Matthew Endara

Breast reconstruction following nipple-sparing mastectomy: a systematic review of the literature with pooled analysis.

Background: Nipple-sparing mastectomy is a controversial option for breast cancer treatment due to locoregional recurrence and distant metastasis. In addition to these oncologic factors, technical factors such as ideal incision type or reconstructive options are also debatable. This systematic review examines current trends with nipple-sparing mastectomy, including selection criteria, locoregional and distant metastasis rates, incision choice, and reconstructive options. Methods: Systematic electronic searches were performed in the PubMed and Ovid databases using search terms for studies reporting outcomes following nipple-sparing mastectomy and all forms of reconstruction. Studies between 1970 and 2013 were reviewed. Pooled descriptive statistics with separate analyses for incision type and reconstructive method were performed. Results: Forty-eight studies met inclusion criteria, yielding 6615 nipple-sparing mastectomies for analysis. The overall pooled complication rate was 22 percent, the nipple necrosis rate was 7 percent, the locoregional recurrence rate was 1.8 percent, and the distant metastasis rate was 2.2 percent. Comparing combined patient cohorts for two-stage expander to implant, one-stage direct to implant, and autologous reconstruction demonstrated overall complication rates of 52.8, 16.7, and 23.7 percent and nipple necrosis rates of 4.5, 4.1, and 17.3 percent, respectively. Incision types were divided into five categories: radial, periareolar/circumareolar, inframammary, mastopexy, and transareolar, with nipple necrosis rates of 8.83, 17.81, 9.09, 4.76, and 81.82 percent, respectively Conclusions: Nipple-sparing mastectomy appears to be an oncologically safe option for properly selected patients, with low rates of locoregional and distant metastasis. Overall complication and nipple necrosis rates are affected by incision location and reconstruction method. Randomized controlled trials are warranted to determine best incision and reconstructive methods. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The role of chronic and perioperative glucose management in high-risk surgical closures: a case for tighter glycemic control.

Background: The exact risk that poor glucose control introduces to patients undergoing surgical closure has yet to be fully defined. Methods: The authors retrospectively analyzed a prospectively collected database of patients seen at their wound care center to evaluate the effects of chronic and perioperative glucose control in high-risk patients undergoing surgical wound closure. Hemoglobin A1c and blood glucose levels for the 5 days before and after surgical closure were recorded and compared with the primary endpoints of dehiscence, infection, and reoperation. Univariate and multivariate analyses were performed. Results: Seventy-nine patients had perioperative glucose levels and 64 had hemoglobin A1C levels available for analysis. Preoperative and postoperative hyperglycemia (defined as any blood glucose measurement above 200 mg/dl) as well as elevated A1C levels (above 6.5 percent or 48 mmol/ml) were significantly associated with increased rates of dehiscence (odds ratio, 3.2, p = 0.048; odds ratio, 3.46, p = 0.028; and odds ratio, 3.54, p = 0.040, respectively). Variability in preoperative glucose (defined as a range of glucose levels exceeding 200 points) was significantly associated with increased rates of reoperation (odds ratio, 4.14, p = 0.025) and trended toward significance with increased rates of dehiscence (p = 0.15). In multivariate regression, only perioperative hyperglycemia and elevated A1c were significantly associated with increased rates of dehiscence. Conclusions: In primary closure of surgical wounds in high-risk patients, poor glycemic control is significantly associated with worse outcomes. Every effort should be made to ensure tight control in both the chronic and subacute perioperative periods. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Postoperative Headache Following Acoustic Neuroma Resection: Occipital Nerve Injuries Are Associated With a Treatable Occipital Neuralgia

Objective.— To demonstrate that occipital nerve injury is associated with chronic postoperative headache in patients who have undergone acoustic neuroma excision and to determine whether occipital nerve excision is an effective treatment for these headaches.

Applications of Fat Grafting in Facial Aesthetic Skeletal Surgery

BACKGROUND Aesthetic skeletal surgery of the face is a powerful tool to alter the facial skeleton; the facial form is enhanced through the use of alloplastic implants and osteotomies of the facial bones. However, the ultimate aesthetic appearance is dictated by how the soft tissue envelope drapes over the altered skeletal foundation. Intraoperative and postoperative fat grafting enhances the final aesthetic result in patients who undergo skeletal aesthetic procedures. OBJECTIVES The authors describe cases in which selective fat grafting has been successful in optimizing facial soft tissue symmetry in patients undergoing skeletal aesthetic surgery of the face. METHODS A retrospective chart review of all patients who underwent aesthetic skeletal surgery of the face between November 1, 2003, and October 31, 2011, in the Department of Surgery at Georgetown University Hospital was performed, and any patient who required fat grafting either at the time of aesthetic facial skeletal surgery or in the postoperative period was identified (n = 21). Common indications for fat grafting and the surgical plans are reviewed and presented in this article. RESULTS Twenty-one patients were identified who required 37 fat grafting procedures either at the time of aesthetic skeletal surgery of the face or in the postoperative period. The procedures most frequently requiring fat grafting were genioplasty, facial shape modifications, and facial symmetry improvement. Fat grafting most commonly corrected irregularities or asymmetries and improved the soft tissue contour overlying repositioned bone or alloplastic implants. Most patients were female (72%) with a mean age of 42 years (range, 4-58 years). There were 4 complications in total: 3 surgical site infections (managed conservatively in 1 patient and with incision and drainage in the remaining 2) and 1 hematoma requiring drainage and closure on the day of surgery. CONCLUSIONS Knowledge of which procedures are likely to require fat grafting and the techniques for doing so can improve the plastic surgeons ability to provide optimal aesthetic results following facial skeletal alterations.

Using color to guide debridement.

ABSTRACT Chronic wounds are typically halted in the inflammatory stage of wound healing secondary to a prolonged inflammatory response of the body to bacterial colonization, as planktonic bacteria and biofilm and senescent cells present at the wound’s edges. Surgical debridement of these wounds is a critical step taken by the treating physician to attain complete healing. In order for debridement to successfully reset the stages of wound healing, residual biofilm and senescent cells must be removed. Despite the importance of complete and thorough debridement, few methods exist, and even fewer articles have been written describing techniques to ensure that all portions of a wound are equally addressed with each procedure. Using methylene blue dye to color the wound allows the surgeon to address and debride all portions of the wound adequately. In addition, the surgeon must be very familiar with what the normal tissue colors are following removal of the methylene blue-dyed tissue. Getting to tissue with those colors provides an end point to the debridement and helps prevent removal of excess healthy tissue. This article describes the primary author’s technique for staining tissues with methylene blue dye prior to wound debridement, as well as the colors to look for to signal completion of surgery. In addition, a review of biofilm and senescent cells is presented as both are targeted but frequently missed when wounds are incompletely debrided.

Routine pathological evaluation of neuroma specimens: is there a rationale?

The routine pathological analysis of therapeutically resected traumatic or postoperative neuroma specimens to confirm diagnosis and rule out occult malignancy remains a controversial issue. Some experts advocate histological analysis of all specimens, and others rely on institutional policy. A retrospective chart review of all patients who underwent excision of clinically diagnosed neuroma over a 6-year period at one institution by a single surgeon was initiated. The correlation of preoperative diagnoses with histological analysis and cost of analyzing specimens individually and over the 6-year period was calculated. Of 515 neuromas resected, 100 were sent for pathological review. Every submitted specimen was histologically confirmed to be a traumatic neuroma, and none of the specimens harbored occult malignancy. Ultimately, no treatment plan was altered after final histology was confirmed. The cost to analyze each specimen (Current Procedural Terminology code 88305) was

Occult radiation injury following angiographic procedures: recognition and treatment of an evolving complication.

495, expressed in U.S. dollars. If every specimen was analyzed, a total cost of

A critical look at the effect of hyperbaric oxygen on the ischemic nipple following nipple sparing mastectomy and implant based reconstruction: a case series

254,925 would have be incurred over the 6-year period. Routine pathological analysis of clinically and intraoperatively confirmed neuromas must be questioned in terms of standard of care requirements given its failure to aid in treatment plans as well as its significant cost to health care systems.

Free Tissue Transfer for Limb Salvage in High-Risk Patients: Worth the Risk

As the indications for fluoroscopically guided procedures increase, so do the potential complications from radiation. Radiation-induced wounds can have an insidious onset and time course that the plastic surgeon and wound specialist must be able to identify early.We review 3 cases of radiation-induced wounds following fluoroscopic procedures, which presented at various stages of diagnosis and healing. The pathophysiology of these wounds is discussed to aid in their diagnosis by providing an understanding of the resultant time course of injury and characteristics of the wounds. In addition, a familiarity of the concepts of interventional procedures and an increased element of caution in those patients most susceptible to injury is critical for prevention. Finally, an appropriate treatment protocol is proposed including early diagnosis, local wound care, hyperbaric oxygen, en bloc resection of the affected tissue, and reconstruction with tissue outside the zone of injury for recalcitrant or late stage wounds.

Tertiary breast reconstruction using a free contralateral latissimus dorsi musculocutaneous flap.

Background Nipple preservation provides superior aesthetic results as well as patient satisfaction in patients treated with both therapeutic and prophylactic mastectomy. Post-operative nipple ischemia and necrosis presents a unique clinical challenge that may be treated with hyperbaric oxygen therapy or conservative measures alone. To date, the efficacy of hyperbaric oxygen on post-operative nipple ischemia has yet to be evaluated. Methods A retrospective review of patients treated with either hyperbaric oxygen or conservative management was performed. Post-operative photographs were evaluated using a novel imaging data pathway to in both groups to determine rates of healing. Results Although patients treated with hyperbaric oxygen experienced rates of healing nearly twice those of patients treated with conservative measures alone, no statistical significance was found between groups in this series. Conclusions No significance difference was found between groups treated with hyperbaric oxygen or conservative management in this series. Further large scale, multi-center studies are warranted to further determine clinical utility and cost-effectiveness of hyperbaric oxygen for nipple ischemia following nipple sparing mastectomy (NSM) and implant based reconstruction.