Joseph Haik

Managing the relationship between quality and cost-effective burn care

In the modern era of fiscal prudence, managing the relationship between quality health care and cost reduction is a complex and challenging task for policy makers and health care providers. Health economics is an applied field that aids in assessing the feasibility of incorporating new interventions in a certain field. Applying these tools when allocating funds for burn care is even more complicated due to the lack of clinical data regarding the cost effectiveness of different aspects in burn care. Herein we review the existing literature and summarize different approaches for achieving cost effective health care in general and in burn care specifically. Special considerations to funds allocation in burn care are also discussed.

The effect of acellular dermal matrix on drain secretions after immediate prosthetic breast reconstruction

Abstract In recent years the acellular dermal matrix (ADM) has gained popularity in prosthetic breast reconstruction. These procedures involve placement of a closed suction drain in the reconstructed breast. Although it is now widely accepted that ADM has an overall positive effect on the outcome of breast reconstruction, data regarding its effect on postoperative drain secretions is lacking. This study was designed to quantitatively evaluate the influence of ADM on postoperative drain secretions in the setting of immediate prosthetic breast reconstruction (IPBR). This is a prospective, comparative controlled study. Two groups of 16 patients each underwent skin sparing mastectomies (SSM) and IPBR with or without ADM. Closed suction drains were left in all the reconstructed breasts and daily secretion volumes were recorded and compared. Postoperative complications were also noted. Patients in the ADM group showed higher daily and overall secretion volumes compared with patients in the control group (p = 0.014) and the time for removal of the drains was higher by an average of 5 days (13 compared with 8 days, respectively; p = 0.004). There was no correlation between ADM and infection. This study provides the first objective evidence that ADM contributes to elevated and prolonged drain secretions when used for IPBR. This might affect possible prosthesis-related complications (e.g., rotation and malposition, capsular contraction, seroma formation, and infection). This study also noted erythema of the post-mastectomy skin flaps in selected patients, which may be attributable to a local inflammatory reaction to the ADM rather than infection.

Epidermoid Inclusion Cysts After APTOS Thread Insertion: Case Report with Clinicopathologic Correlates

The APTOS threading procedure is a relatively new method in antifacial ptosis surgery. The reported cases present a small percentage of minor complications. A 57-year-old woman experienced scarring after APTOS threading. Scar biopsy showed an epidermoid inclusion cyst. Epidermoid inclusion cysts are a potential complication of APTOS threading. Proper surgical technique may reduce their likelihood.

Galactorrhea complicating wound healing following reduction mammaplasty.

Galactorrhea complicating wound healing following reduction mammaplasty occurs rarely; only isolated cases have been reported in recent years. We report the case of a 25-year-old woman who presented with delayed healing and dehiscence of surgical wounds 3 weeks following vertical scar reduction mammaplasty. During surgical debridement, spontaneous discharge of milk in the wound was noted. Serum prolactin levels were high, and she was treated with carbegoline, a dopamine agonist, which suppressed the prolactin secretion and led to rapid cessation of lactation. A second debridement and delayed primary closure were performed to achieve a satisfactory postoperative result.

Medicinal leech fixation in precarious locations.

Successful use of the medicinal leech Hirudo medicinalis in the salvage of microvascular free flaps has been widely described. The potent anticoagulant hirudin injected by the leech reduces venous engorgement nonsurgically by improving blood drainage from the flap. Potential risks include local infection (mainly by Aeromonas hydrophila), sepsis, blood loss, and leech migration. A method described by Granzow et al employs limiting the movement of medicinal leeches from the surgical site by affixing one end of a surgical suture to the leech and tying the free end to a firm object or dressing. The following case description reports a modification of this technique by suturing a leech to the skin close to an engorged composite graft at the nasal columella. An otherwise healthy 61-year-old woman presented with a large lesion involving the right nostril floor and columella. Tissue biopsy revealed a Morpheus-type basal cell carcinoma. A Mohs procedure was performed excising the nasal columella, the right vestibular mucosa on the septum, the lining mucosa of the right nostril, and the right septal mucosa. Several composite grafting procedures were needed to achieve acceptable structural results. After the last of these operations, the graft appeared to be congested (Fig. 1), and the patient was readmitted to undergo medicinal leech treatment. The proximity of the graft to the nasal orifice posed a therapeutic challenge, as the risk of leech translocation into the nostril and to the mouth was high. This obstacle was overcome by placing a suture piercing through the middle of the leech and fastening it to the underlying tissue using a connective buttonhole, thus preventing migration into the nasal cavity (Fig. 2). The medicinal leech Hirudo medicinalis has been successfully used in the salvage of congested microsurgical flaps by creating an alternative outflow for engorged blood in a flap compromised by poor venous drainage. Attachment is achieved by manipulation of the leech toward the designated area, both physically and chemically by creating a feeding substrate such as a sucrose solution or fresh blood by needle pricking the target tissue. Once sated, the leech will spontaneously detach, at which point arises the risk of translocation. Traditional methods of gauze application surrounding the treatment site may not be applicable in areas anatomically proximal to apertures such as the nose, ears, mouth, and genital orifices. Transmigration into virtually every bodily cavity has been described, posing an impending risk of internal bleeding. The emotional apprehension associated with leech therapy at any site is further heightened when applied near these challenging sites. These factors warrant the conception