Risk of severe and refractory postoperative nausea and vomiting in patients undergoing diep flap breast reconstruction.

BACKGROUND: Postoperative nausea and vomiting (PONV) are commonly feared after general anesthesia and can impact results. The primary aim of our study was to examine incidence and severity of PONV by investigating complete response, or absence of PONV, to prophylaxis used in patients undergoing DIEP flaps. Our secondary aims were definition of the magnitude of risk, state of the art of interventions, clinical sequelae of PONV, and interaction between these variables, specifically for DIEP patients. METHODS: A retrospective chart review occurred for 29 patients undergoing DIEP flap breast reconstruction from September 2007 to February 2008. We assessed known patient and procedure-specific risks for PONV after DIEPs, prophylactic antiemetic regimens, incidence, and severity of PONV, postoperative antiemetic rescues, and effects of risks and treatments on symptoms. RESULTS: Three or more established risks existed in all patients, with up to seven risks per patient. Although 90% of patients received diverse prophylaxis, 76% of patients experienced PONV, and 66% experienced its severe form, emesis. Early PONV (73%) was frequent; symptoms were long lasting (average 20 hours for nausea and emesis); and multiple rescue medications were frequently required (55% for nausea, 58% for emesis). Length of surgery and nonsmoking statistically significantly impacted PONV. CONCLUSION: We identify previously undocumented high risks for PONV in DIEP patients. High frequency, severity, and refractoriness of PONV occur despite standard prophylaxis. Plastic surgeons and anesthesiologists should further investigate methods to optimize PONV prophylaxis and treatment in DIEP flap patients.

Quality of life before reconstructive breast surgery: A preoperative comparison of patients with immediate, delayed, and major revision reconstruction.

BACKGROUND: Women undergo breast reconstruction at different time-points in their cancer care; knowing patients' preoperative quality of life (QoL) is critical in the overall care of the patient with breast cancer. Our objective was to describe presurgical QoL among women undergoing immediate, delayed, or major revision breast reconstructive surgery at our institution. METHODS: From March 2008 to February 2009, we administered preoperative BREAST-Q questionnaires to women who presented to our institution for breast reconstruction. Univariate and multivariate analyses were performed to compare patient cohorts across multiple QoL domains including body image, physical well-being, psychosocial well-being, and sexual well-being. RESULTS: Of the 231 patients who presented for preoperative consultation, 176 returned the questionnaire (response rate 76%; 117 from the immediate, 21 from the delayed, and 32 from the major revision reconstruction groups, plus 6 mixed or unknown). The three groups differed significantly (P < 0.05) across four of the six domains: body image (satisfaction with breasts), psychosocial well-being, sexual well-being, and physical well-being of the chest and upper body. The immediate reconstruction group had higher (better) scores than the delayed reconstruction group, which had higher (better) scores than the major revision group. CONCLUSION: These data suggest that women presenting for breast reconstruction at different stages of reconstruction have different baseline QoL. Such data may help us better understand patient selection, education, and expectations, and may lead to improved patient-surgeon communication.

Three-dimensional computed tomographic angiography to predict weight and volume of deep inferior epigastric artery perforator flap for breast reconstruction.

BACKGROUND: Three-dimensional computed tomographic angiography (3D CTA) can be used preoperatively to evaluate the course and caliber of perforating blood vessels for abdominal free-flap breast reconstruction. For postmastectomy breast reconstruction, many women inquire whether the abdominal tissue volume will match that of the breast to be removed. Therefore, our goal was to estimate preoperative volume and weight of the proposed flap and compare them with the actual volume and weight to determine if diagnostic imaging can accurately identify the amount of tissue that could potentially to be harvested. METHODS: Preoperative 3D CTA was performed in 15 patients, who underwent breast reconstruction using the deep inferior epigastric artery perforator flap. Before each angiogram, stereotactic fiducials were placed on the planned flap outline. The radiologist reviewed each preoperative angiogram to estimate the volume, and thus, weight of the flap. These estimated weights were compared with the actual intraoperative weights. RESULTS: The average estimated weight was 99.7% of the actual weight. The interquartile range (25th to 75th percentile), which represents the "middle half" of the patients, was 91-109%, indicating that half of the patients had an estimated weight within 9% of the actual weight; however, there was a large range (70-133%). CONCLUSION: 3D CTA with stereotactic fiducials allows surgeons to adequately estimate abdominal flap volume before surgery, potentially giving guidance in the amount of tissue that can be harvested from a patient's lower abdomen.

The emerging role of antineoplastic agents in the treatment of keloids and hypertrophic scars: a review.

The management of keloids and hypertrophic scars continues to challenge health-care providers. Though both forms of pathologic scarring are distinct entities at the macro and microscopic level, their etiologies and treatment are often similar. Potential treatment approaches are progressing, and combinations of treatment options have been proposed in the literature with promising outcomes. The treatment evolution has reached a level where molecular therapeutic modalities are being investigated. Currently, no gold standard treatment exists. Overall success rates and patient satisfaction seem to be slowly climbing, but additional investigational studies must continue to be performed. Several studies have investigated antineoplastic agents, and there seems to be a marked improvement in rates of recurrence, patient satisfaction, and overall quality of scar when these agents are used. Intralesional injection and/or wound irrigation with interferon-a2b, interferon-g, mitomycin-C, bleomycin, or 5-fluorouracil seems to have a positive effect on the reduction of pathologic scars. There is mounting evidence that these drugs used alone or in combination therapy, have the potential to be an integral part of the treatment paradigm for hypertrophic scars and keloids.

Breast sensation after breast reconstruction: a systematic review.

Studies show some return of breast sensation after breast reconstruction; however, recovery is variable and unpredictable. Efforts are being made to restore innervation by reattaching nerves (neurotization). We sought to systematically review the literature addressing breast sensation after reconstruction. The following databases were searched: EMBASE, Cochrane, and PubMed. Additionally, the PLASTIC AND RECONSTRUCTIVE SURGERY journal was hand searched from 1960 to 2009. Inclusion criteria included breast reconstruction for cancer, return of sensation with objective results, and patients aged 18 to 90 years. Studies with purely cosmetic procedures, case reports, studies with less than 10 patients, and studies involving male patients were excluded. The initial search yielded 109 studies, which was refined to 20 studies with a total pool of 638 patients. Innervated flaps have a greater magnitude of recovery, which occurs at an earlier stage compared with the noninnervated flaps. Overall, sensation to deep inferior epigastric artery perforator flaps may recover better sensation than transverse rectus abdominis myocutaneous flaps, followed by latissimus dorsi flaps, and finally implants. Women's needs and expectations for sensation have led plastic surgeons to investigate ways to facilitate its return. Studies, however, depict conflicting data. Larger series are needed to define the role of neurotization as a modality for improving sensory restoration.

Beyond Anthracyclines: Preemptive Management of Cardiovascular Toxicity in the Era of Targeted Agents for Hematologic Malignancies.

Advances in drug discovery have led to the use of effective targeted agents in the treatment of hematologic malignancies. Drugs such as proteasome inhibitors in multiple myeloma and tyrosine kinase inhibitors in chronic myeloid leukemia and non-Hodgkin lymphoma have changed the face of treatment of hematologic malignancies. There are several reports of cardiovascular adverse events related to these newer agents. Both "on-target" and "off-target" effects of these agents can cause organ-specific toxicity. The need for long-term administration for most of these agents requires continued monitoring of toxicity. Moreover, the patient population is older, often over 50 years of age, making them more susceptible to cardiovascular side effects. Additional factors such as prior exposure to anthracyclines often add to this toxicity. In light of their success and widespread use, it is important to recognize and manage the unique side effect profile of targeted agents used in hematologic malignancies. In this article, we review the current data for the incidence of cardiovascular side effects of targeted agents in hematologic malignancies and discuss a preemptive approach towards managing these toxicities.

The Positive Effect of Neurolysis on Diabetic Patients with Compressed Nerves of the Lower Extremities: A Systematic Review and Meta-analysis.

BACKGROUND: Despite proven benefits of upper extremity nerve decompression in diabetics, neurolysis for diabetic patients with lower extremity (LE) nerve compression remains controversial. METHODS: A search of ClinicalTrials.gov and Cochrane clinical trials registries, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, LILACS, CINAHL, SCOPUS, and Google Scholar from 1962 to 2012, yielded 1956 citations. Any potential randomized or quasi-randomized controlled trials and observational cohort studies of diabetics with neurolysis of the common peroneal nerve, deep peroneal nerve, or tibial nerve were assessed. We included articles in any language that 1) provided information about diabetic patients who had neurolysis for symptomatic nerve compression diagnosed by (+) Tinel sign or electrodiagnostic study, and 2) quantified outcomes for pain, sensibility, or ulcerations/amputations. Case reports, review articles, animal or cadaver studies, and studies with <10 patients were excluded. We assessed pain relief, recovery of sensibility, and postoperative incidence of ulcerations/amputations at follow-up >3 months. A meta-analysis of descriptive statistics was performed. RESULTS: Ten clinical series with a mean clinical relevance score of 70% and a mean methodologic quality score of 50% met inclusion criteria. We included 875 diabetic patients and 1053 LEs. Pain relief >3 points on visual analog scale occurred in 91% of patients; sensibility improved in 69%. Postoperative ulceration/amputation incidence was significantly reduced compared to preoperative incidence (odds ratio = 0.066, 95% confidence interval = 0.026-0.164, P < 0.0001). CONCLUSIONS: Observational data suggest that neurolysis significantly improves outcomes for diabetic patients with compressed nerves of the LE. No randomized controlled trials have been published.