermal hypoplasia (FDH, Goltz syndrome) is a developmental defect with focal distribution of affected tissues due to a block of Wnt signal transmission from cells carrying a detrimental PORCN mutation on an active X‐chromosome. Molecular characterization of 24 unrelated patients from different ethnic backgrounds revealed 23 different mutations of the PORCN gene in Xp11.23. Three were microdeletions eliminating PORCN and encompassing neighboring genes such as EBP, the gene associated with Conradi‐Hünermann‐Happle syndrome (CDPX2). 12/24 patients carried nonsense mutations resulting in loss of function. In one case a canonical splice acceptor site was mutated, and 8 missense mutations exchanged highly conserved amino acids. FDH patients overcome the consequences of potentially lethal X‐chromosomal mutations by extreme skewing of X‐chromosome inactivation in females, enabling transmission of the trait in families, or by postzygotic mosaicism both in male and female individuals. Molecular characterization of the PORCN mutations in cases diagnosed as Goltz syndrome is particularly relevant for genetic counseling of patients and their families since no functional diagnostic test is available and carriers of the mutation might otherwise be overlooked due to considerable phenotypic variability associated with the mosaic status.

Fibrin glue fixation in forehead endoscopy: evaluation of our experience with 206 cases.

The endoscopic approach has totally replaced the bicoronal approach for the treatment of forehead aging in our practice since November of 1993. The fixation in proper position is obtained with fibrin glue. Results of a series of 206 procedures performed in 196 patients are presented. Eyebrow positioning and muscle weakening were rated on a scale of 1 to 4. The evaluation has been made at a minimal follow-up time of 6 months. The comparison of the results between the first series of 28 patients during the first 6 months of our experience and the second series of 69 patients during the following period showed a significant increase in the number of excellent results (from 47 to 78 percent). Altogether, the satisfactory results (rated excellent or good) increased from 71 to 86 percent. Fibrin glue provides a stable fixation with the possibility of displacement in several directions, including transversal expansion. Complications have been minimal. Secondary procedures and association with other facial operations have been analyzed.

Risk analysis of deep sternal wound infections and their impact on long-term survival: a propensity analysis.

The objectives of this study are to determine risk factors associated with deep sternal wound infections (DSWIs) following cardiac surgery, and to describe their impact on long-term survival. Data was obtained from a departmental database. Analysis included 7,978 consecutive patients who underwent cardiac surgery between 1997 and 2003. To identify risk factors for DSWI, regression analysis was performed. The probability scores obtained from logistic regression were used for propensity analysis of 2 groups. Kaplan-Meier analysis with log-rank test and Cox proportional hazard models were then used in survival analysis. DSWI developed in 123 of 7,978 patients (1.5%). Preoperative predictors of DSWI were body mass index >30 kg/m2 (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1 to 2.4; P < 0.05), diabetes mellitus (OR, 2.4; 95% CI, 1.6 to 3.4; P < 0.001), urgent operation (OR, 1.7; 95% CI, 1.2 to 2.6; P < 0.05), smoking history within past year (OR, 2.7; 95% CI, 1.5 to 4.9; P < 0.001), smoking history within past 2 weeks (OR, 2.6; 95% CI, 1.5 to 4.5; P < 0.001), and a history of stroke (OR, 1.9; 95% CI, 1.1 to 3.1; P < 0.005). In addition, total length of hospital stay (OR, 1.01; 95% CI, 1.01 to 1.02; P < 0.05) and sepsis and/or endocarditis following surgery (OR, 5.1; 95% CI, 2.9 to 9.0; P < 0.001) were also predictive of DSWI. Patients with DSWI had a prolonged total length of hospital stay (40.3 days versus 16.1 days; P < 0.001), and higher 30-day mortality (1.6% versus 7.3% in DSWI group, P < 0.05). There were no differences between groups in 4-year and 8-year survival rates, with 77.2% and 61.8%, respectively, in patients with DSWI compared with 78.0% and 67.5% in patients without DSWI (P = 0.16). After adjustments for preoperative, intraoperative, and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with DSWI was 0.9 (95% CI, 0.6 to 1.2, P = 0.39). Though DSWIs are associated with increased early mortality, patients undergoing cardiac surgery complicated by DSWI do not experience worse long-term survival.

Abdominal Wall Morbidity following Unilateral and Bilateral Breast Reconstruction with Pedicled TRAM Flaps : An Outcomes Analysis of 117 Consecutive Patients

Background: Recently, there has been increasing concern regarding the potential for abdominal wall morbidity following breast reconstruction with pedicled transverse rectus abdominis myocutaneous (TRAM) flaps. The purpose of this study was to analyze a large, consecutive series of pedicled TRAM flaps performed by a single surgeon and examine the incidence of abdominal morbidity. Methods: Between December of 1998 and June of 2005, 117 women underwent breast reconstruction with pedicled TRAM flaps by the senior author (J.A.A.). All abdominal repairs were reinforced with polypropylene mesh. Reconstruction was unilateral in 105 women (90 percent) and bilateral in 12 women (10 percent). The charts were reviewed retrospectively for abdominal complications and associated demographics. Results: The mean follow-up period was 23.3 months. In the 117 patients, there was one hernia (0.85 percent), two abdominal wall bulges (1.7 percent), two superficial infections (1.7 percent), one partial skin loss (0.85 percent), one hematoma (0.85 percent), and zero seromas. Three patients (2.6 percent) had prolonged abdominal wall discomfort/tightness that was treated successfully with physical therapy. No patient developed a mesh infection or required mesh removal secondary to infection or exposure. In addition, no patient complained of persistent abdominal weakness, and there were no TRAM flap losses. Conclusions: Although many authors have reported concern over potentially high rates of abdominal wall morbidity following pedicled TRAM flaps, abdominal complication rates in the current series were uniformly low. The authors therefore believe that pedicled TRAM flaps remain a good option for many women seeking breast reconstruction.

Treatment of hyperhidrosis with botulinum toxin.

Botulinum toxin type A is a safe and effective method for treating focal hyperhidrosis, providing longer-lasting results than topical treatments without the necessity of invasive surgical procedures. Although more useful for axillary hyperhidrosis, botulinum toxin injections can also be effective in treating palmar and plantar disease. The effects of botulinum toxin last for six to nine months on average, and treatment is associated with a high satisfaction rate among patients. In this article, the authors discuss their preferred methods for treating axillary, palmar, and plantar hyperhidrosis. This article serves as guide for pretreatment evaluation, injection techniques, and posttreatment care.

Mycobacteria abscessus outbreak in US patients linked to offshore surgicenter.

We recently encountered 5 patients with Mycobacterium abscessus infection following cosmetic procedures performed at a surgicenter located off the United States coastline which, by report, actively recruits domestic patients. Additional patients with similar clinical histories and presentation have been identified at other practices along the Eastern seaboard as well. A recent Centers for Disease Control and Prevention investigation has confirmed a common link. All procedures were performed in Santo Domingo, Dominican Republic, between 2003 and 2004. More than half were performed at the same facility. We report herein a series of patients presenting with M. abscessus infections who underwent cosmetic surgery offshore. The goal of this manuscript is to heighten awareness among physicians who may encounter such patients in their practices. The indolent clinical presentation, laboratory studies utilizing acid-fast stains and cultures, and treatment including surgical debridement and pharmacologic regimens in the ultimate diagnosis and therapy for M. abscessus infections are discussed.

Intracranial volumes in a large series of healthy children.

Background: Craniosynostosis alters the normal growth of the infant skull and can influence intracranial pressure and intracranial volume. The purpose of this study was to measure intracranial volumes in a large series of healthy children to serve as a reference for further studies exploring the impact of craniosynostosis and vault remodeling on intracranial growth. Methods: A total of 123 children were included in this study from a retrospective review of pediatric emergency room visits for evaluation of head trauma where a head computed tomography scan was performed. Intracranial volumes were obtained using a semiautomated image segmentation technique and volume-rendering software. Results: Volume measurements were obtained and plotted against age, and a best fit curve approximation was derived. In this study of healthy children, intracranial volume doubled by 9 months of age and tripled by 6 years of age. Conclusions: This large study contributes to the existing data demonstrating intracranial volumes in healthy children up to 6 years of age. These data can be used by clinicians as a reference in the assessment of a child presenting with cranial dysmorphology.

Docetaxel (taxotere) extravasation: a report of five cases with treatment recommendations.

Docetaxel (Taxotere) is a relatively new antineoplastic agent that is proving to be clinically useful in the treatment of a number of major solid tumors, including breast, ovarian, lung, and prostate carcinoma. Common systemic toxicities include neutropenia, alopecia, nausea, and vomiting. The authors report 5 patients (age range, 54-89 years) who experienced extravasation injuries with dramatic clinical presentations during peripheral intravenous administration of docetaxel. The authors did not find any other reported series of docetaxel extravasation in an extensive literature review. They present these 5 patients and provide treatment recommendations.