R. Barrett Noone

Psychosocial Correlates of Immediate versus Delayed Reconstruction of the Breast

Two groups of consecutive patients from two different plastic surgical practice populations were evaluated to determine psychosocial differences between those who underwent immediate (n = 25) versus delayed (n = 38) breast reconstruction. Psychological assessment consisted of a standardized symptom inventory (BSI) and a specially designed self-report questionnaire investigating reactions unique to mastectomy and reconstruction. Both groups were extremely equivalent with regard to sociodemo-graphic data, with the typical subject being a well-educated and employed Caucasian wife. Verbal reports of physical complaints revealed no significant differences between the two groups except for difficulty with arm movement, which was statistically higher for the immediate group (p = 0.006.). This difference most likely was due to the axillary dissection being performed simultaneously at the time of reconstruction. The relationship between timing of reconstruction and self-reported distress over the mastectomy experience revealed that only 25 percent of the women who underwent immediate repair reported “high distress” in recalling their mastectomy surgery compared with 60 percent of the delayed reconstruction group (p = 0.02). In reference to the two scales measuring psychological symptoms, a general trend was present, with the delayed group scoring higher (although not statistically significantly) on 9 of our 12 scales. Ninty-six percent of the immediate group and 89 percent of the delayed group reported satisfaction with results. These findings challenge previously held assumptions about the timing of breast reconstruction, including a sociodemographic stereotype for the women requesting immediate repair, a presumed benefit from “living with the deformity,” and a diminished level of satisfaction for those who elect immediate reconstruction.

Recurrence of breast carcinoma following immediate reconstruction: a 13-year review.

To evaluate the effect of immediate reconstruction on the incidence, location, detection, and treatment of recurrent breast cancer, a review of 306 patients operated on according to a standard protocol during the 10-year period 1979 through 1988 was performed. Reconstruction techniques included submuscular implants (207), tissue expanders (84), and musculocutaneous flaps (15). During a minimum follow-up period of 3 years with a mean of 6.4 years, 60 patients (19.6 percent) developed recurrent disease, at a mean interval to recurrence of 31 months. The first locations of recurrences were local (16), regional (11), and systemic (33). Recurrence rates by stage included stage I, 7 patients (5.2 percent); stage II, 45 patients (32.1 percent); and stage III, 8 patients (40 percent). It was not possible to include comparisons with internal control groups of patients in our institution who were not reconstructed or who had delayed reconstructions, thereby preventing conclusions based on such comparisons. Our recurrence data are similar to literature reports of recurrence rates in patients who were not reconstructed after mastectomy. Detection and treatment of recurrences were not inhibited by the reconstructions. When radiation therapy was used in the treatment of local recurrences, the development of symptomatic capsular contracture was recorded in 58 percent of the patients. (Plast. Reconstr. Surg. 93: 96, 1994.)

The mutagenicity of electrocautery smoke.

Careful analysis of electrocautery smoke produced during breast surgery has found organic compounds that are unidentifiable with current analytical techniques. The purpose of this study was to determine the potential mutagenicity of the smoke produced by the electrocautery knife during reduction mammaplasty. Multiple air samples were collected in the operating room during two reduction mammaplasty procedures. Airborne smoke particles were tested for mutagenic potential in both tester strains of Salmonella typhimurium (TA98 and TA100) using the standard Salmonella microsomal test (Ames test). All testing was performed by the Hazard Evaluations and Technical Assistance Branch of the National Institute of Occupational Safety and Health. The smoke produced with the electrocautery knife during reduction mammaplasty was found to be mutagenic to the TA98 strain. The Ames test, an established technique for evaluating the mutagenicity of a substance, was convincingly positive for the smoke collected during the breast surgery. Whether the smoke represents a serious health risk to operating room personnel is not known. Development of techniques to limit electrocautery smoke exposure in the operating room appears to be needed, and surgeons should attempt to minimize their exposure.

Salvage of jeopardized total-knee prosthesis ; the role of the gastrocnemius muscle flap

Total-knee arthroplasty has provided many patients with excellent long-term functional results. However, exposure of a total-knee replacement usually eventuates in failure. The relatively superficial location of the prosthesis, the need for early active motion, previous surgical incisions, and a variety of systemic factors may militate against early wound healing. Restoration of well-vascularized soft-tissue cover can salvage an otherwise disastrous situation. The authors recommend early operative intervention upon observation of wound breakdown, devitalized skin edges, or significant subcutaneous infection leading to necrotic overlying skin. The operative procedure found to salvage the majority of prostheses consists of adequate debridement, antibiotic irrigation (of the joint, if exposed), and coverage with a well-vascularized muscle flap, preferably the medial gastrocnemius muscle. The operative technique and ultimate long-term outcome are reviewed based on experience with 10 consecutive patients presenting with a jeopardized knee prosthesis. Follow-up ranged from 1 to 6 years. Representative case histories are presented.

An objective analysis of immediate simultaneous reconstruction in the treatment of primary carcinoma of the breast.

In January 1977, the authors developed a protocol to test the advisability and feasibility of immediate simultaneous reconstruction in the treatment of primary carcinoma of the breast. Initial concerns included the morbidity of the procedure, the potential for compromise of cure and of adjuvant cancer therapy, and the aesthetic acceptability of immediate reconstruction both to the patient and to the surgeon. All patients were seen preoperatively by both the oncologic surgeon (T.G.F.) and the plastic and reconstructive surgeon, (R.B.N.), and underwent modified radical mastectomy and simultaneous reconstruction. The initial protocol included only those patients with tumors 1 cm or smaller, but over the last 25 cases the protocol has been expanded to include any patient presenting with clinical Stage I carcinoma of the breast. To date, 70 such patients (ages 27–63 years) have undergone immediate simultaneous reconstruction as part of their treatment. Twenty‐five patients had evidence of microscopic nodal disease (35.7%). All patients were offered adjuvant therapy, and in no case was therapy delayed beyond 4 weeks postoperatively. Three patients developed complications resulting in loss of implant (4.3%). All patients have been followed at regular intervals, and no patient has been lost to follow‐up. In only one patient was there a local recurrence without distant disease. Survival curves are consistent with the stage of the disease. The surgical techniques utilized and the methods of patient selection are discussed. The authors conclude that this is a desirable and viable option in selected patients with primary breast cancer, and that immediate simultaneous reconstruction can be done with an acceptable morbidity and without compromise of cancer therapy. Cancer 55:1202‐1205, 1985.

Suture suspension malarplasty with SMAS plication and modified SMASectomy: a simplified approach to midface lifting.

Background: The elements of midfacial aging include elongation of the lower eyelid, flattening of the malar eminence, hollowing in the submalar area, laxity of the jowls, and deepening of the nasolabial crease. Attention to rejuvenation of these areas has included various techniques involving movement of the superficial musculoaponeurotic system (SMAS) and elevation of the malar fat pad. A trend toward simplification in midface lifting has introduced the use of suspension sutures. Methods: This paper describes an approach to midfacial rejuvenation that combines the elements of SMAS plication and lateral SMASectomy with a suture suspension of the malar fat pad to achieve long-lasting improvement of the aging midface. The ptotic malar fat pad is suspended by suture to the deep temporal fascia. The suture passes from the subcutaneous position where it is fixed to the malar fat pad, through the SMAS, and over the periosteum of the zygoma, and is fixed to the deep temporal fascia. Plication of the SMAS over the suture, combined with lateral SMASectomy, provides three vectors of elevation beneath the skin in midface rhytidectomy. Results: This technique was used in 259 patients between October of 2000 and October of 2004, producing effective long-lasting results with limited convalescence and minimal complication rates. Conclusions: Safe dissection in the subcutaneous plane avoids injury to facial nerve branches. Plication of the SMAS with suture suspension of the malar fat pad avoids the prolonged convalescence and other morbidities of extensive sub-SMAS or deep plane dissections. This simplified approach can be quickly and easily performed under local anesthesia as an isolated midface procedure, or can be combined with surgery of the forehead, eyebrows, eyelids, or neck by standard techniques of rejuvenation.

An evidence-based approach to reduction mammaplasty.

Bryn Mawr, Pa. The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented. (Plast. Reconstr. Surg. 126: 2171, 2010.)

Perineal Reconstruction With Bilateral Bilobed Flap for Cloacal-Like Defect After Childbirth

Fourth degree lacerations of the vaginal wall and perineum following childbirth can cause cloacal-like defects of the perineum. The loss of the anterior anal sphincter and resultant thinning of the perineum and rectovaginal septum can lead to fecal incontinence and difficulties with sexual activity. This article introduces a technique to combine repair of the anterior anal sphincter with reconstruction of the perineal body with bilateral pedicled bilobed flaps.