Yoav Kaufman

Breast implant infections: Is cefazolin enough?

Background: Bacterial infection is a well-known risk of breast implant surgery, occurring in 2.0 to 2.5 percent of cosmetic cases and up to 20 percent of reconstructive cases. The Centers for Disease Control and Prevention recommends a first-generation cephalosporin for perioperative prophylaxis; however, no guidelines exist for the empiric treatment of established breast implant infections. A recent increase in methicillin-resistant Staphylococcus aureus infections has prompted interest in using alternative antibiotics with anti–methicillin-resistant S. aureus activity for both prophylactic and empiric therapy. The goal of the present study was to assess the bacteriology and antibiotic susceptibility of breast implant-related infections at two tertiary care hospitals in the Texas Medical Center to determine whether a baseline for empiric therapy for breast implant infections could be established. Methods: A retrospective review of patients who developed periprosthetic infections within 1 month after breast implant placement between 2001 and 2006 was completed. One hundred six patients with 116 infected breasts were identified. Patients were included in the study only if they had documented culture data. Results: Thirty-one breasts in 26 patients met inclusion criteria. Sixty-seven percent of the infected breasts had S. aureus infections; of these, 68 percent were methicillin-resistant S. aureus infections and 32 percent were methicillin-susceptible S. aureus infections. We noted Gram-negative rods and sterile cultures in 6 percent and 26 percent of breasts, respectively. Conclusions: Because of the high incidence of methicillin-resistant S. aureus infections in breast implant recipients, we believe that choosing an antibiotic with anti–methicillin-resistant S. aureus activity is justified for empiric treatment of breast implant infections, until culture and sensitivity data, if obtained, become available.

Principles of facial trauma: orbital fracture management.

Often, complex, optimal management of the orbital fracture is directly dependent on thorough initial evaluation, correct injury assessment, and timely initiation of chosen therapy. Most often, secondary to assault or motor vehicle collision, these fractures are frequently associated with additional traumatic injury. With recent advances in imaging, alloplastic materials, and bone fixation technology, the evolution of orbital fracture management now enables reconstruction of even the most severe injuries.

Orbitozygomatic fracture management.

Summary: Orbitozygomatic fractures are frequently encountered in plastic surgery. Management depends on a thorough preoperative physical examination, with attention to the ophthalmologic assessment. Coronal and axial computed tomography is essential for identifying fracture extent and orbital involvement. Adequate exposure and mobilization of fracture segments is essential for successful anatomical reduction. Failure to perform effective fixation may lead to subsequent complications, such as enophthalmos and diplopia. The authors illustrate the appropriate management of orbitozygomatic fractures in an effort to reduce complications and attain aesthetically satisfying results.

Giant, Congenital Folliculosebaceous Cystic Hamartoma : A Case Against a Pathogenetic Relationship With Trichofolliculoma

Folliculosebaceous cystic hamartoma (FSCH) is a rare cutaneous hamartoma consisting of dilated folliculosebaceous units invested in mesenchymal elements. These solitary lesions typically affect adults, have a predilection for the central face or scalp, and remain less than 1.5 cm in greatest dimension. Although giant FSCH variants have been documented, the congenital presentation of a giant FSCH stands in contrast to earlier views of its histogenetic relationship with trichofolliculoma. We describe a giant pedunculated FSCH arising from the posterior neck of a 9-month-old Hispanic male and discuss various aspects of this highly unusual case.

Local foreign-body reaction to commercial biodegradable implants: an in vivo animal study.

Biodegradable plates have been used extensively in fracture fixation since the 1960s. They rarely cause stress-protection atrophy or problems requiring secondary plate removal, common complications seen with metallic plates. However, aseptic foreign-body reactions have been reported, sometimes years after the original implantation. Both inadequate polymer degradation and debris accumulation have been implicated as causes. The current generation of commercial biodegradable plates is formulated to minimize this complication by altering the ratio of polylactic and polyglycolic acids. This in vivo study compares the degree of local foreign-body reaction of two commercially available resorbable plates in rabbits. Two types of biodegradable plates were examined: poly(D/L)lactide acid (PDLLA) and polylactide-co-glycolide acid (PLGA). Each plate was placed into a periosteal pericalvarial pocket created beneath the anterior or posterior scalp of a rabbit. Humane killing occurred at 3, 6, and 12 months postoperatively. Foreign-body reaction was evaluated histologically. The PDLLA plates demonstrated marked local foreign-body reactions within the implant capsule as early as 3 months after implantation, with presence of inflammatory cells and granulomatous giant cells in close association with the implant material. All local foreign-body reactions were subclinical with no corresponding tissue swelling requiring drainage. PLGA plates did not demonstrate any signs of inflammatory reactions. In addition, the PLGA plates did not appear to resorb or integrate at 12 months. Neither PDLLA nor PLGA plates demonstrated inflammation of the soft tissue or adjacent bone outside the implant capsule. In our study, the PDLLA plates demonstrated histological evidence of foreign-body reaction that is confined within the implant capsule, which was not seen with the PLGA plates. This finding may be attributable to the lack of significant resorption seen in the PLGA plates. Both PDLLA and PLGA plates were biocompatible with the rabbit tissue environment and should be considered for continued use in craniofacial, maxillofacial, and orthopedic reconstruction.

Facial clefting and oroauditory pathway manifestations in ankyloblepharon-ectodermal defects-cleft lip/palate (AEC) syndrome.

Ankyloblepharon–ectodermal defects‐cleft lip/palate (AEC) Syndrome is a rare disorder characterized by ectodermal dysplasia, along with other malformations such as cleft lip and palate, and various secondary issues such as chronic sinusitis, otitis media, and conductive hearing loss (CHL). The International Research Symposium for AEC Syndrome convened at Baylor College of Medicine in Houston, Texas. Patients with a suspected diagnosis of AEC syndrome attended, and members of the dental, dermatology, plastic surgery, otolaryngology, and audiology services examined each patient. Eighteen patients with a diagnosis of AEC were evaluated. Mean age was 7.5 years (range: 4 months–30 years). Fourteen of the 15 subjects tested (93.33%) demonstrated CHL, with seven showing moderate to severe hearing deficits (41–90 dB). Nine of 13 respondents reported hoareness or voice problems; 8 were noted to display this on examination. Fourteen of 16 subjects reported speech was below average for age; 8 were in speech therapy. All 18 subjects reported a history of otitis externa or otitis media. Eleven of the subjects (61.11%) required myringotomy and pressure equalizing (PE) tubes. All patients demonstrated cleft palate defects. Of these, 16 (94.11%) presented with clefting of the soft palate, and 10 (58.82%) showed hard palate defects. Three subjects (16.67%) were noted to have submucous clefts. Our experience leads us to propose that while the oroauditory problems in those with AEC syndrome is likely multifactorial, many issues may stem from palatal clefting. Despite this, some abnormalities persist following surgical cleft closure, which indicates other complicating factors are also involved.

Contemporary issues in facial gunshot wound management

Facial gunshot wounds pose a significant challenge for reconstructive surgeons, particularly when composed of significant soft and bone tissue defects. Often the result of assault, accident, or suicide attempt, facial defects must be thoroughly evaluated to devise an appropriate tissue repair and replacement with the likely prospect of secondary revision. In the acute setting after injury, the primary concern is patient stabilization centered on advanced trauma life support. Thorough examination along with appropriate imaging is critical for identifying any existing defects. As opposed to past surgical management that advocated delayed definitive treatment using serial debridement, todays management favors the use of more immediate reconstruction. Recent improvements in microsurgical technique have shifted favor from local tissue advancement to distant free-flap transfers, which improve cosmesis and function. This has reduced the number of surgeries necessary to achieve reconstruction. Given the diversity and complexity of facial gunshot injuries, a systematic algorithm is essential to help manage the different stages of healing and to ensure that the best outcome is ultimately achieved.

A modified keyhole technique for correction of macroglossia

The enlarged tongue, or macroglossia, may compromise vital function to the point that surgical correction is necessary. Although earlier procedures simply aimed at reducing tongue bulk, contemporary techniques attempt to decrease lingual dimension yet preserve critical neurosensory function. Still, modern approaches advise a broad variety of differing incisions and propose excision of various anterior, lateral, central, or circumferential lingual tissues. The keyhole technique allows direct excision of midline musculomucosal tissue along the tongue’s length. With this central tongue-reduction procedure, significant lingual resection is possible and crucial tongue function and neurovascular structure are maintained. In this article, as a supplement to our video demonstration, we describe a modified keyhole technique for macroglossia correction.

Facial Gunshot Wounds: Trends in Management

Facial gunshot wounds, often comprising significant soft and bone tissue defects, pose a significant challenge for reconstructive surgeons. Whether resulting from assault, accident, or suicide attempt, a thorough assessment of the defects is essential for devising an appropriate tissue repair and replacement with a likely secondary revision. Immediately after injury, management is centered on advanced trauma life support with patient stabilization as the primary goal. Thorough examination along with appropriate imaging is critical for identifying any existing defects. Whereas past surgical management advocated delayed definitive treatment using serial debridement, todays management favors use of more immediate reconstruction. Recent advances in microsurgical technique have shifted favor from local tissue advancement to distant free flap transfers, which improve cosmesis and function. This has resulted in a lower number of surgeries required to achieve reconstruction. Because of the diversity of injury and the complexity of facial gunshot injuries, a systematic algorithm is essential to help manage the different stages of healing and to ensure that the best outcome is achieved.

Cleft Nasal Deformity and Rhinoplasty

The cleft nasal deformity is a complex challenge in plastic surgery involving the skin, cartilage, mucosa, and skeletal platform. Ever since Blair and Brown first described the intricacies of the cleft pathology in 1931, the appropriate approach has been extensively debated in the literature with respect to timing, technique, and extent of surgical intervention. In this article, the authors review the literature and summarize the various modalities for achieving a successful rhinoplasty in the patient with a cleft nasal deformity.