Sarvam P. Terkonda

Latissimus dorsi flap remains an excellent choice for breast reconstruction.

Latissimus dorsi flap has been unfairly relegated to a second option in breast reconstruction. One hundred consecutive latissimus dorsi muscle flaps (LDMF) with tissue-expander reconstruction were studied, mean follow-up 34.5 months (range, 1–175), 50 immediate, 50 delayed. With attention to a few technical details, excellent esthetic, soft reconstructions were achieved. Complications included 1 partial flap loss; 2 patients required inframammary fold revision; and 6 patients required surgery for capsular contracture. Donor-site seroma occurred in 34 patients; 6 required operative revision. Results were similar in the immediate versus the delayed groups. LDMF remains an esthetic, reliable, safe reconstructive choice.

Latissimus dorsi reconstruction: a good option for patients with failed breast conservation therapy.

The majority of patients with breast carcinoma are being treated with breast conservation therapy (BCT): lumpectomy and postoperative radiation. Local recurrence reported at 8% to 11% is often treated with salvage mastectomy. This has led to a growing group of patients requiring breast reconstruction after failed BCT. Reluctance to use the latissimus dorsi flap (LDF) has resulted from reports of high implant capsular contracture rates. We present a series of 12 patients who underwent LDF reconstruction after the development of recurrent breast cancer after BCT. All 12 patients had a satisfactory esthetic result. Despite previous radiation, the capsular contracture rate was 12.5% (median follow up, 50 months; range, 20–93 months). The most common complication was donor site seroma in 25% (3 of 12) of cases. The LDF yielded satisfactory esthetic results with a low capsular contracture rate. Despite prior radiation, LDF remains a good option for breast reconstruction after failure of BCT.

MRI Appearance of Myocutaneous Flaps Commonly Used in Orthopedic Reconstructive Surgery

OBJECTIVE Our aim was to describe the MRI appearance of myocutaneous flaps and to determine whether postoperative radiation therapy affects imaging. MATERIALS AND METHODS We retrospectively reviewed 30 myocutaneous flaps in 27 patients (n = 165 examinations; mean, 6.1 examinations per patient). Examinations were analyzed for flap type, location, degree of atrophy, signal intensity, and enhancement. RESULTS Sixty-three percent (19/30) of the flaps developed high T1-weighted signal (mean, 15 months); 83% (25/30) developed high T2-weighted signal (mean, 10 months). This occurred sooner in those patients with postoperative radiation therapy (9 vs 12 months). T2-weighted signal returned to baseline in 32% (8/25) of the flaps (mean, 21 months); this occurred sooner in flaps not exposed to postoperative radiation (10 months vs 38 months). Seventy-one percent (20/28) of the flaps enhanced greater than the background musculature. Enhancement was seen more frequently in patients treated with postoperative radiation therapy than those not treated with radiation (83% vs 63%). All flaps atrophied; however, the two functional latissimus dorsi flaps atrophied less. Although increased T2-weighted signal and enhancement were seen in flaps after postoperative radiation therapy as compared with those without, this was not significant (p = 0.35 and p = 0.40, respectively). CONCLUSION Myocutaneous flaps used in orthopedic reconstructive surgery typically show increased signal intensity on T2-weighted images and contrast enhancement initially, followed by some degree of atrophy and increased signal intensity on T1-weighted images. Postoperative radiation therapy may increase the likelihood that the flap will exhibit increased T2-weighted signal and enhancement.

Spontaneous perforating hematoma of the rectum

Intramural hematomas of the intestine most often occur in the setting of blunt abdominal trauma. However, spontaneous hematomas can occur secondary to either hematologic disorders or use of anticoagulant therapy. There has been no clearly documented report of a spontaneous rectal hematoma. We describe the novel treatment of a patient with a spontaneous intramural hematoma of the rectum which presented as an abdominal catastrophe.

Ambulance-based assessment of NIH Stroke Scale with telemedicine: A feasibility pilot study

Background Ischemic stroke is a time-sensitive disease, with improved outcomes associated with decreased time from onset to treatment. It was hypothesised that ambulance-based assessment of the National Institutes of Health Stroke Scale (NIHSS) using a Health Insurance Portability and Accountability Act (HIPAA)–compliant mobile platform immediately prior to arrival is feasible. Methods This is a proof-of-concept feasibility pilot study in two phases. The first phase consisted of an ambulance-equipped HIPAA-compliant video platform for remote NIHSS assessment of a simulated stroke patient. The second phase consisted of remote NIHSS assessment by a hospital-based neurologist of acute stroke patients en route to our facility. Five ambulances were equipped with a 4G/LTE-enabled tablet preloaded with a secure HIPAA-compliant telemedicine application. Secondary outcomes assessed satisfaction of staff with the remote platform. Results Phase one was successful in the assessment of three out of three simulated patients. Phase two was successful in the assessment of 10 out of 11 (91%) cases. One video attempt was unsuccessful because local LTE was turned off on the device. The video signal was dropped transiently due to weather, which delayed NIHSS assessment in one case. Average NIHSS assessment time was 7.6 minutes (range 3–9.8 minutes). Neurologists rated 83% of encounters as ‘satisfied’ to ‘very satisfied’, and the emergency medical service (EMS) rated 90% of encounters as ‘satisfied’ to ‘very satisfied’. The one failed video attempt was associated with ‘poor’ EMS satisfaction. Conclusion This proof-of-concept pilot demonstrates that remote ambulance-based NIHSS assessment is feasible. This model could reduce door-to-needle times by conducting prehospital data collection.

An evaluation of calcium hydroxylapatite (Radiesse) for cosmetic nasolabial fold correction: a meta-analysis and patient centric outcomes study.

The use of calcium hydroxylapatite (Radiesse, BioForm Medical, San Mateo, California) for cosmetic soft tissue augmentation has increased significantly in recent years. Only a handful of authors have reported patient satisfaction data.A meta-analysis of published data was performed using a 5-point scale for patient satisfaction to allow data comparison across studies. A patient-centric outcomes study was also performed at our institution, using a blinded questionnaire.Five usable studies were identified for meta-analysis. Patient satisfaction was 4.16 of 5 in 324 patients at 3 to 6 months and 4.15 in 86 patients at 1 year. In our institutional patient-centric outcomes study, the early satisfaction rate was 3.7 of 5. At 1 year the rate was only 2.3 of 5.Calcium hydroxylapatite remains a viable option for augmentation of facial soft tissue structures. However, this report shows that further, accurate, large population outcomes assessments are absolutely required.

Breast Reconstruction After Solid Organ Transplant.

BackgroundSolid organ transplant patients frequently develop posttransplant malignancies including breast cancer. They may desire breast reconstruction after mastectomy, which could potentially be complicated by their transplant status, immunosuppressive regimen, and previous operations. We review our experience with patients who have undergone solid organ transplant and subsequent breast reconstruction after mastectomy MethodsAfter institutional review board approval, we queried our prospective breast reconstruction and solid organ transplant databases for corresponding patients. Inclusion criteria comprised breast reconstruction after solid organ transplant. A chart review was conducted of identified patients. ResultsSeventeen patients were identified: 1 pulmonary transplant, 4 cardiac transplants, 2 liver transplants, 1 pancreas transplant, 2 combined kidney/pancreas transplants, and 7 kidney transplants. Indications for mastectomy included posttransplant malignancy and prophylaxis. Median time from transplant to completion of reconstruction was 186 months (range, 11–336 months). Median age at transplant was 34.5 years (range, 21–65 years) with the median age of the patients at reconstructive surgery 51.5 years (range, 34–71 years). Median body mass index was 25.3 (range, 21.3–46.5). No significant complications were noted after reconstructive surgery. All patients were on full immunosuppression at time of reconstruction. ConclusionsBreast reconstruction is a viable option for transplant patients after mastectomy and should not be refused based on their transplant status. Close coordination with the transplant team and careful preoperative planning is essential for optimal outcomes.

Perioperative Glycemic Control in Plastic Surgery: Review and Discussion of an Institutional Protocol.

Perioperative hyperglycemia is a well-known risk factor for surgical morbidity such as wound healing, infection, and prolonged hospitalization. This association has been reported for a number of surgical subspecialties, including plastic surgery. Specialty-specific guidelines have become increasingly available in the literature. Currently, glucose management guidelines for plastic surgery are lacking. Recognizing that multiple approaches exist for perioperative glucose, protocol-based models provide the necessary structure and guidance for approaching glycemic control. In this article, we review the influence of diabetes on outcomes in plastic surgery patients and propose a practical approach to perioperative blood glucose management based on current Endocrine Society and Mayo Clinic institutional guidelines.

Micro-fragmented adipose tissue for treatment of knee osteoarthritis with Baker's cyst: A case study

Adipose-derived therapies have increased in popularity for treatment of painful orthopaedic conditions, such as osteoarthritis. We report the passage of fat into a Baker’s cyst after injection of micro-fragmented adipose tissue in a patient with bilateral knee arthritis. Following fat grafting, the patient required drainage of fatty fluid from within the Baker’s cyst on multiple occasions. Approximately 3 months postprocedure, she began to notice an improvement in her knee pain with no further recurrence of pain or swelling from her Baker’s cyst.