Michelle C. Roughton

Optimizing delivery of breast conservation therapy: a multidisciplinary approach to oncoplastic surgery.

BackgroundFor patients with small breasts relative to tumor size and for those with tumors in the central or inferior poles, lumpectomy can be aesthetically devastating. The field of oncoplastic surgery has developed to offset the aesthetic pitfalls of breast conservation. Questions remain regarding oncologic safety, potential complications, and patient selection. In this study, we report our institutional, multidisciplinary experience with oncoplastic surgery. MethodsA retrospective review was performed including all patients at our institution undergoing oncoplastic breast surgery between 2003 and September 2009 at an academic medical center. Mean follow-up period was 38 months. All patients were referred by the institutional multidisciplinary breast team. ResultsForty-five female patients underwent 46 oncoplastic breast reconstructions. Immediate reconstruction was performed in 21 patients, early (within 9 to 73 days of final tumor resection) in 18, and delayed (following completion of radiation) in 6. Three patients (14%) who underwent immediate oncoplastic reconstruction had positive margins on final pathology and proceeded to completion mastectomy. No local cancer recurrence was seen. Two patients developed distant metastatic disease. Twelve complications occurred in 11 patients; by group, 2 (10%) in immediate, 7 (39%) in delayed-immediate group, and 2 (33%) in delayed. Immediate oncoplastic reconstruction, performed as a single-stage procedure, inversely correlated with complication risk (P = 0.059). No other risk factor correlated with complications. ConclusionsOur review suggests this multidisciplinary approach to oncoplastic surgery is safe. Interestingly, women undergoing immediate oncoplastic reconstruction trended toward a lower rate of complications. The benefit of immediate reconstruction must be balanced by risk of positive tumor margin and subsequent necessity for completion mastectomy. This risk–benefit balance may be best delivered by a multidisciplinary team focused on all aspects of breast cancer care.

Distance to a Plastic Surgeon and Type of Insurance Plan Are Independently Predictive of Postmastectomy Breast Reconstruction

Background: The psychosocial benefits of postmastectomy breast reconstruction are well established; however, health care barriers persist. The authors evaluated statewide patient population to further identify obstacles to reconstruction. Methods: A linked data set combining the North Carolina Central Cancer Registry with administrative claims from Medicare, Medicaid, and private insurance plans identified women diagnosed with breast cancer from 2003 to 2006. For inclusion in the study, women must have had a mastectomy within 6 months of diagnosis and had continuous insurance enrollment at least 2 years postoperatively (n = 5381). Multivariable logistic regression was used to model odds of reconstruction. Results: Approximately 20 percent underwent reconstruction (n = 1130). Distance to a plastic surgeon—10 to 20 miles (OR, 0.78) and greater than 20 miles (OR, 0.73; p < 0.05)—was significantly predictive of no reconstruction, independent of other well-known disparities, including age, race, rural location, and lower household income. Women with government-funded health care, such as Medicare (OR, 0.58) and Medicaid (OR, 0.24; p < 0.001), were also significantly less likely to undergo reconstruction. Consistent with previous study, advanced cancer stage and receipt of radiation therapy decreased the likelihood of reconstruction. Furthermore, when the authors compared immediate to delayed reconstruction, rural location, chemotherapy, and radiation therapy were significantly predictive of delay. Conclusions: This is the first population-based study to demonstrate distance to care and insurance plan as significant predictors of receipt of reconstruction. Additional research is needed to understand health care barriers and to determine whether distance to a plastic surgeon can be ameliorated by outreach programs. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Rigid sternal fixation in the management of pediatric postmedian sternotomy mediastinitis: A 20-year study.

BACKGROUND AND AIM Pediatric patients are at a risk of mediastinitis, a life-threatening complication of median sternotomy, following cardiac surgery for congenital conditions. Our experience with rigid internal sternal fixation in pediatric patients with postmedian sternotomy mediastinitis is presented. METHODS AND MATERIALS A retrospective chart review was performed of patients <18 years of age diagnosed with postoperative mediastinitis between January 1, 1990 and December 31, 2009. Charts were reviewed for demographic data, cardiac history, causative microorganism, and infectious risk factors. The methods of surgical intervention including flap coverage and use and type of sternal plating (resorbable and/or titanium) were also recorded. The primary end point of interest was overall survival. RESULTS Twenty-five pediatric patients were diagnosed with postoperative mediastinitis. Rigid fixation of the sternum following debridement was performed in 20 patients (age range: 1 month-18 years), all of whom successfully tolerated the procedure. Resorbable plates were used in 13 patients. Five patients did not undergo rigid fixation due to either serious ill-health or lack of adequate sternal bone stock. No patient experienced recurrent sternal wound infection. A total of 20 patients (80%) survived to discharge. Three patients succumbed to their heart condition prior to rigid fixation, one died following sternal closure from unrelated causes, and one patient was lost to follow-up. CONCLUSIONS Post-sternotomy mediastinitis in pediatric patients may be addressed using wide debridement, rigid sternal fixation, and flap coverage. In our series of 25 patients with pediatric mediastinitis, none died from mediastinitis. Placement of hardware did not adversely affect patient survival. This study demonstrates the feasibility of rigid sternal fixation.

Granulation tissue masquerading as basal cell carcinoma after treatment with vismodegib

BCC: Basal cell carcinoma INTRODUCTION The case of a 65-year-oldwomanwith an advanced, ulcerated biopsy-proven basal cell carcinoma (BCC) located on the left side of her upper back is reviewed. She was treated with vismodegib with only mild clinical improvement. Pathologic analysis of subsequent surgical resection found only granulation tissue with no evidence of residual tumor. It is important for clinicians to be aware that gross disease may not correlate with microscopic disease after treatment with vismodegib.

Plastic Surgery Training in the Era of Integrated Programs

Plastic surgery training has undergone and evolution in the recent past, like several other surgical specialties, and no longer follows the paradigm of surgical residency followed by specialty training. Although those traditional pathways exist, and allow for entry into plastic surgery from several specialties, integrated programs allow students to match into plastic surgery from medical school. This chapter examines both pathways and offers thoughts on how to be successful in pursuing training in plastic surgery.

Negligent and Inflicted Burns in Children

One in 4 American children have been abused and up to 5 children die per day from abuse. Children are vulnerable and error or lag in diagnosis may lead to further injury or death. In contrast, misdiagnosis of abuse is also unacceptable. Burns are a leading cause of abuse-related fatality and determination of cause can be difficult. It is critical that clinicians distinguish between burns of abuse (inflicted) and neglect and those received accidentally (noninflicted). Discordant narratives, use of alcohol and illicit substances, characteristics of the burn wound, and concomitant injury are all red flags for inflicted and negligent burns.

Plastic Surgery In-training Exam Scores Correlate with US Medical Licensing Exam Step 1 and 2 Scores

1 PuRPOSe Plastic Surgery In-training Exam (PSITE) and American Board of Surgery In-training Exam (ABSITE) scores correlate with written board passage rates and are thus one proxy for production of competent surgeons. We hypothesize standardized test-taking to be a skill and previous success should predict future success. This study examines the relationship between performance on US Medical Licensing Exam (USMLE), ABSITE, and PSITE. Secondarily, we looked for a link between annual case volume and exam success.

The inner prepuce flap for penile scald burns.

Preputial skin has similar color, texture, and composition to the skin of the penile shaft. The inner preputial skin may be transferred as a flap based upon Dartos fascia to resurface full-thickness burns of the penile shaft, providing a gliding and stretchable surface cover unique to the penis. The advantages of using the inner prepuce skin to resurface full-thickness burns of the penile shaft will be elucidated and the technique will be described. A retrospective chart review was performed of three patients whose penile shaft was resurfaced with inner prepuce flaps after tangential excision of their full-thickness scald burns. Patient 1 was a 9-year-old boy who sustained an 8% TBSA scald burn resulting in a full-thickness burn to the dorsum of his penis. Patient 2 was a 3-year-old boy who sustained a 60% TBSA immersion scald burn as a victim of child abuse, resulting in a circumferential penile burn. Patient 3 was an 8- year-old boy who sustained a 3% TBSA grease burn to the dorsum of his penis. The inner surface of the prepuce of the patients was intact. They were treated with an inner preputial flap. Full-thickness scald burns to the penis are unusual and challenging for the patient, family, and burn surgeon. It is advantageous that inner preputial skin is commonly spared. This specialized thin skin is ideal for resurfacing the penile shaft and should be used when available.

Laparoscopic en bloc resection of locally advanced colon cancer with involvement of the liver, small bowel, omentum, and abdominal wall.

Background Locally advanced colon cancer with the involvement of adjacent organs is treated radically with en bloc resection with negative margins. Laparoscopy is seldom recommended for such patients. Methods Operative laparoscopic technique is presented for radical en bloc resection of locally advanced right colon cancer. Results The patient is a 56-year-old morbidly obese (body mass index 47) male, who was scheduled to undergo a routine laparoscopic right hemicolectomy and at exploration was found to have a large mass involving segments V and VI of the liver, small bowel, omentum, and abdominal wall. A laparoscopic-assisted en bloc resection was performed. The patient went home in 7 days. The tumor was staged as T4N0M0, American Joint Commission on Cancer stage IIb with 21 negative nodes. Conclusions Laparoscopic resection for selected patients with locally advanced colonic neoplasms should be considered an option in tertiary referral centers.