Michael A. Howard

A review of mechanical adjuncts in wound healing: Hydrotherapy, ultrasound, negative pressure therapy, hyperbaric oxygen, and electrostimulation

Chronic or non-healing wounds may develop in the setting of many diseases and are the source of considerable morbidity as well as health costs. These wounds demand an aggressive, multifactorial approach including surgical debridement, revascularization, antibiotics and dressings. In addition serveral adjuvant treatment methods have been developed to further stimulate healing. Whirlpool, although used frequently, has not been proven to be of benefit. However, pulsed lavage does show a promising future. Ultrasound has demonstrated beneficial effects but further controlled studies are needed. Subatmospheric pressure therapy is associated with few complications and is fast becoming a mainstay of adjuvant therapy. Hyperbaric oxygen therapy has been shown to be effective for many types of wounds. Unfortunately, cost and access to chambers may prohibit its use on a routine basis. Finally, electrostimulation may be one of the up and coming therapies for the future. Though, more studies are needed to determine the mode of delivery for various types of wounds.

Breast cancer local recurrence after mastectomy and TRAM flap reconstruction: incidence and treatment options.

Background: The transverse rectus abdominis musculocutaneous (TRAM) flap is the standard in autologous breast reconstruction. The management of local recurrence of breast cancer after TRAM flap breast reconstruction has not been well described. The purpose of this study was to examine the incidence of local recurrence of breast cancer after TRAM flap breast reconstruction, evaluate treatment modalities, and determine outcomes in such cases. Methods: A retrospective review was conducted of all patients who underwent immediate breast reconstruction with a free or pedicled TRAM flap over a 15-year period. Those patients who experienced local breast cancer recurrence were identified. A subset of complete skin-sparing mastectomy patients was also identified for review. Results: From 1987 to 2002, 419 TRAM flap breast reconstructions were performed in 395 patients. Thirty-four (9 percent) were complete skin-sparing mastectomy using a periareolar mastectomy incision only. The mean follow-up time in this study was 4.9 years (range, 1 to 14.7 years). Local recurrence occurred in 16 of 419 patients (3.8 percent), with a mean time to local recurrence of 1.6 years (range, 0.2 to 7.0 years). There were no local recurrences seen in patients following complete skin-sparing mastectomy. Treatment of local recurrence included excision, chemotherapy, radiotherapy, and bone marrow transplant. Only three of the 16 patients (19 percent) required removal of the entire TRAM flap to manage local breast cancer recurrence. Nine of 16 patients (56 percent) with local recurrence died of disease at a mean of 1.2 years after the development of recurrence. Conclusion: Long-term follow-up demonstrated a local recurrence rate after TRAM flap breast reconstruction similar to that reported in the literature. Local recurrence was effectively managed with surgical excision of the involved tissues, chemotherapy, and/or radiation therapy. Removal of the entire TRAM flap was only necessary in the setting of multifocal recurrence or involvement of the flap pedicle with disease. The risk of local recurrence was not increased following complete skin-sparing mastectomy.

Complications in smokers after postmastectomy tissue expander/implant breast reconstruction

Smoking is universally considered to be a risk factor for surgical complications. The incidence of complications following tissue expander/implant breast reconstruction in patients who smoke has not been previously evaluated. A review of complications following tissue expander/implant reconstruction in 515 patients was performed. Patients who had 2-stage, tissue expander/implant reconstruction at Memorial Sloan-Kettering Cancer Center between May 2002 and December 2003 were included. Complications in smokers (n = 132) and nonsmokers (n = 383) were compared. The rate of overall complications, reconstructive failure, mastectomy flap necrosis, and infectious complications was significantly higher in smokers compared with nonsmokers. The rate of complications in ex-smokers was also higher than in nonsmokers. Using multivariate statistical analysis to adjust for confounding variables, smoking was identified as independent predictor of postoperative complications. A significant association between smoking status and postoperative complications exists. Thus, smokers who undergo postmastectomy expander/implant reconstruction should be informed of the increased risk of surgical complications and should be counseled on smoking cessation.

Have We Expanded the Equitable Delivery of Postmastectomy Breast Reconstruction in the New Millennium? Evidence from the National Cancer Data Base

BACKGROUND Studies examining patterns of cancer care before 2000 have shown underuse of postmastectomy breast reconstruction as well as racial and socioeconomic disparities in its delivery. These findings prompted legislation designed to broaden use at the turn of the millennium. However, little is known about trends in these findings over the past decade. STUDY DESIGN Patients who underwent mastectomy for stage 0 to III breast cancer between 1998 and 2007 (n = 452,903) were studied using the National Cancer Data Base to evaluate trends in the receipt of immediate and early delayed breast reconstruction. Those who underwent mastectomy between 1998 and 2000 (n = 150,177) and between 2005 and 2007 (n = 123,518) were compared using logistic regression to identify factors influencing the use of breast reconstruction and how they changed over time. RESULTS The use of postmastectomy breast reconstruction increased from 13% to 26% from 1998 to 2007. This increase was statistically significant in almost all patient subsets. Independent factors associated with breast reconstruction included age less than 50 years old; higher census-derived household income; private or managed care insurance; non-African American race; and treatment in an academic hospital setting. Treatment in an academic hospital and higher income became stronger predictors of breast reconstruction over the study period, while age became less of a predictor. CONCLUSIONS Although the use of breast reconstruction has increased from 1998 to 2007, it is still underused among many patient populations. Furthermore, racial and socioeconomic disparities in its delivery have persisted or widened. Additional effort is necessary to broaden the use of breast reconstruction and to ensure equitable access to it.

Oxygen and wound care: A review of current therapeutic modalities and future direction

While the importance of oxygen to the wound healing process is well accepted, research and technological advances continue in this field and efforts are ongoing to further utilize oxygen as a therapeutic modality. In this paper, the authors briefly review the role of oxygen in wound healing and discuss the distinct mechanism of action as well as the advantages and disadvantages of the three major oxygen‐based therapies currently in clinical use (Hyperbaric Oxygen and Topical Oxygen and Continuous Diffusion of Oxygen), as well as review the existing literature regarding these distinct therapeutic modalities.

Oxygen and wound care

While the importance of oxygen to the wound healing process is well accepted, research and technological advances continue in this field and efforts are ongoing to further utilize oxygen as a therapeutic modality. In this paper, the authors briefly review the role of oxygen in wound healing and discuss the distinct mechanism of action as well as the advantages and disadvantages of the three major oxygen‐based therapies currently in clinical use (Hyperbaric Oxygen and Topical Oxygen and Continuous Diffusion of Oxygen), as well as review the existing literature regarding these distinct therapeutic modalities.

Postmastectomy reconstruction of the previously augmented breast: Diagnosis, staging, methodology, and outcome

Although many of the health and safety issues associated with breast augmentation have been thoroughly discussed over the past decade, the literature is remarkably silent regarding postmastectomy reconstruction of the previously augmented breast. A retrospective review of the senior authors reconstructive practice was performed for the years 1983 through March of 1999, revealing 21 women who underwent postmastectomy breast reconstruction after previous breast augmentation. For purposes of measuring aesthetic results, these 21 patients were matched to a carefully selected control group of 15 patients. They were also compared with other, larger populations, including 777 of the senior authors other breast reconstructions, the breast cancer registry at the Lombardi Cancer Center in Washington, D.C., and several large, published epidemiologic studies. The interval between the previous augmentation and the diagnosis of breast cancer ranged from 9 months to 18 years, with a mean of 9.3 years. None of the previous augmentation implants was ruptured at the time of mastectomy. Of the nine patients with previous subpectoral augmentation, cancer was detected mammographically in five (56 percent), whereas of the 12 patients with previous subglandular augmentation, cancer was first detected mammographically in only three (25 percent). This difference was not statistically significant (p = 0.2). Overall, eight of the study patients’ tumors (38 percent) were first detected mammographically, which is similar to other published reports of breast cancer patients in the general population. Seventy‐one percent of the 21 study patients were node‐negative, which also compares favorably with other published series. Sixteen of the women with previous augmentation (76 percent) had purely prosthetic reconstructions. Flaps were used in the other five reconstructions (23 percent): three latissimus dorsi flaps (14 percent) and two transverse rectus abdominis musculocutaneous flaps (9 percent). All five flaps were used in patients who had undergone radiation therapy. Throughout the senior authors entire reconstructive practice history, transverse rectus abdominis musculocutaneous flaps were more frequently used [282 of 777 nonaugmented reconstructions (36 percent) ], whereas latissimus dorsi flaps were less frequently used [17 of 777 nonaugmented reconstructions (2.2 percent)] (p < 0.001). The cosmetic results of the breast reconstructions in the previously augmented study group were generally good‐to‐excellent, with a mean score by blinded observers of 3.35 of a possible 4.0. These results were comparable to or better than those in the matched controls, who scored a mean of 3.0. (Plast. Reconstr. Surg. 107: 1167, 2001.)

Postoperative Pain and Length of Stay Lowered by Use of Exparel in Immediate, Implant-Based Breast Reconstruction.

Background: Patients undergoing mastectomy and prosthetic breast reconstruction have significant acute postsurgical pain, routinely mandating inpatient hospitalization. Liposomal bupivacaine (LB) (Exparel; Pacira Pharmaceuticals, Inc., Parsippany, N.J.) has been shown to be a safe and effective pain reliever in the immediate postoperative period and may be advantageous for use in mastectomy and breast reconstruction patients. Methods: Retrospective review of 90 immediate implant-based breast reconstruction patient charts was completed. Patients were separated into 3 groups of 30 consecutively treated patients who received 1 of 3 pain treatment modalities: intravenous/oral narcotic pain control (control), bupivacaine pain pump, or LB injection. Length of hospital stay, patient-reported Visual Analog Scale (VAS) pain scores, postoperative patient-controlled analgesia usage, and nausea-related medication use were abstracted and subjected to analysis of variance and multiple linear-regression analysis, as appropriate. Results: Subjects were well-matched for age (P = 0.24) regardless of pain-control modality. Roughly half (53%) of control and pain pump–treated subjects had bilateral procedures, as opposed to 80% of LB subjects. Mean length of stay for LB subjects was significantly less than control (1.5 days vs 2.00 days; P = 0.016). LB subjects reported significantly lower VAS pain scores at 4, 8, 12, 16, and 24 hours compared with pain pump and control (P < 0.01). There were no adverse events in the LB group. Conclusion: Use of LB in this group of immediate breast reconstruction patients was associated with decreased patient VAS pain scores in the immediate postoperative period compared with bupivacaine pain pump and intravenous/oral narcotic pain management and reduced inpatient length of stay.

Patient satisfaction with nipple-sparing mastectomy: A prospective study of patient reported outcomes using the BREAST-Q

The authors sought to study patient‐reported outcomes following nipple‐sparing mastectomy (NSM).

Evaluation of genitofemoral nerve donor site morbidity after radical prostatectomy.

Background:The sural nerve is commonly used as a donor site for cavernous nerve grafting. However, the genitofemoral nerve is accessible and easily dissected and may represent an improved donor site for this procedure. Methods:Fourteen patients underwent radical prostatectomy followed by cavernous nerve grafting using the genitofemoral nerve. Seventeen donor sites (3 patients underwent bilateral grafts) were assessed by questionnaires (including the McGill Pain Scale) and focused neurologic examination. Results:Residual numbness in the genitofemoral nerve distribution was noted in 9 of 17 donor sites (53%). No patients reported that the deficits interfered with normal daily activities. All patients denied the presence of burning, cold sensitivity, or pain. All patients scored 0 on each of the 3 pain rating components of the short form McGill Pain questionnaire (sensory, affective, or total). Furthermore, no patients documented pain on either the PPI or VAS portions of the questionnaire. On examination, patients were unable to discriminate between sharp versus dull stimuli in 3 donor sites (17.6%), while 7 donor sites (41.2%) showed decreased light-touch sensation. The Semmes-Weinstein testing demonstrated that 8 (47.1%) were found to have distinct areas with sensory deficit ranging in size from 23 to 63 cm2 (mean, 16.6 cm2). The highest-pressure thresholds for each of the 17 donor sites ranged from 3.61 to 6.45 g/mm2 (mean, 4.91 g/mm2). The mean pressure threshold for the control regions (n = 11) was 3.35 g/mm2 (range, 2.38–4.71 g/mm2, P = 0.014). Only 50% of the sensory deficits documented by the Semmes-Weinstein test were clinically apparent to the patients. Conclusions:Due to its low donor site morbidity, the genitofemoral nerve is an excellent donor source for cavernous nerve grafting during radical prostatectomy. In the majority of the patients, the sensory deficit produced by resection of this nerve is minimal and caused no other adverse symptoms. Harvest of this nerve prevents the additional morbidity associated with a donor site located elsewhere on the body (ie, sural nerve).