Influence of health insurance, hospital factors and physician volume on receipt of immediate post-mastectomy reconstruction in women with invasive and non-invasive breast cancer.

For women with breast cancer who undergo mastectomy, immediate breast reconstruction (IR) offers a cosmetic and psychological advantage. We evaluated the association between demographic, hospital, surgeon and insurance factors and receipt of IR. We conducted a retrospective hospital-based analysis with the Perspective database. Women who underwent a mastectomy for invasive breast cancer (IBC) and ductal carcinoma in situ (DCIS) from 2000 to 2010 were included. Logistic regression analysis was used to determine factors predictive of IR. Analyses were stratified by age (<50 vs. ≥ 50) and IBC versus DCIS. Of the 108,992 women with IBC who underwent mastectomy, 30,859 (28.3 %) underwent IR, as compared to 6,501 (44.2 %) of the 14,710 women with DCIS who underwent mastectomy underwent IR. In a multivariable model for IBC, increasing age, black race, being married, rural location, and increased comorbidities were associated with decreased IR. Odds ratios (OR) of IR increased with commercial insurance (OR 3.38) and Medicare (OR 1.66) insurance (vs. self-pay), high surgeon-volume (OR 1.19), high hospital-volume (OR 2.24), and large hospital size (OR 1.20). The results were identical for DCIS, and by age category. The absolute difference between the proportion of patients who received IR with commercial insurance compared to other insurance, increased over time. Immediate in-hospital complication rates were higher for flap reconstruction compared to implant or no reconstruction (15.2, 4.0, and 6.1 %, respectively, P < .0001). IR has increased significantly over time; however, modifiable factors such as insurance status, hospital size, hospital location, and physician volume strongly predict IR. Public policy should ensure that access to reconstructive surgery is universally available.

Artificial skin for closure and healing of wounds created by skin cancer excisions.

BACKGROUND: A dermal regeneration template indicated for life-threatening third-degree burn injuries is a product with potential application to smaller wounds to aid in healing and closure of complex excision sites. OBJECTIVE: To assess the effectiveness of dermal regeneration template for closure of skin cancer excision sites that would have otherwise required complicated closures. METHODS: Five patients, 61-84 years old, with skin cancer surgery yielding a total of six wounds were treated with the dermal regeneration template to close and heal their wounds. RESULTS: Four of five patients had complete healing (five of six wounds) with cosmetically acceptable results. The one treatment failure was application of the dermal regeneration template over exposed skull where inadequate neodermis formed. Successful healing was observed in five complex skin cancer excision sites including two wounds in previously irradiated grafted skin, a large and deep temporal defect, a wide excision in the supraclavicular region, and an excision down to cartilage on the antihelix of the ear. No infections were noted, although in four of five patients prophylactic oral antibiotics (either erythromycin or cephalexin) were prescribed postoperatively for 1-2 weeks. CONCLUSION: The product simplified wound care, subjectively appeared to decrease pain and postoperative bleeding, and yielded cosmetically acceptable wound repair. Autografting was not necessary; wounds healed in 2-4 months by epithelialization over neodermis after removal of the silicone layer. Furthermore, the product was a convenient long-term dressing and healing device for wounds where complex repairs, autografts, and/or flaps would otherwise be considered for closure.

Complete agenesis of the soft palate.

This report documents the physical characteristics and treatment of a patient with the extremely rare finding of complete agenesis of the soft palate. The posterior hard palate cleft and soft palate agenesis were treated with a palatal pushback procedure.

The use of muscle flaps to treat left ventricular assist device infections.

Left ventricular assist devices have become an important adjunct in the therapeutic armamentarium for patients with end-stage heart failure. Although they may provide a bridge to transplantation, they are prone to certain problems, expecially infection. Because these are life-sustaining devices, changing the device or simple explantation may be a risky, if not impossible, option. Therefore, we evaluated the effectiveness of a surgical alternative, namely, coverage of infected devices with muscle or myocutaneous flaps. Eighty-two consecutive patients who underwent the insertion of 88 left ventricular assist devices at our institution over a 6.5-year period were evaluated. Follow-up was provided for all patients and ranged from 1 to 7.5 years. The duration of ventricular support ranged from 0 to 434 days. All patients who demonstrated clinical evidence of infection were identified. Overall, 54 patients (66 percent) had infections locally at the device site, at distant sites, or systemically during support. Cultured organisms included gram-positive and -negative bacteria, fungi, and viruses. Of the 56 infections in these 54 patients, 21 (38 percent) were device-related, i.e., in the pocket created by the device, in the device itself, or from the driveline. Thus, 24 percent (21 of 88) of all ventricular support devices inserted demonstrated device infection during use. Therapeutic modalities used to combat device-related infection included both nonsurgical management with antibiotics alone and surgical procedures such as device change or relocation, device explant, and flap coverage. Eight of the 20 patients in whom the 21 device-related infections occurred underwent surgical intervention. Four of these eight patients undenwent local flap coverage of their infected left ventricular assist devices. All four patients also had evidence of systemic infection, or "device endocarditis." Coverage was successfully achieved in all cases with pedicled rectus abdominis flaps. There were no perioperative complications. Two patients later underwent successful transplantation; the other two died from causes unrelated to the flap. In conclusion, the treatment of infected left ventricular assist devices currently includes both nonsurgical and surgical alternatives. Of the latter, muscle flaps should be considered a first-line intervention to assist in eradicating infection by providing well-vascularized tissue. Although there were no perioperative complications, the 50 percent mortality rate is consistent with that reported for patients with "device endocarditis." It may be that flap coverage of infected ventricular assist devices, if instituted at an earlier stage in the therapeutic process, could help prevent systemic infection in these patients and, therefore, improve their overall outcome.

Docetaxel (taxotere) extravasation: a report of five cases with treatment recommendations.

Docetaxel (Taxotere) is a relatively new antineoplastic agent that is proving to be clinically useful in the treatment of a number of major solid tumors, including breast, ovarian, lung, and prostate carcinoma. Common systemic toxicities include neutropenia, alopecia, nausea, and vomiting. The authors report 5 patients (age range, 54-89 years) who experienced extravasation injuries with dramatic clinical presentations during peripheral intravenous administration of docetaxel. The authors did not find any other reported series of docetaxel extravasation in an extensive literature review. They present these 5 patients and provide treatment recommendations.

Palatal distraction in a canine cleft palate model.

The purpose of this study was to determine whether the canine hard palate can be lengthened by distraction osteogenesis in a cleft palate model using a mostly submucosal distractor. Five mongrel dogs were used. After raising mucoperiosteal flaps, a midline strip of bone was removed from the hard palate of each dog to simulate the bony defect seen in a cleft palate. A transverse osteotomy was then made to separate the posterior segment of the hard palate from the anterior segment. Posterior osteotomies were also made laterally parallel to the teeth so that the 2 posterior segments (one on either side of the bony cleft) were mobile. An intraoral distractor that was mostly submucosal was attached to the anterior hard palate and both segments of the mobilized posterior hard palate. Radiopaque bone markers were placed, and x-rays were obtained. After a 10-day latency period, the distractor was expanded 0.675 mm per day until it had been lengthened 10.125 mm. Distractors were left in place for an additional 8 weeks. After distractor removal, animals were observed for an additional 8 weeks before euthanization. Follow-up x-rays and histologic examinations were performed. New bone formation was found at the site of distraction in all dogs at the time of death. This new bone was seen on the follow-up x-rays and on histologic examination of the hard palates using both hematoxylin and eosin staining and Masson's trichrome stain. Distraction osteogenesis using a mostly submucosal device is an effective technique for lengthening the hard palate in a canine cleft palate model. The technique may eventually provide an alternative treatment for velopharyngeal incompetence in humans that is more precise and involves less morbidity than existing treatments.

Obtaining maximal use of expanded scalp rotation flaps via an experimental model.

The relative inelasticity of scalp skin and the irregular convexity of the cranial vault necessitate careful planning in the design and mobilization of scalp flaps. Rotation flaps adapt particularly well to the curves of the cranial vault. An experimental model has enabled us to study the design and mobilization of expanded scalp rotation flaps and to obtain maximal efficiency from the tissue expansion process. The use of a round tissue expander situated immediately adjacent to a scalp defect is an excellent method for the creation of a rotation flap. To optimize the use of the expanded tissues, the flap should be designed so that its border passes along the periphery of these expanded tissues. In cases in which it is advisable to separate the expander from the defect, such as when the defect is highly contaminated, efficient use of the expanded tissues can still be obtained by placing the expander at the site of a rotation flap backcut. Furthermore, although this study focuses on rotation flaps only, this same model can be used to examine and compare different closure methods using other types of flaps as well.

Single-stage treatment of sternal wound complications in heart transplant recipients in whom pectoralis major myocutaneous advancement flaps were used.

Treatment of sternal wound complications is controversial, particularly in immunosuppressed heart transplant recipients. Regardless of the severity of infection, we combine immediate, aggressive débridement with bilateral pectoralis major myocutaneous advancement flaps in a single procedure. Compared with management with pectoralis major turnover flaps or distant pedicled muscle flaps, treatment of these sternal wounds with pectoralis major myocutaneous advancement flaps is simpler and quicker and provides better aesthetic results. Furthermore, because pectoralis major myocutaneous flaps are based on the thoracoacromial arteries, whether or not the internal mammary arteries have previously been harvested for coronary grafts is irrelevant. Twenty consecutive heart transplant recipients with sternal wound complications were treated with this technique. No intraoperative or perioperative deaths occurred. The morbidity rate was 30%, with seroma treated by needle aspiration in four patients (20%) being the most common complication. Only one patient had a postoperative wound infection. All patients had excellent functional and aesthetic results.

Heterotopic transplantation of a reattached digit.

A patient who had suffered amputations at different levels of his nondominant left hand, and who had initially been treated with reattachment of his index and long fingers, presented with a minimally functional left hand. He was then managed by transplantation of his reattached index finger stump to the shortened ring finger. This significantly improved hand function and contour and alleviated a painful neuroma at the former ring finger amputation site. However, compared with the long finger, which was reattached once, the twice-reattached finger had less sensibility recovery, more pronounced cold intolerance, decreased basal skin temperature, and a slower digital rewarming time. Thus, even though it is technically feasible to transfer a previously reattached digit, other possible physiologic limitations must be considered before doing so.

Reconstruction of acquired ear defects with transauricular flaps.

Retroauricular flaps based superiorly, inferiorly, or posteriorly may be tunneled through the ear to close a variety of acquired ear defects in a single-stage procedure. The technique is particularly helpful for larger, nonmarginal deformities in which both skin and perichondrium have been excised.

Single-stage management of 74 consecutive sternal wound complications with pectoralis major myocutaneous advancement flaps.

The optimal management of sternal wound complications remains controversial. Since 1985, we have utilized a combination of immediate, aggressive debridement with simultaneous repair using bilateral pectoralis major myocutaneous advancement flaps, regardless of the degree of infection. As compared with the use of distant pedicled muscle flaps or pectoralis major turnover flaps, the management of complicated sternal wounds with immediate pectoralis major myocutaneous advancement flaps provides an effective yet simpler, quicker method of management with improved aesthetic results. In addition, basing the pectoralis major myocutaneous flaps on the thoracoacromial arteries eliminates the need for intact internal mammary arteries, valuable since the latter are increasingly used for coronary grafts. Seventy-four consecutive patients, 17 (23 percent) of whom were immunosuppressed heart transplant recipients, have been managed with this procedure. There were no intraoperative deaths. The 30-day perioperative mortality rate was 9 percent (7 of 74), with only 1 death related to persistent sepsis. The morbidity rate was 39 percent, with the most common complication being seroma managed by needle aspiration (18 of 74, 24 percent). The aesthetic and functional results have been uniformly excellent.

An intramuscular ganglion presenting as a thenar mass.

Soft-tissue masses in the hand are frequently due to ganglion cysts. We report a ganglion originating from a common location, the volar wrist, but presenting in a unique fashion as a thenar mass. This case helps demonstrate why ganglion cysts should be considered in the differential diagnosis of any soft-tissue hand mass.

Rat ear transplantation: a feasibility study.

The feasibility of rat ear replantation and its inherent advantages as an experimental model have previously been demonstrated. The purpose of this study was to validate the technical feasibility of rat ear transplantation. To eliminate immunologic rejection as a complicating factor, highly inbred Lewis rats (strain LEW/CRIBR) were utilized. The external, internal, or common carotid artery served as the arterial pedicle, and the posterior facial vein as the venous pedicle; tubal cartilage was anastomosed for structural support. Four of five transplanted ears were viable at 10 to 14 weeks postoperatively. The other ear appeared entirely viable, when its host animal died of respiratory complications on postoperative day 2. Rat ears therefore seem to provide a feasible model for transplantation of non-vital organs.