Monitoring for Breast Cancer Recurrence Following Goldilocks Breast Reconstruction.

BACKGROUND: The Goldilocks breast reconstruction utilizes redundant mastectomy skin flaps to fashion a breast mound; however, there is concern that imbrication of these skin flaps may predispose to fat necrosis and make detection of local breast cancer recurrence more difficult. Goldilocks patients follow a traditional postmastectomy screening pathway that includes clinical examination for locoregional recurrence, but it is unclear if this is sufficient. We evaluate our Goldilocks reconstruction case series to determine rates of diagnostic imaging, biopsy, and locoregional and distant recurrence. METHODS: Sixty-six patients (94 breasts) undergoing Goldilocks breast reconstruction were retrospectively reviewed. Any diagnostic postoperative imaging/biopsies performed and that confirmed local or distant breast cancer recurrence were noted. RESULTS: Average time of follow-up was 45 months. Most patients in this cohort had stage 0 (27.3%) or stage I (40.9%) breast cancer. There were a total of 11 (11.7%) concerning breast masses identified. Seven (7.4%) masses were biopsied, of which 5 were benign and 2 were invasive cancer recurrence. Four masses (4.3%) underwent diagnostic imaging only, all with benign findings. Five patients in this series were found to have either distant disease or a second primary cancer in the nonoperative contralateral breast. CONCLUSIONS: Rates of local recurrence following Goldilocks are not higher than expected after other types of postmastectomy reconstruction. Clinical monitoring successfully detected local recurrence in all affected patients in this series. More definite guidelines around the routine screening of Goldilocks mastectomy patients may aid in early detection of local breast cancer recurrence.

Demographics and Clinical Characteristics Associated with the Spread of New-Onset Laryngeal Dystonia.

OBJECTIVES: Adult-onset idiopathic laryngeal dystonia (LD) can be associated with the risk of spread to muscles in the body. Subjects with extralaryngeal onset of dystonia have exhibited spread to the larynx. Previous studies analyze the spread of other dystonias but emphasis has not been placed on LD. The objective was to identify demographic and clinical factors contributing to the spread of dystonia to and from the larynx. METHODS: Data were obtained from the Dystonia Coalition (DC)-patients from 49 international clinical centers. Clinical and demographic data was taken from 143 out of 409 patients with diagnosed LD. Patient criteria included adult-onset LD diagnosed on exam with no co-morbid neurologic conditions and no dystonia in other locations. RESULTS: Among the 143 patients, 94 (65.7%) patients were diagnosed with focal laryngeal onset, with the remainder having extralaryngeal onset. Family history and age at study were statistically significant indicators of a patient developing laryngeal versus extralaryngeal onset of dystonia. Among the laryngeal onset group, 21 cases (22.3%) had an average time of 5.81 ± 5.79 years to spread from diagnosis, most commonly to neck (61.9%). Among extralaryngeal onset patients, mean time of larynx spread was 7.92 ± 7.737 years, most commonly to neck (22.7%). CONCLUSIONS: Our data indicates approximately a quarter of patients with laryngeal-onset dystonia will exhibit spread. There were no demographic or clinical factors that were statistically predictive of the likelihood of spread from larynx. Patients with dystonia elsewhere in the body should be counseled on the possibility of spread to larynx, and vice versa. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:2295-2299, 2024.

Outcomes of the Goldilocks Technique in High-Risk Breast Reconstruction Patients.

BACKGROUND: The Goldilocks technique seeks to provide a safe alternative for patients who are otherwise at risk of adverse complications during reconstruction. The technique involves deepithelializing and locally contouring mastectomy skin flaps to create a breast mound. The purpose of this study was to analyze outcomes in this cohort of patients. METHODS: A review was performed on a prospective database of all patients who underwent postmastectomy Goldilocks reconstruction between June of 2017 and January of 2021 at a tertiary care center. Data queried included patient demographics, comorbidities, complications, outcomes, and subsequent secondary reconstructive surgery. RESULTS: This series included 58 patients (83 breasts) who underwent Goldilocks reconstruction. Mean age at reconstruction was 56 years (range, 34 to 78 years), and 82% (48 patients) were obese (average body mass index, 36.8). When analyzed by individual breast, the overall complication rate was 18%. Most complications ( n = 9), such as infection, skin necrosis, and seroma, were treated in the office. Six breasts experienced major complications (ie, hematoma and skin necrosis) requiring additional surgery. At the time of follow-up, 35% ( n = 29) of breasts had a secondary reconstruction, consisting of 17 implants (59%), two expanders (7%), three fat grafts (10%), and seven autologous reconstructions (24%). The complication rate for secondary reconstruction was 14%. CONCLUSIONS: The Goldilocks breast reconstruction technique is safe and effective for high-risk breast reconstruction patients. Although early postoperative complications are limited, patients should be counseled on the likelihood of a subsequent secondary reconstruction procedure to achieve their desired aesthetic outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Cladophialophora bantiana orbital cellulitis after penetrating injury.

A 75-year-old immunocompetent male presented with a right orbital cellulitis after a foreign body penetrating injury. He was taken for orbitotomy with foreign body removal and started on broad-spectrum antibiotics. Intra-operative cultures were positive for Cladophialophora bantiana, a mold known for causing brain abscesses with no prior reports of orbital invasion in the literature. Following culture results, the patient was managed with voriconazole and required multiple orbitotomies and washouts for infection control.

Safety and Efficacy of Liposomal Bupivacaine Supraclavicular Nerve Blocks in Open Treatment of Distal Radius Fractures: A Perioperative Pain Management Protocol.

INTRODUCTION: Distal radius fractures (DRFs) are common fractures requiring surgical fixation. The literature varies regarding opioid prescribing habits, opioid consumption, and postoperative pain scores. We hypothesized that the preoperative administration of a liposomal bupivacaine (LB) supraclavicular nerve block would be safe and effective in controlling postoperative pain. METHODS: A standardized pain management protocol was implemented at a single institution from July 2021 to March 2022 for patients undergoing open reduction internal fixation of DRF. Protocol elements included a preoperative LB supraclavicular nerve block and a multimodal postoperative pain regimen. Primary clinical outcomes included postoperative pain scores and number of opioid tablets consumed. RESULTS: Twenty patients underwent a newly implemented protocol. The average age was 56 years. Mean number of oxycodone 5-mg tablets consumed was 4.1 (median, 2.5), and mean visual analog scale pain score at first postoperative appointment was 2.8. There were no incidences of missed acute carpal tunnel postoperatively. When compared with an institutional historical control (n = 189), number of opioid pills prescribed was reduced by 60% (21.4 vs 8.6 tablets, P < 0.0001), and no patients had unscheduled health care contact because of uncontrolled pain (22% vs 0%, P < 0.016). CONCLUSIONS: Liposomal bupivacaine supraclavicular nerve blocks are safe and effective in the treatment of postoperative pain after open reduction internal fixation of DRF. Patients consumed <5 oxycodone tablets on average, which is less than many recommend prescribed quantities (>20-30 tablets). Patients had low pain scores (2.8/10) at the first postoperative follow-up. To our knowledge, this is the first study demonstrating the utility of LB in this clinical setting.

A review of pediatric macromastia etiology and indications for reduction mammaplasty.

BACKGROUND: Macromastia in adolescents is both physically and psychologically debilitating during a period in life when individuals are particularly vulnerable to peer pressure and social norms. Early recognition and intervention by both pediatricians and surgeons are critical to avoid unnecessary suffering. While reduction mammaplasty is the gold standard for the management of symptomatic macromastia in adults, the management of macromastia in pediatric patients remains controversial. In particular, there is great discussion regarding the timing of reconstructive breast surgery in pediatric patients. METHODS: A comprehensive review of the literature was performed to identify all articles related to macromastia in patients ≤16 years of age, the age at which full development is typically achieved in the United States. The etiologies of pediatric macromastia, approaches to management, and outcomes are summarized herein. FINDINGS: Pathological breast hypertrophy in pediatric patients is a rare finding and may occur secondary to juvenile hypertrophy of the breast (JHB) and pseudoangiomatous stromal hyperplasia (PASH). While medical management of these pathologies has been attempted with varying success, reduction mammaplasty is safe and effective in pediatric patients. There are, however, a number of pediatric-specific considerations that must be taken into account prior to surgery. We provide an algorithm for approaching pediatric macromastia.

Occult Colon Adenocarcinoma and Multiple Myeloma Associated With Clostridium septicum Panophthalmitis With Orbital and Chiasmal Extension: A Case Report.

A previously healthy 62-year-old African American female presented with a fulminant orbital cellulitis of the right eye with diffuse scleritis and orbital inflammation extending to the optic chiasm on neuroimaging. She was taken for an emergent orbitotomy with an orbital fat biopsy and started on broad-spectrum intravenous (IV) and topical antibiotics. Within 36 hours of presentation, scleral thinning and a corneal melt ensued, ending in enucleation. Intraoperative cultures were positive for Clostridium septicum, leading to a systemic work-up exposing a previously undiagnosed colon adenocarcinoma and metastatic multiple myeloma.

Adherence to Long-Term Follow-up in Patients With Sporadic Vestibular Schwannomas Managed With Serial Observation.

OBJECTIVES: To examine the long-term adherence to serial imaging of patients with sporadic vestibular schwannoma and analyze factors associated with being lost to follow-up. STUDY DESIGN: Retrospective chart review with telephone interview. SETTING: Single tertiary care center. METHODS: Patients with a sporadic vestibular schwannoma and started on observational surveillance management between January 2005 and December 2010 were included. Demographic data, tumor size, hearing and vestibular changes, and follow-up length were recorded. Patient factors were analyzed for association with being lost to follow-up. RESULTS: In total, 122 patients were included with a median length of follow-up of 5 months (range, 0-146). After initial surveillance, 22.1% (n = 27) of patients had a change in management to either microsurgery or radiosurgery. Of the remaining 77.9% (n = 95), nearly half (44.2%, n = 42) never returned for a second visit, and all but 3 were eventually lost to follow-up. There was no association between sex, race, age at diagnosis, initial tumor size, insurance status, household income, or driving distance to hospital and being lost to follow-up. Of 26 interviewed patients initially lost to follow-up, 11 (42.3%) sought care at another institution, 5 (19.2%) chose to no longer receive care, 1 (3.8%) had transportation difficulties, and 9 (36.4%) had poor understanding of their diagnosis or instructions. CONCLUSIONS: The length of follow-up for patients undergoing surveillance of sporadic vestibular schwannoma varies widely, and patients are commonly lost to follow-up. Further efforts should be made to identify at-risk patients and provide adequate education to improve long-term surveillance.