Jensen Ja

Tissue oxygenation, anemia, and perfusion in relation to wound healing in surgical patients.

Oxygen tension and collagen deposition were measured in standardized, subcutaneous wounds in 33 postoperative surgical patients. Pertinent clinical and wound parameters were analyzed by Pearsons correlation test and sequential linear regression analysis. Collagen deposition was directly and significantly proportional to wound oxygen tension and measures of perfusion. There were no significant correlations with hematocrit, estimated blood loss, length of operation, smoking, age, weight, sex, or urine output. This study in humans confirms animal experiments showing that collagen deposition and tensile strength in wounds are limited by perfusion and tissue oxygen tension. It appears unnecessary to maintain hemoglobin at normal levels to support repair, provided that peripheral perfusion can be maintained at a high level in compensation for anemia. These circumstances reflect the fact that although oxygen is essential to many aspects of healing, and must be delivered at adequate partial pressures, reparative tissue consumes relatively little of it.

A long-term study of outcomes, complications, and patient satisfaction with breast implants.

Background: Breast implants have been used worldwide for more than 40 years. Despite extensive clinical experience, there is continued concern about the safety of these devices. The purpose of this study was to compare the efficacy, complication rates, frequency of reoperation, and degree of patient satisfaction with different types of implants. Methods: This is a consecutive, population-based study consisting of all patients receiving implants at a multidisciplinary breast center between 1979 and 2004 (25 years). A prospective implant database was constructed and maintained in Excel, and statistical analysis was performed using SAS 8.2. Various outcomes, including infections, hematomas, undesirable waviness, capsular contracture, deflation, rupture, reoperation, and patient satisfaction, were monitored. Results: Data were collected on 3495 implants in 1529 women. The longer implants were in place, the greater the cumulative risk of developing contracture; hematoma significantly increased the risk of contracture; smooth and textured implants had similar contracture rates; polyurethane foam–covered implants had a reduced risk of contracture persisting for at least 10 years after implantation. There was a relatively high rate of reoperation and a relatively short interval between primary surgery and reoperation; the most common indication for reoperation was capsular contracture. Implant recipients expressed a high overall level of satisfaction. Conclusions: Breast implants are associated with a significant rate of local complications and reoperation. There are marked differences in outcomes as a function of implant surface type and surgical indication. Despite relatively frequent complications and reoperations, implant recipients are largely satisfied.

The fate of breast implants : a critical analysis of complications and outcomes

Complications and outcomes were monitored following the implantation of 1655 breast implants over a 15-year period. Smooth, polyurethane, and textured implants were used in a variety of clinical settings. The time course of capsular contracture was analyzed by the Kaplan-Meier method. Regardless of implant type or indication for surgery, the probability of contracture increased with time. Polyurethane-covered implants were associated with a significant reduction in the risk of contracture for at least 7 years following implantation. Smooth and textured silicone implants had contracture rates similar to each other, and the particular type of surface texturing (Biocel versus Siltex) was of no consequence. Contracture was more common following breast reconstruction and implant replacement than after augmentation mammaplasty and was not affected by filler material or implant size. Implant position did not alter the risk of contracture after augmentation; tissue expansion did not affect the risk of contracture after breast reconstruction. Infections were unusual but most common after reconstruction and unrelated to surface texture or filler material. Skin wrinkling was more frequent with saline implants and in the presence of surface texturing. Implant rupture was rare, with an incidence of 1 per 760 implant-years. Implant-associated connective-tissue disease was noted in only one individual, an incidence of 1 per 3801 implant-years.

Breast conservation therapy after augmentation mammaplasty : Is it appropriate ?

&NA; Breast conservation therapy, consisting of lumpectomy, axillary node dissection, whole‐breast irradiation, and a boost to the tumor bed, is an increasingly popular option for the treatment of breast cancer. Among patients with stage I and stage II disease, breast conservation therapy yields survival rates equivalent to those for mastectomy. The cosmetic results of radiotherapy are usually good, and this approach preseryes an intact, sensate breast. Most studies on breast conservation therapy, however, have been performed in nonaugmented patients. Relatively little has been published regarding breast conservation therapy in the presence of silicone implants. Between 1981 and 1994, we treated 33 augmented patients with breast conservation therapy. Among 26 individuals for whom complete follow‐up data were available, 17 (65 percent) developed significant capsular contracture on the irradiated side. Thus far 8 patients with radiation‐induced contracture have undergone corrective surgery. In our experience, augmented breast cancer patients treated with breast conservation therapy have less satisfactory cosmetic results than nonaugmented women. In addition, mammographic follow‐up, critical for identifying local recurrence, may be impaired by the presence of an implant and capsular contracture. On the basis of these considerations, breast conservation therapy may be less than optimal in augmented cancer patients unless explantation is performed before treatment.

The influence of a brief preoperative illness on postoperative healing.

In a study of wound healing at high altitude, subcutaneously implanted PTFE tubes were used to stimulate and measure accumulation of wound hydroxyproline (an index of collagen) in 26 patients who had appendectomy and in 38 patients who had cholecystectomy. Patient age, length of surgery, and postoperative recovery seemed to predict better healing in patients who had appendectomy, but there was a difference in the preoperative illness of the two groups: acute cholecystitis was treated medically and cholecystectomy performed after resolution of the acute phase of illness, whereas patients who had appendectomy were taken to surgery as soon as a diagnosis was made. It was observed that patients who had appendectomy accumulated 20% less hydroxyproline than patients who had cholecystectomy (p < 0.02), and that the depression of hydroxyproline accumulation was significantly related to length of preoperative illness (p = 0.008). This decrease in wound hydroxyproline accumulation is attributed to the acute preoperative illness. Conceptually, this is a unique situation since the brief illness did not produce lasting debility, and the source of illness, the inflamed appendix, was not present during healing. This indicates that even a brief preoperative illness has a more prolonged influence on postoperative healing than usually anticipated.

Cardiac cryolesions as an experimental model of myocardial wound healing.

The standard coronary ligation model for experimental myocardial infarction results in variable areas and patterns of necrosis; therefore, the healing of such infarctions is also variable. The authors developed an experimental myocardial injury model using simple cryoinjury, which allows standardization of the size, depth, and location of the wound. Thirty-eight left ventricular cryolesions were created in 19 dogs, which were then killed from 3 to 35 days after injury. A consistent decrease in the depth of scar (p less than 0.005) and accumulation of collagen (p less than 0.0001) over time characterized this healing myocardial wound. Histologic examination revealed that the cellular pattern of healing myocardial cryolesions is similar to that of a healing myocardial infarction but with less variability. The authors advocate the use of cardiac cryolesions as a model of experimental myocardial wound healing.

Comparative experience with smooth and polyurethane breast implants using the Kaplan-Meier method of survival analysis.

Smooth-walled silicone implants have been widely used in breast surgery. Capsular contracture, causing undesirable firmness and spherical deformity, has been a common problem. Recent studies suggest that polyurethane-covered breast implants are associated with a lower incidence of capsular contracture. The statistical methodology employed in some of these studies, however, may be subject to criticism. Between July of 1984 and June of 1990 (72 months), 427 polyurethane breast implants were used in 279 patients and 439 smooth prostheses were used in 250 patients for a variety of aesthetic and reconstructive procedures. The occurrence of capsular contracture was carefully monitored and then analyzed using the Kaplan-Meier method of survival analysis. This method is particularly well suited to analysis of these types of clinical data because it allows for the fact that contractures occur at varying intervals after surgery and that follow-up of patients is incomplete. The probability of capsular contracture with smooth-walled prostheses was found to be significantly greater than with polyurethane-covered implants in each group of patients studied (p<0.05). Other complications occurred at a similar rate regardless of prosthesis type. This study supports the belief that polyurethane breast implants have a lower contracture rate; furthermore, it introduces the Kaplan-Meier method for analyzing the outcome of alternative plastic surgical therapies.

Extended Skin Island Delay of the Unipedicle Tram Flap: Experience in 35 Patients

A technique to surgically delay a single-pedicle TRAM flap is described. This extended skin island delay essentially divides the unipedicle TRAM flap into two stages separated by 1 week. Experience with this flap in 35 patients is reported. On the basis of this experience, we believe that the extended skin island delayed TRAM flap should be considered a safe and reliable alternative to double muscle pedicle and free tissue transfer in high-risk patients.

Knowledge, Concern, and Satisfaction Among Augmentation Mammaplasty Patients

Eighty-five patients with augmentation mammaplasty were surveyed. Patients were polled about knowledge of risks, level of concern, awareness of media publicity, incidence of complications, and degree of satisfaction with breast implants. Sixty-one percent of the patients were satisfied or very satisfied with implants, whereas 32% were somewhat or very unsatisfied. Level of satisfaction was not related to knowledge of risks, but did correlate with having experienced side effects or complications. Virtually all patients were aware of recent media publicity about implants, and 90% of women perceived the publicity to be negative. Seventy-five percent of the patients expressed concern about implant safety. Even after exposure to negative publicity, however, <10% of those surveyed regret having had the surgery and only 6% indicated they would like their implants removed. Overall, patients with augmentation mammaplasty perceive the benefits of implants greatly outweigh the risks.

Intraductal Breast Carcinoma: Experiences from The Breast Center in Van Nuys, California

The Breast Center in Van Nuys, California was the first free-standing, truly multidisciplinary, breast treatment center in the United States (Silverstein et al. 1986a). Housed in a 14000 square foot area, it includes a home-like waiting room, an operating and recovery suite, diagnostic and education center, clinical center, physicians offices, and psychiatric center. Members of the diagnostic and therapeutic teams are always available. The diagnostic center contains four modern mammography machines, a digital stereotactic unit, and ultrasonography equipment. The staff includes surgical, medical and radiation oncologists, a diagnostic radiologist, two reconstructive surgeons, two pathologists and a psychologic team headed by a psychiatrist (psycho-oncologist).