Umar Choudry

Prognosis and management of extramammary paget's disease and the association with secondary malignancies

BACKGROUND Extramammary Pagets disease (EMPD) is a rare clinical entity and can be associated with other malignancies. We analyzed our experience for prognosis and impact of therapy on outcomes. STUDY DESIGN We conducted a retrospective review of all patients (n = 33) with EMPD treated at a tertiary care center from 1971 to 1998. Pathologic features of EMPD, concurrent secondary malignancies, and the effect of operations on recurrence were analyzed. Overall survival was compared with that of the general population. RESULTS Male-to-female ratio was 4:29, and median age was 70 years. Median followup was 68 months, and no patient died from EMPD. The lesion was predominantly found on the vulva (76%). Patch-like, nonconfluent growth was present in 45% of patients, and no patient had pathologic lymph nodes. The most common signs and symptoms were irritation or pruritus (73%) and rash (61%). The presence of patches, invasive tumor growth, or a second malignancy were significantly associated with a higher recurrence rate. The type of operation, either local excision or hemivulvectomy, was not related to the time to recurrence. Complete gross resection was achieved in 94% of cases. Fifty-six percent of patients had microscopically positive margin and this correlated with a significantly higher recurrence rate (p = 0.002). The tumor recurred clinically in 14 of 33 patients (42%) after a median of 152 months (range 5 to 209 months). In those patients, between one and six reexcisions were performed. In 14 of 33 patients with EMPD (42%), 16 concurrent secondary malignancies were found. Overall survival rates for EMPD patients were similar to those of the general population. CONCLUSIONS EMPD is an infrequently diagnosed disease that is preferably managed with complete local excision and reexcisions if needed. A thorough search for frequently occurring secondary malignancies might be beneficial to provide the best outcomes for these patients.

The vascularized medial femoral condyle periosteal bone flap for the treatment of recalcitrant bony nonunions.

The purpose of this study was to examine our experience with this flap for the treatment of recalcitrant nonunions of the extremities. A retrospective chart review was performed on 11 consecutive patients treated with the medial femoral periosteal bone flap from June 2003 to March 2005. Patient demographics, nonunion characteristics, complications, and long-term outcome based on radiographic and clinical parameters were analyzed. Nine free transfers and 3 pedicled flaps were used for a total of 12 nonunion sites in 11 patients. The average age of the patient population was 49 years (21–64 years). The location of the nonunion sites were femur (n = 4), tibia (n = 2), humerus (n = 3), clavicle (n = 2), and radius (n = 1). The nonunion sites were secondary to traumatic fractures complicated by osteomyelitis (n = 10) and tumor extirpation (n = 2). The time period of nonunion prior to the use of vascularized periosteal bone graft ranged from 10 months to 23 years (median = 23 months). All patients had previous attempts at debridement with or without antibiotic bead placement, and all underwent rigid fixation with or without nonvascularized bone grafts prior to vascularized grafting. Following flap placement, 9 (75%) of the nonunion sites healed primarily without complication at an average period of 3.8 months (2–7 months). Two nonunions healed secondarily following hardware modification. There was only 1 flap failure secondary to arterial thrombosis, resulting in a below-knee amputation. The rate of limb salvage was 91%. Donor-site morbidity was minimal, with postoperative seromas occurring in 3 patients.

Increased adipose protein carbonylation in human obesity

Insulin resistance is associated with obesity but mechanisms controlling this relationship in humans are not fully understood. Studies in animal models suggest a linkage between adipose reactive oxygen species (ROS) and insulin resistance. ROS oxidize cellular lipids to produce a variety of lipid hydroperoxides that in turn generate reactive lipid aldehydes that covalently modify cellular proteins in a process termed carbonylation. Mammalian cells defend against reactive lipid aldehydes and protein carbonylation by glutathionylation using glutathione‐S‐transferase A4 (GSTA4) or carbonyl reduction/oxidation via reductases and/or dehydrogenases. Insulin resistance in mice is linked to ROS production and increased level of protein carbonylation, mitochondrial dysfunction, decreased insulin‐stimulated glucose transport, and altered adipokine secretion. To assess protein carbonylation and insulin resistance in humans, eight healthy participants underwent subcutaneous fat biopsy from the periumbilical region for protein analysis and frequently sampled intravenous glucose tolerance testing to measure insulin sensitivity. Soluble proteins from adipose tissue were analyzed using two‐dimensional gel electrophoresis and the major carbonylated proteins identified as the adipocyte and epithelial fatty acid‐binding proteins. The level of protein carbonylation was directly correlated with adiposity and serum free fatty acids (FFAs). These results suggest that in human obesity oxidative stress is linked to protein carbonylation and such events may contribute to the development of insulin resistance.

Soft-tissue coverage of the elbow: An outcome analysis and reconstructive algorithm

Background: Soft-tissue defects surrounding the elbow can be a challenging problem for the reconstructive surgeon. Multiple reconstructive options are available, but there are few published outcome studies. The authors performed an outcome analysis of soft-tissue coverage for elbow defects to determine the benefits and limitations of various reconstructive options in this problematic area. Methods: A retrospective review was performed of all elbow defects requiring flap coverage from 1988 to 2005. Patient demographics, defect characteristics, type of flaps used, complications, and long-term outcomes were analyzed. The t test was used for statistical comparison. Results: A total of 99 flaps were performed in 96 patients. Forty-seven percent of the defects were secondary to trauma. Sixty-six percent of the flaps used were pedicled flaps and 19 percent were free flaps. The most common pedicled flap used was the radial forearm flap, whereas the most commonly used free flap was the latissimus dorsi muscle flap. Reconstructive failures occurred in 10 percent of patients; these 10 patients required a second flap for limb salvage. The pedicled latissimus dorsi muscle flap had the highest complication rate (57 percent), with distal necrosis being the most frequent complication. The pedicled latissimus dorsi flap was associated with a higher complication rate when compared with the radial forearm flap (p = 0.01). Conclusions: The pedicled latissimus was associated with a high rate of distal necrosis when it was used to cover defects distal to the olecranon. The authors recommend the use of the radial forearm flap or a free flap for soft-tissue coverage of defects lying over the proximal ulna.

Soft-tissue coverage and outcome of gustilo grade IIIB midshaft tibia fractures: A 15-year experience

Background: The authors describe a 15-year experience with Gustilo grade IIIB fractures of the midtibia based on the type and timing of soft-tissue coverage. Methods: A retrospective chart review was performed and patient demographics, risk factors, choice and timing of coverage, fracture outcome, and limb survival data were collected. Results: Sixty-five fractures were treated. Soft tissue coverage was performed either acutely [<1 week (48 percent)] or delayed [>1 week (52 percent); with either a soleus muscle flap [group A; n = 25 (38 percent)] or a free tissue transfer [group B; n = 40 (62 percent)]. In group A, 17 (68 percent) were performed acutely (subgroup A1) and eight (32 percent) were delayed (subgroup A2). In subgroup A1, eight (47 percent) had uncomplicated healing, whereas seven (41 percent) ended in nonunion. In subgroup A2, all eight patients went onto nonunion. The overall limb survival rate for group A was 92 percent (n = 23). In group B, 14 (35 percent) were performed acutely (subgroup B1) and 26 (65 percent) were delayed (subgroup B2). In subgroup B1, six (43 percent) had uncomplicated healing, and six (43 percent) ended in nonunion. In subgroup B2, six (23 percent) healed primarily, and 17 (65 percent) went onto nonunion. The overall limb survival rate for group B was 88 percent (n = 45). Conclusions: Soft-tissue coverage is not the only determinant for successful outcome. Delayed coverage resulted in higher nonunion rates. Despite high nonunion rates, 89 percent of fractures ultimately healed successfully.

Preoperative assessment preferences and reported reoperation rates for size change in primary breast augmentation: a survey of ASPS members.

Background: The purpose of this study was to determine the current preferences of plastic surgeons regarding preoperative assessment and their effect on clinical outcome in primary breast augmentation. Methods: An eight-question online survey was sent to members of the American Society of Plastic Surgeons. Data collected online were analyzed using Students t test or Pearsons chi-square test. A value of p < 0.05 was considered statistically significant. Results: The response rate was 20.1 percent (604 respondents). Breast base diameter [n = 286 (47.4 percent)] was ranked the most important consideration vital in choosing implants. Most surgeons chose to reeducate their patients to resolve a conflict between their patients implant size request and the surgeons clinical judgment [n = 385 (63.7 percent)], whereas 151 (25 percent) would proceed anyway. Those surgeons who chose reeducation ranked breast base diameter as a vital consideration significantly higher than those who would accommodate their patients (2.03 ± 1.41 versus 2.31 ± 1.41; p = 0.041). Similarly, surgeons who reeducated their patients ranked implant volume as the vital consideration significantly lower than those who accommodated their patients (2.90 ± 1.67 versus 2.44 ± 1.47; p = 0.002). Regarding size change, 332 surgeons (55 percent) reported their rate was 5 percent or less, whereas 272 (45 percent) reported it was greater than 5 percent. Surgeons who reported a 5 percent or less rate ranked implant volume significantly lower than those with reoperation rates greater than 5 percent (2.93 ± 1.71 versus 2.55 ± 1.53; p = 0.004). Conclusions: Breast base diameter and implant volume were the two most important considerations in choosing an implant for breast augmentation. Reported reoperation rates for size change were significantly lower for surgeons who regarded breast base diameter as more vital than those who valued implant volume more.

Head and neck reconstruction with a second free flap following resection of a recurrent malignancy.

A retrospective analysis of 12 patients with a head and neck tumor recurrence within a previous free flap treated with extirpation and a second free flap is reported. A 15-year experience at Mayo Clinic, Rochester, from 1988 to 2003 of 12 patients (5 men, 7 women) who underwent 25 free flaps is reviewed. The overall flap survival rate was 92%, with a 100% survival rate in the first free-tissue transfer and 85% survival rate in the second free-tissue transfer. There was 1 minor complication (8%) and there were 2 major complications (15%) among the second free flaps. Overall, 10 of 13 (77%) second free flaps were anastomosed to ipsilateral neck vessels. Moreover, in 5 of 13 cases (38%) the same artery and in 7 of 13 cases (54%) the same vein were used for both the first and second free flaps. Reconstruction of the head and neck with a second free flap in patients with a recurrent tumor is safe and effective. The original recipient vessels can often be used for the second reconstruction.

The proximal first dorsal metacarpal artery free flap for reconstruction of complex digital defects

We describe our experience and outcome with the ‘Proximal first dorsal metacarpal artery free flap’. Ten consecutive cases utilizing the proximal first dorsal metacarpal artery free flap for complex digital defects were studied. Surgical technique, patient demographics, and flap outcome data were collected. Patient satisfaction was analysed using a questionnaire. All defects healed successfully with no loss of free flaps. The short-pedicle proximal first dorsal metacarpal artery free flap enables primary closure of the donor site up to 2 cm of width (in nine of the ten donor sites). The flap is a reliable and versatile alternative in selected cases of complex digital injuries.

Perineal wound complications, risk factors, and outcome after abdominoperineal resections

BackgroundWe describe the risk factors for complications and outcome of perineal wounds after abdominoperineal resections (APRs). MethodsA retrospective chart review was performed, and patient demographics, risk factors, extent of APR, closure of perineal wounds, exposure to radiation, and outcome were collected. ResultsThere were 87 APRs performed during an 8-year period. The mean follow-up period was 2.0 years (range, 18 days to 7.8 y). The mean body mass index (BMI) of the cohort was 27.8 kg/m2 (range, 16.8–47.5 kg/m2). Of these patients, 36 (41%) have normal weight (BMI < 25 kg/m2) and 51 (59%) were overweight (BMI > 25 kg/m2). Direct closure of the perineum was performed in 67 patients (77%). Twenty patients (23%) had musculocutaneous flap closures of the perineum. Fifty-seven patients (66%) had radiation exposure to the perineal region. Nineteen patients (22%) had complications of the perineal wound. We found that direct closure of the perineum in patients who were overweight (P < 0.05), active smokers (P < 0.05), or had chronic obstructive pulmonary disease (P < 0.01) was associated with higher wound complications. ConclusionsThe use of musculocutaneous flap closures of the perineum after APRs in patients who are overweight (BMI > 25 kg/m2), are smokers, or have chronic obstructive pulmonary disease may decrease wound complications.

The importance of preoperative hemoglobin evaluation in large volume liposuction: lessons learned from our 15-year experience.

Liposuction of >5 L of total aspirate at one setting is defined as large volume liposuction (LVL). A retrospective chart review was performed on all patients who underwent LVL from January 1990 to June 2005. Sixty-two patients underwent LVL. The mean volume of total aspirate was 8 L (5.0–11.7 L). There were a total of 6 patients who had complications. These included symptomatic postoperative anemia requiring blood transfusions on postoperative day 1 (n = 5), and an expanding hematoma requiring operative evacuation without transfusion (n = 1). Two of the patients who had blood transfusions had a history of gastric bypass and all of the patients were preoperatively anemic (<11.5 mg/dL). The mean follow up was 38 months. LVL is safe when performed in healthy patients under strict guidelines. Hemoglobin levels of all potential LVL patients should be checked preoperatively, and surgery should be withheld for levels <12 g/dL.