Peter Kreymerman

Reconstruction of the Burned Hand

This article summarizes the initial management of acute burn injuries to the hand, in addition to treatment and reconstructive options. The goal of treatment for a burn injury to the hand is primarily a functional hand. This is best achieved by appropriate early treatment, the right selection from a wide range of possible reconstructive procedures, and focused occupational hand therapy.

Neoadjuvant therapy and breast cancer surgery: a closer look at postoperative complications

BACKGROUND Neoadjuvant therapy is important in the treatment of advanced breast cancer. METHODS Postoperative complications in neoadjuvant patients were analyzed. RESULTS One hundred forty patients underwent 148 breast cancer surgeries after neoadjuvant therapy: 28% breast-conserving therapy procedures, 36% mastectomies, 28% mastectomies with immediate reconstruction, and 8% mastectomies with delayed reconstruction. Forty-seven patients (34%) suffered 59 complications: 18% of those undergoing breast-conserving therapy, 30% of those undergoing mastectomy, 44% of those undergoing mastectomy with immediate reconstruction, and 67% of those undergoing mastectomy with delayed reconstruction. Major complications occurred in 18% of patients. Skin loss occurred in 6% of patients. One patient had partial nipple necrosis. Three patients suffered implant loss. One patient had deep inferior epigastric artery perforator flap loss. Eleven hematomas and 5 infectious complications required reoperation. CONCLUSIONS Surgery after neoadjuvant therapy is safe, but careful counseling is warranted given that 18% of patients experienced major complications. Complications rates are higher with reconstruction, but feared complications of skin, nipple, implant, or flap loss were infrequent.

Can lymphatic drainage of head and neck melanoma be predicted

The lymphatic drainage patterns of the head and neck (H&N) is complex. Therefore, identification of the sentinel lymph node (SLN) for H&N melanoma can be challenging.

Management of Postblepharoplasty Chemosis

Clinically significant chemosis occasionally complicates lower eyelid blepharoplasty. In this report, the etiologic components of postblepharoplasty chemosis are discussed. The time course and duration of chemosis vary according to the underlying cause. Early, late, and prolonged chemosis are managed with different strategies. Diagnostic and therapeutic algorithms for chemosis assessment and management are presented.

Guidelines for using breast magnetic resonance imaging to evaluate implant integrity.

The purpose of this report was to review our experience with using breast magnetic resonance imaging to evaluate breast implant integrity and to offer a decision tree to assist physicians in managing these patients. Data were available for 81 patients with 146 implants placed either unilaterally or bilaterally for either cosmesis or breast reconstruction. The chief complaint for a majority of patients (n = 24) was breast pain. Thirty-two patients were found to have 44 ruptured implants, the majority of whom were found to have either contracture (n = 7) or negative findings (n = 7) on physician examination. The likelihood of rupture increased with number of years in place. When a patient presents for a possible implant rupture, the initial concern is to rule out malignancy, but because clinical and radiologic findings are often convoluted and complicated, a decision tree is helpful.

Contradicting an established mantra: microsurgeon experience determines free flap outcome.

Background: Since the inception and popularization of microsurgery in the 1960s and 1970s, it has been commonly accepted that the outcome of free tissue transfer directly correlates with surgeon experience. Methods: The clinical outcomes of three young microsurgeons at a single institution were retrospectively reviewed. Free flaps performed by these individuals were categorized according to the surgeon’s years of practice and analyzed using statistical methods. Results: A total of 410 free flaps were identified. No correlation was found between the surgeon’s years of experience and the outcomes measured. Conclusions: There has been increased exposure to microsurgery during plastic surgery training at many programs, and consequently, residents have often already surpassed the learning curve. The imperfect correlation between experience and superior outcomes in medicine serves to suggest that further research in the specific underlying principles of surgical learning is needed to understand the relationship between experience and superior surgical outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Computed Tomographic Angiography: Assessing Outcomes

Perforator flaps are preferable for breast reconstruction after mastectomy in many patients. Preoperative imaging of the perforators and source vessels is desirable to reduce surgeon stress, limit donor and recipient site complications, and minimize operative time and associated costs. Computed tomographic angiography (CTA) has been shown to provide highly accurate representations of vascular anatomy with excellent spatial resolution. A critical review of the currently available literature was performed to identify the benefits of preoperative imaging (specifically CTA) in perforator flap reconstruction.

Etiology of Breast Masses Following Autologous Breast Reconstruction

reSultS: 366 flaps were performed on 278 patients (254 DIEP, 35 SIEA, 20 ms free TRAM, 25 latissimus, and 32 pedicled TRAM flaps) with a mean follow up of 34 months. Breast masses were identified in 66 breasts (18%). Fat necrosis was diagnosed in 54 breasts (15% overall; DIEP 13.4%, SIEA 5.7%, ms free TRAM 15%, lat 0%, pedicled TRAM 47%) and was first identified at a mean of 2.9 months. Recurrent carcinoma was diagnosed in 13 breasts (3.6%) and was first discovered at a significantly later time period following reconstruction (23.7 months). The development of recurrent carcinoma most frequently occurred when pathologic tumor margins were less than one centimeter at the time of extirpation. Radiologic imaging was utilized in 18 breasts in patients with fat necrosis (18/54, 33%) to study the etiology of the mass. 16 suggested a benign process, whereas 2 were suspicious for carcinoma, both of whom were later found to have a tumor recurrence. Imaging was utilized in 10 of 13 cases in patients with recurrent carcinoma, 9 of which suggested recurrence, whereas one was indeterminate.