The spare-parts technique: A safe and efficient single-stage nipple and areola reconstruction.

BACKGROUND: The authors hypothesized that optimization of nipple-areolar reconstruction using full-thickness skin graft and cartilage graft can be completed safely in a single-stage procedure. METHODS: A retrospective analysis of abdominal-based flap breast reconstruction patients who underwent nipple-areolar reconstruction (NAR) using the modified double-opposing tab (mDOT)1 flap technique was conducted. Complication rates were compared between patients who underwent NAR in a traditional staged procedure versus a single stage. The single-stage group of patients had NAR performed at the time of revision surgery. Reconstruction was performed with full-thickness skin graft from the abdominal standing-cone deformity and costal cartilage that was removed at the time of breast reconstruction and banked subcutaneously until the revision surgery. RESULTS: In this study, 1,233 nipple reconstructions were reviewed, of which 113 procedures using themDOT technique were analyzed. No significant differences in complication rates were found between the single-stage and the traditional staged NAR, including the risk of total loss of reconstruction or delayed skin graft take. However, the risk of delayed wound healing of the nipple reconstruction was higher in the single-stage group. CONCLUSIONS: Our study shows that optimizing NAR results by adding cartilage to the nipple construct and enhancing the areolar component by full-thickness skin grafting can be achieved safely in a single stage at the time of flap revision. This represents potential for better long-term nipple projection and better areolar texture mimicry of NAR for breast reconstruction patients.

Poly Implants Prosthèse Breast Implants: A Case Series and Review of the Literature.

BACKGROUND: Silicone breast implants from the French manufacturer Poly Implants Prosthèse (PIP) were recalled from the European market after the French regulator has revealed the implants contain non-medical-grade silicone filler. In December 2011, following a large increase in reported rupture rate and a possible cancer risk, the French Ministry of Health recommended consideration of the PIP explantation, regardless of their condition. In 2012, the Israel Ministry of Health recommended to replace the implants only upon suspected implant rupture. OBJECTIVES: The aims of this study were to characterize breast-augmented Israeli patients with PIP implants, compare their outcomes with those of breast-augmented patients with different implant types, and review the current PIP literature. METHODS: Breast-augmented patients who underwent an elective breast implant exchange in Israel between January 2011 and January 2017 were included in the study. Data were collected from electronic and physical medical files. RESULTS: There were 73 breast-augmented female patients with 146 PIP breast implants included in this study. Average implant age was 6.7 ± 2.79 years. Mean implant size was 342.8 ± 52.9 mL. Fourteen women (19 implants [16%]) had a high-grade capsular contracture (Baker grade 3-4). During exchange, 28 implants were found to be ruptured (19.2%). CONCLUSIONS: Less than 10 years following breast augmentation, PIP implants demonstrated higher rupture rate compared with other implants. Our data are comparable to overall available rupture rate. Among patients with definitive rupture diagnosis, an elective implant removal should be recommended. In cases of undamaged implants, plastic surgeons should also seriously consider PIP implant explantation. When the patient does not desire to remove the implant, an annual physical examination and breast ultrasound are recommended, beginning a year after augmentation.

A Prospective, Randomized, Controlled Trial of Paravertebral Block versus General Anesthesia Alone for Prosthetic Breast Reconstruction.

BACKGROUND: Paravertebral blocks have gained popularity because of ease of implementation and a shift toward ambulatory breast surgery procedures. Previous retrospective studies have reported potential benefits of paravertebral blocks, including decreased narcotic and antiemetic use. METHODS: The authors conducted a prospective controlled trial of patients undergoing breast reconstruction over a 3-year period. The patients were randomized to either a study group of paravertebral blocks with general anesthesia or a control group of general anesthesia alone. Demographic and procedural data, in addition to data regarding pain and nausea patient-reported numeric scores and consumption of opioid and antiemetic medications, were recorded. RESULTS: A total of 74 patients were enrolled to either the paravertebral block (n = 35) or the control group (n = 39). There were no significant differences in age, body mass index, procedure type, or cancer diagnosis between the two groups. Patients who received a paravertebral block required less opioid intraoperatively and postoperatively combined compared with patients who did not receive paravertebral blocks (109 versus 246 fentanyl equivalent units; p < 0.001), and reported significantly lower pain scores at 0 to 1 (3.0 versus 4.6; p = 0.02), 1 to 3 (2.0 versus 3.2; p = 0.01), and 3 to 6 (1.9 versus 2.7; p = 0.04) hours postoperatively. The study group also consumed less antiemetic medication (0.7 versus 2.1; p = 0.05). CONCLUSIONS: Incorporating paravertebral blocks carries considerable potential for improving pathways for breast cancer patients undergoing breast reconstruction--with minimal procedure-related morbidity. This is the first prospective study designed to assess paravertebral blocks in the setting of prosthetic breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Birth wind and fire: raising awareness to operating room fires during delivery.

OBJECTIVE: We researched whether the obstetric operating room (OR) qualified as a fire-risk environment so as to take preventive measures accordingly. METHODS: We analyzed a series of iatrogenic burns inflicted during birth by collecting clinical data and comparing it with known OR fire risk factors and with other factors that repeated in all cases in search of unique characteristics of the obstetric OR. RESULTS: All three cases shared in common the same type of oxygen-rich open ventilation system, alcohol-based prepping solution, and the hastiness of cesarean delivery while spontaneous vaginal delivery was already in progress. CONCLUSION: The obstetric OR is, as suspected, a fire-prone zone in more ways than the regular OR. Therefore, preventive measures should be undertaken and awareness for the possibility for such occurrences should be raised.

Trends in breast reduction technique.

BACKGROUND: There are two main approaches to breast reduction surgery today: the traditional long scar ("Wise-pattern") technique and the more recent short ("vertical") scar technique, which is becoming more popular. During the last two decades there has been a gradual shift between the two techniques, including at our institute. OBJECTIVES: To evaluate the evidence behind this obvious trend. METHODS: We retrospectively collected data fromarchived hospital charts of all patients who underwent breast reduction surgery during the period 1995-2007. Epidemicological, clinical and postoperative data were analyzed and compared between patients in whom the short scar vs. the long scar techniques was used. RESULTS: During the study period 91 patients underwent breast reduction surgery in our department: 34 with the Wise-pattern breast reduction technique and 57 with the short-scar procedure. There was no significant difference in operative and postoperative data, including length of hospital stay. In some of the categories there was even a slight advantage (but not statistically significant) to the former. The only significant difference was the size of reduction, with a tendencyto prefer the long scar technique for larger reductions; however, with experience gained the limit for short scar reductions was gradually extended to a maximum of 1470 g. CONCLUSIONS: We noticed a sharp increase in the safe and uneventful practice of the short scar technique in breast reduction of < or = 1400 g--especially in young women without extreme ptosis. This observation, together with other advantages, namely, reduced scar length, prolonged shape preservation and better breast projection, support the use of this technique.

Epidemiology of metatarsal stress fractures versus tibial and femoral stress fractures during elite training.

BACKGROUND: The training of elite infantry recruits takes a year or more. Stress fractures are known to be endemic in their basic training and the clinical presentation of tibial, femoral, and metatarsal stress fractures are different. Stress fracture incidence during the subsequent progressively more demanding training is not known. The study hypothesis was that after an adaptation period, the incidence of stress fractures during the course of 1 year of elite infantry training would fall in spite of the increasingly demanding training. MATERIALS AND METHODS: Seventy-six male elite infantry recruits were followed for the development of stress fractures during a progressively more difficult training program composed of basic training (1 to 14 weeks), advanced training (14 to 26 weeks), and unit training (26 to 52 weeks). Subjects were reviewed regularly and those with clinical suspicion of stress fracture were assessed using bone scan and X-rays. RESULTS: The incidence of stress fractures was 20% during basic training, 14% during advanced training and 23% during unit training. There was a statistically significant difference in the incidence of tibial and femoral stress fractures versus metatarsal stress fractures before and after the completion of phase II training at week 26 (p=0.0001). Seventy-eight percent of the stress fractures during phases I and II training were either tibial or femoral, while 91% of the stress fractures in phase III training were metatarsal. Prior participation in ball sports (p=0.02) and greater tibial length (p=0.05) were protective factors for stress fracture. CONCLUSION: The study hypothesis that after a period of soldier adaptation, the incidence of stress fractures would decrease in spite of the increasingly demanding elite infantry training was found to be true for tibial and femoral fractures after 6 months of training but not for metatarsal stress fractures. Further studies are required to understand the mechanism of this difference but physicians and others treating stress fractures should be aware of this pattern.

[A prospective study to evaluate the safety of minor cutaneous surgery during aspirin treatment].

BACKGROUND: Many patients undergoing cutaneous surgery are treated with aspirin due to its proven advantages. Discontinuation of aspirin prior to surgery is still controversial. We conducted a large-scale, prospective study to evaluate the safety of dermatologic surgery in patients receiving aspirin. OBJECTIVES: The authors' objectives were to evaluate the complication rate in patients undergoing cutaneous surgery while treated with aspirin. METHODS: All patients operated on solely by one plastic surgeon were included in the study. The study group included all patients receiving aspirin during surgery, while the rest of the patients comprised the control group. Demographic data, surgery type and complication rate were collected. Complications were classified as major or minor hematoma, wound infection and dehiscence. Statistical significance was calculated using the Student's t-test and Chi test. RESULTS: During the study period 7259 patients underwent minor cutaneous surgery (without local flaps or skin grafts). A group of 115 patients taking either Plavix (Clopidrogel) or Coumadin (Warfarin) were excluded. The study group consisted of 1088 patients who were taking aspirin regularly while 6056 patients comprised the control group. A statistically significant change was found between the two groups regarding sex, age, background chronic diseases and in the distribution of lesions across the body. No significant change was found regarding the peri-operative complications. CONCLUSIONS: In this large-scale prospective study, dermatologic surgery on patients receiving aspirin was found to be safe, as no statistically different complication rate was found between the study and the control groups. This statement is further emphasized due to the significantly statistically older age, chronic illness rate and the head and neck location of the lesions in the study group.

[Dermoscopy--a glimpse into the skin].

The acronym ABCDE, which was originally described to help with clinically discriminating between benign and malignant pigmented skin lesions, represents the key clinical criteria for diagnosing cutaneous malignant melanoma (CMM). The early stage in CMM is sometimes hard to identify for it frequently mimics the characteristics of atypical nevus. It is estimated that clinical diagnosis accuracy in CMM lies somewhere between 50-75%. This warrants the search for better diagnostic tools. During the last decade, and specifically with the advances in dermoscopy, also known as dermatoscopy or epiluminescence microscopy (ELM), there is literally a new depth and dimension to the clinical diagnosis of pigmented skin lesions. What strikes out as its distinct clinical advantage is its ability to differentiate between an atypical nevus--for which follow-up is the preferred clinical choice, and CMM--which warrants surgical treatment at an early stage. This edge dermoscopy process, put together with a digital interface applied in total-body mapping--as practiced in directed centers, may help decrease the number of false positive excisions without an increase in morbidity from CMM.

Tracheal mucormycosis presented as an intraluminal soft tissue mass.

BACKGROUND: Mucormycosis is a potentially lethal disease caused by an opportunistic fungal infection. It occurs mostly in diabetic or immunosuppressed patients and usually involves the lungs or paranasal sinuses. METHODS: We report a rare case of a patient with diabetic ketoacidosis who presented with progressive cough and dyspnea. CT of the neck and chest showed an intraluminal soft-tissue mass extending from the first tracheal ring to the thoracic inlet, causing severe destruction of the trachea. Direct laryngoscopy and biopsy demonstrated hyphal invasion with architecture typical of invasive mucormycosis. RESULTS: The patient underwent resection of the upper trachea and prolonged amphotericin B therapy and is disease free at 24 months after surgery. CONCLUSIONS: In patients with diabetes presenting with progressive hoarseness, dyspnea, and endobronchial mass, a fungal infection should be considered. In case of invasive tracheal mucormycosis, prompt diagnosis and early surgical resection may help improve survival.