Local Infiltration of Tranexamic Acid in Breast Reduction for Symptomatic Macromastia.

BACKGROUND: With a surge of tranexamic acid (TXA) use in the plastic surgery community and a constant demand for breast reduction for symptomatic macromastia, questions about the benefits and risks emerge. The aims of this study are to evaluate and compare outcomes of patients undergoing breast reduction while receiving local TXA as opposed to standard procedure without TXA and to assess intraoperative bleeding and operative time. METHODS: A retrospective review of breast reductions at a single institution from June 2020 to December 2021 was performed. The breast was infiltrated with tumescent solution at the time of surgery, with or without TXA. The population was divided into 2 groups: the TXA receiving group and tumescent only group. Demographics, intraoperative bleeding, operative time, complications, and drain duration were compared between groups. T test and χ 2 test analyses were performed on IBM SPSS.TM. RESULTS: A total of 81 patients and 162 breasts were included. Mean age among patients was 30 ± 13.44 years. Mean SN-N distance was 32.80 ± 3.62 cm. Average resected breast specimen weight was 903.21 ± 336.50 g. Mean operating room time was 159 minutes. Intraoperative blood loss and operative time were not statistically different between groups ( P = 0.583 and P = 0.549, respectively). T-junction dehiscence was lower in the TXA group ( P = 0.016). Incidence of suture granulomas was lower in the TXA group ( P = 0.05). Drain duration was statistically significantly higher in the TXA group ( P = 0.033). CONCLUSIONS: No decreases in intraoperative blood loss, operative time, or hematoma were seen after local administration of TXA during breast reduction. The rate of overall complications was not increased by using TXA, and incidence of T-junction dehiscence was lower in the TXA group lending to TXA's relatively safe profile. More research is necessary to further elucidate the TXA-related benefits in standard breast reductions.

Low Baseline Expression of Fibrotic Genes in an Ex Vivo Human Skin Model is a Potential Indicator of Excessive Skin Scarring.

One of the challenges plastic surgeons face is the unpredictability of postoperative scarring. The variability of wound healing and subsequent scar formation across patients makes it virtually impossible to predict if a patient's surgery will result in excessive fibrosis and scarring, possibly amounting to keloids or hypertrophic scars. There is a need to find predictive molecular indicators of patients or skin location with high risk of excessive scarring. We hypothesized that baseline expression levels of fibrotic genes in the skin can serve as a potential indicator of excessive scarring. Methods: An ex vivo model of skin fibrosis was used with abdominal and breast skin tissue from 45 patients undergoing breast reduction and/or abdominoplasty. Fibrosis was induced in skin explants in organ culture with transforming growth factor-ß (TFGß). Fibrotic gene response was assessed via quantitative real-time polymerase chain reaction and correlated with skin location, age, and baseline levels of fibrotic genes. Results: The increase in TFGß-induced fibronectin1 (FN1) gene expression in skin explants was significantly higher than for Collagen 1A1, alpha smooth muscle actin, and connective tissue growth factor. Also, FN1 expression positively correlated with donor age. Moreover, lower expression of the fibrotic genes FN1, Collagen 1A1, and alpha smooth muscle actin correlated with a more pronounced fibrotic response, represented by higher induction levels of these genes. Conclusions: Skin sites exhibit different baseline levels of profibrotic genes. Further, low baseline expression levels of fibrotic genes FN1, Collagen 1A1, and alpha smooth muscle actin, in donor skin may indicate a potential for excessive scarring of the skin.

Increasing Recognition of Community-Acquired, Non-Tuberculous Mycobacterial Infections of the Hand and Wrist.

Background In this study, we present our experience with community-acquired, culture-positive, non-tuberculous mycobacterial (NTM) infections of the hand and wrist and compare the clinical features, risk factors, diagnostic delays, and treatment outcomes among patients referred for surgical consultation at our institution over a five-year period. Methodology We retrospectively identified patients on chart review who were diagnosed with culture-positive, extrapulmonary, cutaneous NTM infections between January 1, 2014, and December 31, 2018. Only patients with community-acquired NTM infections of the hand and wrist were included. Patient demographics, risk factors, location, diagnostic delays, NTM species isolated, treatment modalities, and treatment outcomes were collected and analyzed. These variables were further compared between patients who participated in fishing-related activities and those who did not. Results A total of 10 patients were identified with community-acquired NTM infections of the hand or wrist. Of these patients, eight (80%) were male, and six (60%) had participated in fishing-related activities prior to the initial presentation. The majority of patients had Mycobacterium marinum isolates (n = 6, 60%) and involved the hand (n = 8, 80%). M. marinum isolates were associated with a significantly shorter time to diagnosis (p = 0.02). All patients underwent surgical management with a prolonged course of postoperative antibiotics and were cured of their infection at the end of their treatment course. Conclusions Proper risk factor documentation and heightened clinical awareness are essential to reduce delays in the diagnosis of NTM skin and soft tissue infections and provide the best chance for curative therapy.

High-Pressure Injection Injuries of the Hand: A 10-Year Retrospective Analysis at a Single Academic Center.

INTRODUCTION: The incidence of high-pressure injection injuries of the hand is low. Although the occurrence is rare, the precarious progression of the injury exacts prompt surgical evaluation in order to avoid complications and amputation. The current study was devised in order to make comparisons to the current data, in addition to supplementing the literature with observations regarding clinical course and management. METHODS: A multisurgeon, retrospective chart review from a single institution was performed. Inclusion criteria included cases involving a high-pressure injection injury to the hand that underwent surgical management. Patient demographics, injury details, and hospital course were all reviewed and recorded. RESULTS: This retrospective review identified 20 cases meeting criteria, all of which involved males. The average age at time of injury was 39.7 years (range, 21-71 years). The incidence of injection injuries over a 10-year time period was 2.1 cases per year. The nondominant hand was injured in 11 cases (63%). The most common site of injury was the index finger with 11 recorded incidents (55%). Other reported locations included the metacarpal (40%) and small finger (5%). Occupational data included 10 construction workers, 5 painters, and 2 cleaning crew members, and 3 had nonmanual occupations. Paint was the most commonly injected substance with 17 reported cases (85%). On average, the delay until surgery was observed to be 21.9 hours (n = 16). Only 1 patient underwent surgery at 6 hours after surgery. The average number of procedures performed was 1.8 (range, 1-4). Hospitalization duration was on average 3.9 days (range, 1-9 days), and the average follow-up length was 69 days (range, 7-112 days). There were no identified cases that necessitated amputation. CONCLUSIONS: This form of injury most commonly affects male, middle-aged laborers. Our study found very low amputation rates when compared with the current literature, despite observing longer delays to surgery according to current recommendations. Limited comparisons can be made from data regarding clinical course and management because of the small sample size of the current study and the limited published data. This indicates a need for further exploration and collection of data involving parameters such as clinical course and management.

Ketorolac and Hematoma Incidence in Postmastectomy Implant-Based Breast Reconstruction.

BACKGROUND: Ketorolac tromethamine (Toradol) is an effective a nonsteroidal anti-inflammatory drug and a powerful analgesic for patients undergoing breast surgery. However, the potential for postoperative bleeding has not yet been explored specifically in women undergoing implant-based breast reconstruction. There is concern that an increased risk of bleeding exists in this population due to the lack of tissue apposition as a result of implant placement. We therefore seek to assess the associated risk of bleeding complication in implant-based breast reconstruction at our academic institution. To the best of our knowledge, this represents the first case series addressing safety profile of Toradol specifically in patients undergoing nonautologous, implant-based breast reconstruction. METHODS/RESULTS: A single-center, retrospective review was performed analyzing our institutional experience with Toradol in nonautologous, implant-based breast reconstruction following mastectomy. A prospective database of 522 patients collected between 2008 and 2013 was analyzed. Within the database, 57 patients who received intraoperative ketorolac were identified among a total of 180 patients undergoing prosthetic reconstruction. No statistically significant difference was found in the incidence of clinically relevant hematoma formation between the control and Toradol groups. The frequency of hematoma formation in the control was 0.09 (11/123 patients, 95% confidence interval = 0.05-0.15) and 0.04 in the Toradol group (2/57 patients, 95% confidence interval = 0.01-0.12), resulting in a P value of 0.32. Regarding the secondary outcomes, we did not detect a statistically significant difference in the total number of complications or length of hospital stay in the Toradol and control groups. CONCLUSIONS: Review of our breast reconstruction database did not find a trend toward an elevated incidence of hematoma associated with intraoperative Toradol use in implant-based postmastectomy reconstruction.

The treatment of gustilo grade IIIB tibia fractures with application of antibiotic spacer, flap, and sequential distraction osteogenesis.

Gustilo grade III (GIII) B-C open tibia shaft fractures have a wide spectrum of injury to the bone and soft tissues. At the severe end of the spectrum are GIII B tibia fractures that combine segmental bone loss with soft tissue injuries which require flap reconstruction. These complex injuries can be treated combining circular tensioned wire fixation and distraction histiogenesis with flap reconstruction. GIII B tibia shaft fractures were retrospectively reviewed at an urban Level One Trauma Center from 1992 to 2008 which were treated with the Ilizarov method. Seventy-six patients with 78 fractures were treated. Thirty-eight fractures were treated with flaps. Out of this cohort, a subset of 19 fractures were treated using the protocol of initial multiple debridements, half pin resuscitation external fixation, soft tissue reconstruction over antibiotic spacers and delayed Ilizarov reconstruction after stabilization of the soft tissue envelope. The fractures had multiple aggressive debridements removing nonviable bone. Thirteen free flaps and 6 rotation flaps were applied. Flaps were applied a mean time of 34 days (12-77) after initial injury. Two free flaps failed and had a second successful application. Flap survival was 17 of 19 (89%). There was one partial necrosis and one flap hematoma. There was no flap complication from delayed elevation and spacer removal. Mean tibial bone defect was 9.4 cm (5-17). Reconstruction time was 26.5 months (12-73). Eighteen of 19 fractures were reconstructed with union and no deep infection or osteomyelitis. One fracture had a hypertrophic nonunion in a noncompliant patient. The use of antibiotic spacers and flaps to construct a soft tissue tunnel combined with distraction histiogenesis is an effective technique to salvage complex GIII B tibia fractures with segmental bone loss.

Tendon injuries in the pediatric hand.

Injuries to the flexor and extensor tendons in the hand are common and require cautious evaluation and treatment or repair. Flexor tendon injuries are often associated with neurovascular injury and thus must be considered in the differential workup. Extensor injuries may involve intra-articular damage, which must also be identified. The diagnosis and management of common flexor and extensor tendon injuries of the hand are described.

Vascular anomalies of the upper extremity in children.

Vascular malformations in the pediatric upper extremity remain a diagnostic and therapeutic challenge. Recent knowledge about diagnosis and treatment is provided including specific markers, imaging techniques, and management.

Pediatric hand burns: thermal, electrical, chemical.

Young children often use their hands for exploration of their surroundings, and this often leads to the hand being the primary site of injury. Because of this and many associated factors, burns of the pediatric hands are relatively common, with thermal injuries being the most frequent. Electrical and chemical etiologies contribute a minor portion of the burn injuries in the pediatric population. Some key differences should be considered in the management of hand burns in a pediatric patient versus an adult. In general, minor superficial burns will heal satisfactorily only with topical care. Deeper partial-thickness and full-thickness burns, however, require surgical interventions. Special care should always be taken in the management of electrical and chemical burns because the pathophysiology of these injuries are unique. Treatment of pediatric hand burns should also involve close and thorough follow-up to assess not only for healing and restoration of function of the injury but also for psychologic and emotional trauma.

Replantation in the pediatric hand.

Replantation in the pediatric hand is not an uncommon procedure, and it is 1 of the most common microsurgical operations in children. Microsurgeons should be aware of the indications and technical issues involving pediatric patients because there are differences compared to adult patients. In general, pediatric patients can be approached in a liberal and aggressive manner, but they tend to be more technically challenging. This review attempts to describe the various considerations in dealing with these patients to provide a framework for surgical management. Based on a survey of the literature, replantation has been a successful procedure in the pediatric population and has become a mainstay of treatment because it provides a better functional and aesthetic outcome.

Controversies in the diagnosis and treatment of pediatric brachial plexus injuries.

Brachial plexus injuries have a steady occurrence in the pediatric population from a variety of sources. The various approaches taken to diagnosing and treating this injury have long been fraught with controversy. This has been compounded with advances in medical technology and surgical techniques. Our paper attempts to give a short discussion of the epidemiology of brachial plexus injuries and delineate the specific controversies that exist in diagnosis and treatment.

Osteomyelitis of the craniofacial skeleton.

Skull-based osteomyelitis, which is a true bony infection, originates from a chronic, inadequately treated infection. Because of the complex craniofacial skeletal anatomy and associated aesthetic concerns, osteomyelitis of the craniofacial skeleton must be uniquely managed and is more difficult to treat than osteomyelitis of other bones of the body. It is thought that osteomyelitis is decreasing in prevalence due to broad-spectrum antibiotic treatment; however, it still remains a challenging clinical entity in developing countries and lower socioeconomic areas.

Lower extremity fascial reconstruction using an acellular dermal matrix graft .

UNLABELLED: Background. AlloDerm® acellular dermal matrix ([ADM], Lifecell Corp, Branchburg, NJ) is gaining increasing popularity in virtually every surgical subspecialty for use in the closure of soft tissue defects, structural support, or tissue augmentation. There is limited experience in lower extremity fascial reconstruction secondary to trauma, as this can be a challenging problem for the plastic surgeon. The purpose of this case report is to demonstrate the reliability of acellular dermal matrix grafts in lower extremity fascial reconstructions. METHODS: We present a patient who underwent tensor fascia lata reconstruction with ADM following a large fascial defect. The patient previously underwent a lateral thigh fasciotomy for compartment syndrome and developed a large fascial hernia of the thigh. RESULTS: The defect was repaired using an ADM graft, which resulted in excellent aesthetic and functional outcomes. CONCLUSION: In selected patients, the use of acellular dermal matrix grafts for lower extremity fascial reconstructions produces adequate soft tissue coverage and optimal aesthetic and functional results. .

Pediatric breast deformity.

Congenital breast anomalies represent a relatively common set of disorders encountered by pediatric plastic surgeons with a spectrum of severity that ranges widely from the relatively benign polythelia to the very complex disorders such as Poland's syndrome and tuberous breast deformities. While the former can be treated in a single surgical setting with minimal morbidity, the more complicated disorders often require a staged reconstructive algorithm. Some disorders also require a multidisciplinary management for both workup and management. Although rarely a source of functional morbidity, these physical deformities are often a significant source of psychological stress for the adolescent male or female who feels alienated from their peers. The purpose of this article is to review the most common congenital breast disorders including the diagnosis, workup, and management especially the timing of surgical intervention as guided by normal developmental milestones.

Improved esthetic results with fine-tip Dermabond application technique.

Tissue glues and adhesives have achieved increasing popularity as alternatives to small wound closure. When applying these substances, it is often difficult to avoid contact with the surrounding skin and foreign objects such as surgical gloves. A technique for the application of Dermabond is described in this report. Twenty wounds less than 10 cm in length were reapproximated using a fine-tip tuberculin syringe applicator. The wounds were evaluated immediately after the application, and 2, 4, and 6 weeks after surgery. Use of the tuberculin fine-tip technique allowed reapproximation of the wound edges with no clinical evidence of surrounding tissue damage. There were no apparent decreases in wound strength or associated discoloration or fuzziness onto the skin. Esthetic results were considered good to excellent by patients. Dermabond can be accurately applied with a tuberculin syringe, avoiding the surrounding tissue damage and foreign object adhesion reported in the literature.

A simple method for the control of medicinal leeches.

The medicinal leech, Hirudo medicinalis, has been widely used in the salvage of microvascular free flaps. Numerous publications have detailed the biology, use, benefits, and risks of leech therapy. One reported significant risk is the risk of leech movement or migration from the surgical site, possibly into body orifices or even deeper into the wound itself. The authors report a simple method of limiting the movement of medicinal leeches from the surgical site, namely, affixing one end of a surgical suture to the leech and tying the free end to a firm object or dressing. This simple method limits the potential range of movement of the leech and reduces the risk of leech migration to unwanted areas.

Hand abnormalities associated with craniofacial syndromes.

One in approximately every 626 newborns has a congenital anomaly of the upper limb. Frequently, patients with craniofacial syndromes may have associated hand anomalies. In this article, we try to answer why certain craniofacial syndromes have associated hand anomalies through an examination of the common factors in development and maldevelopment of these two very complex structures. In general, we conclude that the common factors responsible for patients with craniofacial syndromes that have associated hand anomalies are the common time course of development of these two structures and certain mutations of genes controlling limb and craniofacial development. This article attempts to elucidate the sequence and crucial factors responsible for proper limb growth, as we understand it today. The most common craniofacial syndromes that include craniosynostosis and upper extremity anomalies are presented. These are Apert's, Saethre-Chotzen, Pfeiffer's, and Carpenter's syndromes. As we discuss each of these syndromes, basic principles regarding the surgical correction of the associated hand anomalies are described. We hope that this overview serves to give the pediatrician and the craniofacial specialist general guidelines for what to look for and expect in the hands and upper extremities of children under their care.