Steven R. Jacobson

Focused Cervical Exploration for Primary Hyperparathyroidism without Intraoperative Parathyroid Hormone Monitoring or Use of the Gamma Probe

Selected patients with primary hyperparathyroidism (pHPT) who have a positive preoperative sestamibi scan can be managed safely and successfully with a focused cervical exploration without either adjuvant intraoperative parathyroid hormone (PTH) monitoring or use of a gamma probe. This article reports a retrospective analysis of a consecutive series of patients surgically treated at a tertiary referral center. From August 1998 to August 2002, 100 patients (68 women, 32 men; mean age 63 years [range: 29–89 years]) underwent a focused cervical approach without intraoperative PTH monitoring or use of the gamma probe after perioperative sestamibi injection. The study group comprised 9% of all patients (n = 1063) undergoing cervical exploration for pHPT during the study period. Ninety patients underwent an initial exploration, and 10 others underwent repeat cervical exploration following prior parathyroid (n = 7) or thyroid (n = 3) operation. Sestamibi scanning correlated with one enlarged parathyroid gland in all patients. Other enlarged glands were, however, not demonstrated in three patients (true positive = 97%; false negative = 3%). The single enlarged glands excised in all patients had a mean weight of 795 mg (range: 90–3640) and were histologically compatible with an adenoma. Postoperatively, 97% of patients were eucalcemic. Three patients remained hypercalcemic (3%). Of the three patients with persistent hypercalcemia, one underwent successful re-exploration with excision of a 500 mg second adenoma, whereas the other two patients (with confirmed familial HPT) remained hypercalcemic. Mean hospitalization was 0.5 days (range: 0–3 days). There was no operative mortality. No patients had permanent hypocalcemia. Postoperative morbidity occurred in three patients: two self-limiting cervical hematomas and one permanent vocal cord paralysis. Selected patients with pHPT due to single-gland disease and an unequivocally positive preoperative sestamibi scan can safely and successfully be managed with a focused unilateral cervical exploration without either intraoperative PTH monitoring or use of the gamma probe. Further experience with this surgical approach seems warranted to determine the overall cure rate, operative morbidity, and the sensitivity and specificity of preoperative localization studies.

Surgical anatomy of the midcheek: facial layers, spaces, and the midcheek segments.

This article describes the surgical anatomy of the midcheek. The articles key points: (1) Structurally, the midcheek is formed by the convergence of three components: the lid-cheek segment, the malar segment, and the nasolabial segment. (2) The midcheek skeleton provides the attachment for the muscles and ligaments of both the lower lid and the upper lip. (3) The midcheek contains proportionally more spaces and fewer ligaments than other parts of the face. (4) Each midcheek segment overlies a specific facial space. (5) The lid-cheek contour transition does not have a fixed relationship to the inferior orbital rim. (6) The youthful lid-cheek transition is above the orbital rim and the aged is below the rim. (7) Facial nerve branches course in predictable locations.

Revisiting an Old Place: Single‐Surgeon Experience on Post‐Mastectomy Subcutaneous Implant‐Based Breast Reconstruction

Significant advances have been made to the reconstructive tools available to plastic surgeons allowing for the re‐exploration of subcutaneous breast reconstruction. The purpose of the current study is to examine the safety, efficacy, and aesthetic results of subcutaneous breast reconstruction by a single‐surgeon. A retrospective chart review was performed on all patients undergoing subcutaneous implant‐based breast reconstruction between April 2012 and September 2014. All implants were fully wrapped in Alloderm and placed in the subcutaneous (pre‐pectoral) plane. Primary outcome was a successful subcutaneous breast reconstruction. All complications were recorded. Aesthetics of the preoperative and postoperative photographs were examined. A total of 135 breasts (79 patients) were reconstructed. Direct‐to‐implant reconstruction was performed in 8 patients (10%). Successful breast reconstruction was achieved for 130 breasts in 76 patients (96%). Sixty‐nine patients (87%) had a course free of any unexpected event or complication. There were no patients with implant extrusion or skin necrosis requiring operative intervention. When comparing pre‐mastectomy breasts with post‐mastectomy reconstructions, there was an improvement in the overall aesthetic outcome. Subcutaneous post‐mastectomy breast reconstruction is safe and effective with comparable complication rates to standard techniques. Yet, this minimally invasive approach does not sacrifice the aesthetic results. Long‐term studies will be required to prove the durability of aesthetic results overtime.

Simultaneous mastopexy in patients undergoing prophylactic nipple-sparing mastectomies and immediate reconstruction

BACKGROUND In some patients, a satisfactory aesthetic result of reconstruction following a nipple-sparing mastectomy (NSM) is limited by breast ptosis that goes uncorrected in the early phase of reconstruction. Most plastic surgeons remain hesitant to perform a mastopexy at the time of NSM due to concerns with nipple and/or skin flap loss. METHODS From 1990 to 1995, 33 female patients underwent NSM with simultaneous mastopexy and immediate implant-based reconstruction by a single surgeon at our institution. On chart review, the following data were extracted: age, co-morbidity, indication, breast size, initial/final implant volumes, type of implant, mastopexy technique, mastectomy flap/nipple necrosis, other complications, revision surgery and follow-up. An unpaired, two-tailed t-test was performed where indicated. P-value<0.05 was considered significant. RESULTS Wound complications occurred in 18.2% patients (10.9% breasts) without delaying tissue expansion. As many as 3% patients developed unilateral, isolated partial ischaemia of the mastectomy flap and 8% patients developed unilateral, superficial areolar loss. All resolved with conservative treatment. Only one patient developed bilateral total nipple loss. There was no correlation between preoperative breast size and postoperative complications. None of the patients developed breast cancer. Average follow-up was 11.6 years. CONCLUSION With proper technique, simultaneous mastopexy is a safe procedure in highly selected patients undergoing NSM with reconstruction.

Tailoring through Technology: A Retrospective Review of a Single Surgeon's Experience with Implant-Based Breast Reconstruction before and after Implementation of Laser-Assisted Indocyanine Green Angiography.

Reported complication rates of implant‐based breast reconstruction in the literature exceed 50%, with mastectomy skin flap necrosis reported to occur in up to 25% of cases. Laser‐assisted indocyanine green angiography (LA‐ICGA) technology allows the surgeon to optimize preservation of the mastectomy skin flap while avoiding skin necrosis. The purpose of this study was to determine if outcomes of breast reconstruction are beneficially affected by using LA‐ICGA. A total 269 consecutive women (467 breast reconstructions) undergoing implant‐based breast reconstruction from 2008 to 2013 were examined. The complication rates of those who underwent reconstruction prior to the implementation of LA‐ICGA were compared with those who were reconstructed after implementation of LA‐ICGA. A total of 254 consecutive breast reconstructions were performed prior to implementation of LA‐ICGA, and 213 breasts were reconstructed with the use of LA‐ICGA. After implementation of LA‐ICGA System, the rate of mastectomy skin flap necrosis decreased by 86% (6.7% versus 0.9%, p = 0.02). The overall complication rate prior to LA‐ICGA was 13.8% compared with 6.6% with the use of LA‐ICGA (p = 0.01). After LA‐ICGA was incorporated, the percentage of patients undergoing single‐stage reconstruction increased from 12% to 32% (p = <0.001). Implementation of LA‐ICGA provides the surgeon with an objective assessment of mastectomy flap perfusion resulting in a trend toward overall reduction in complications as well as an 86% decrease in the rate of subsequent skin necrosis. The objective assessment of mastectomy flap perfusion allows the surgeon to tailor breast reconstruction intraoperatively, in real‐time, adjusting for the individual patients mastectomy flap perfusion.

Red Breast Syndrome: A Review of Available Literature

There is scant literature regarding a recently identified clinical entity termed red breast syndrome. Its clinical presentation has been described as a non-infectious, self-limited erythema of a post-mastectomy breast reconstructed using acellular dermal matrix. Its incidence, risk factors, pathophysiology, clinical course, management, and long-term sequelae are largely unknown. We present a review of the available literature on this phenomenon and highlight some opportunities for further research.Level of Evidence VThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Microbial Biofilms and Breast Tissue Expanders

We previously developed and validated a vortexing-sonication technique for detection of biofilm bacteria on the surface of explanted prosthetic joints. Herein, we evaluated this technique for diagnosis of infected breast tissue expanders and used it to assess colonization of breast tissue expanders. From April 2008 to December 2011, we studied 328 breast tissue expanders at Mayo Clinic, Rochester, MN, USA. Of seven clinically infected breast tissue expanders, six (85.7%) had positive cultures, one of which grew Propionibacterium species. Fifty-two of 321 breast tissue expanders (16.2%, 95% CI, 12.3–20.7%) without clinical evidence of infection also had positive cultures, 45 growing Propionibacterium species and ten coagulase-negative staphylococci. While vortexing-sonication can detect clinically infected breast tissue expanders, 16 percent of breast tissue expanders appear to be asymptomatically colonized with normal skin flora, most commonly, Propionibacterium species.

Current strategies with 2-staged prosthetic breast reconstruction

Over the last decade, prosthetic-based breast reconstruction has been revolutionized with technological advancements. Reconstructive surgeons now have a multitude of prosthetic devices and tissue expanders, tools for intraoperative perfusion analysis, implantable bioprosthetic materials and a technique for autoaugmentation within their armamentarium to reconstruct natural breasts today like never before.

A systematic review of the use of Botulinum toxin type A with subpectoral breast implants

OBJECTIVE To determine the efficacy of Botulinum toxin A (BTX-A) injections for pain relief following placement of subpectoral tissue expanders and breast implants. METHODS MEDLINE and EMBASE were searched from their inception to December 2012 to identify studies reporting the efficacy of perioperative BTX-A injections following breast surgery with subpectoral prostheses. Study designs included controlled and uncontrolled studies. RESULTS Seven studies met the inclusion criteria (2 prospective controlled cohort, 3 retrospective cohort and 2 case series). Five studies assessed the efficacy of BTX-A and three measured pain improvement as a primary outcome. The studies enrolled 427 women: 91.8% received intraoperative BTX-A injection at the time of tissue expander breast reconstruction and 4.7% following augmentation mammaplasty. Only 3.5% of women received BTX-A injections in the postoperative setting. Overall, all the studies demonstrated improvement in pain and favorable side effect profile without any major adverse effects. However, the quality of this evidence was low. CONCLUSION The results of this systematic review suggest that BTX-A may alleviate postoperative pain associated with the placement of subpectoral tissue expanders and implants. The available data on outcome assessment of this practice are inconsistent and lack methodological rigor. With paucity of high-level evidence to support this practice in implant-based breast surgery, further studies are needed.

Intraoperative Angiography Provides Objective Assessment of Skin Perfusion in Complex Knee Reconstruction

BackgroundWound necrosis is a potentially devastating complication of complex knee reconstruction. Laser-assisted indocyanine green angiography (LA-ICGA) is a technology that has been described in the plastic surgery literature to provide an objective assessment of skin perfusion in the operating room. This novel technology uses a plasma protein bound dye (ICG) and a camera unit that is calibrated to view the frequency emitted by the dye. The intention of this technology is to offer real-time visualization of blood flow to skin and soft tissue in a way that might help surgeons make decisions about closure or coverage of a surgical site based on blood flow, potentially avoiding soft tissue reconstruction while preventing skin necrosis or wound breakdown after primary closures, but its efficacy is untested in the setting of complex TKA.Questions/purposesThe purpose of this study was to evaluate perfusion borders and tension ischemia in a series of complex knee reconstructions to guide optimal wound management.MethodsBeginning in mid-2011, an LA-ICGA system was used to evaluate soft tissue viability in knee reconstruction procedures that were considered high risk for wound complications. Seven patients undergoing complex primary or revision TKA from 2011 to 2013 were included. These patients were chosen as a convenience sample of knee reconstruction procedures for which we obtained consultation with the plastic surgery service. The perfusion of skin and soft tissue coverage was evaluated intraoperatively for all patients with the LA-ICGA system, and the information was used to guide wound management. Followup was at a mean of 9 months (range, 6–17 months), no patients were lost to followup, and the main study endpoint was uneventful healing of the surgical incision.ResultsAll seven closures went on to heal without necrosis. One patient, however, was subsequently revised for a deep periprosthetic infection 4 months after their knee reconstruction and underwent flap coverage at the time of that revision.ConclusionsImplementation of LA-ICGA provides an objective intraoperative assessment of soft tissue perfusion. This technology may help guide the surgeon’s decisions about wound closure in real-time to accommodate the perfusion challenges unique to each patient. Specifically, patients with medical risk factors for poor perfusion or wound healing (such as diabetes, peripheral vascular disease, tobacco use, corticosteroid therapy, infection) or anatomical/surgical risk factors (ie, previous surgery about the reconstruction site, trauma wounds, or reconstruction of severe deformity) may benefit from objective intraoperative information regarding perfusion of the wound site. Furthermore, LA-ICGA could be used to prospectively evaluate the physiologic impact of different wound closure techniques.Level of Evidence Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.