Evaluation of wait times for patients seeking cosmetic and reconstructive breast surgery.

BACKGROUND: Patients seeking cosmetic or reconstructive procedures in plastic surgery typically face significant wait times for consultations. Little attention has been given to potential disparities in wait times between elective cosmetic and reconstructive procedures. In this initial pilot study, we audited a broad sample of plastic surgery offices within a single state for wait times in initial consultations for both breast reconstruction and breast augmentation. METHODS: A sample of board-certified plastic surgeons was audited from the American Society of Plastic Surgeons (ASPS) Web site that listed both cosmetic and reconstructive breast surgery. Scripted patient telephone calls were made to 67 plastic surgery clinics within a single state on May 2012. Two calls separated by 7 days were made to each office by the same actor seeking an initial appointment for either breast reconstruction or breast augmentation. Wait times were calculated from the date of the call until the date of appointment offered. RESULTS: There were 72 paired calls completed on 36 plastic surgery clinics. Significant disparities in appointment wait times existed between elective cosmetic versus reconstructive procedures (P = 0.02). Mean wait times for breast reconstruction consultation (26.1 days) were significantly longer than mean consultation wait times for breast augmentation (20.9 days). Interestingly, 17.9% of offices contacted no longer perform certain procedures currently advertised on the ASPS Web site. CONCLUSIONS: Disparities exist in access to care between patients seeking elective breast augmentation and reconstruction after mastectomy. Patients seeking breast augmentation have more rapid access to plastic surgeons. This study did not evaluate possible explanations for the observed differences. Potential causes may include physician preference and compensation benefits for cosmetic procedures.

Fat necrosis in autologous abdomen-based breast reconstruction: a systematic review.

BACKGROUND: Fat necrosis is a common and potentially exasperating complication of autologous breast reconstruction. The authors performed a systematic review of the English literature on autologous breast reconstruction to determine significant patient and surgical factors that are predictors of postoperative fat necrosis. METHODS: A PubMed search using the terms "fat necrosis" and "breast reconstruction" was conducted. Articles were screened using predetermined inclusion and exclusion criteria. Data collected included patient characteristics, reconstructive techniques used, and the specific postoperative morbidity of interest. Patient cohorts were pooled, and the incidence of fat necrosis was calculated in the presence and absence of each risk factor. Chi-square analysis was applied, and p < 0.05 was considered statistically significant. RESULTS: Of 172 articles found, 70 met the inclusion criteria. The mean rate of fat necrosis was 11.3 percent. Deep inferior epigastric artery perforator flaps had the highest rate of fat necrosis (14.4 percent), followed by pedicled transverse rectus abdominis musculocutaneous (12.3 percent), superficial inferior epigastric artery (8.1 percent), and free transverse rectus abdominis musculocutaneous flaps (6.9 percent). Significant predictors of fat necrosis included obesity (p = 0.035), prereconstruction irradiation (p = 0.022), postreconstruction irradiation (p < 0.001), active smoking (p < 0.001), and abdominal scars (p = 0.05). Protective factors included supercharging (p < 0.001) and bilateral reconstruction (p = 0.01). CONCLUSIONS: Although there is little agreement in the literature regarding risk factors for fat necrosis, the authors were able to demonstrate several significant predictors by systematically analyzing 70 articles. Improved knowledge of the risk factors for fat necrosis can help surgeons provide improved preoperative counseling and take measures to minimize the risk of this complication.

Bone flap perfusion assessment using near-infrared fluorescence imaging.

BACKGROUND: Microsurgical vascularized bone flaps are a versatile technique for reconstructing large bone defects. However, the assessment of perfusion is challenging, because clinical examination is difficult intraoperatively and often not possible postoperatively. Therefore, it is important to develop techniques to assess the perfusion of vascularized bone flaps and potentially improve the surgical outcomes. Near-infrared (NIR) fluorescence imaging has previously been shown to provide real-time, intraoperative evaluation of vascular perfusion. The present pilot study investigated the ability of NIR imaging to assess the perfusion of vascularized bone flaps. METHODS: Vascularized bone flaps were created in female Yorkshire pigs using well-established models for porcine forelimb osteomyocutaneous flap allotransplantation (n = 8) and hindlimb fibula flaps (n = 8). Imaging of the bone flaps was performed during harvest using the FLARE intraoperative fluorescence imaging system after systemic injection of indocyanine green. Perfusion was also assessed using the standard of care by clinical observation and Doppler ultrasonography. NIR fluorescence perfusion assessment was confirmed by intermittent clamping of the vascular pedicle. RESULTS: NIR fluorescence imaging could identify bone perfusion at the cut end of the osteotomy site. When the vascular pedicle was clamped or ligated, NIR imaging demonstrated no fluorescence when injected with indocyanine green. With clamp removal, the osteotomy site emitted fluorescence, indicating bone perfusion. The results using fluorescence imaging showed 100% agreement with the clinical observation and Doppler findings. CONCLUSIONS: Vascularized bone transfers have become an important tool in reconstructive surgery; however, no established techniques are available to adequately assess perfusion. The results of our pilot study have indicated that NIR imaging can provide real-time, intraoperative assessment of bone perfusion.

Face transplant perfusion assessment using near-infrared fluorescence imaging.

BACKGROUND: Composite tissue allografts (CTAs) including partial face transplantation have been achieved clinically. However, risks of complications including tissue ischemia, rejection, and transplant failure are significant. Safe and effective techniques to assess perfusion are needed to decrease complications in composite tissue flaps. Near-infrared (NIR) fluorescence imaging has been previously shown to provide a real-time, intraoperative evaluation of perfusion. This study investigates the use of NIR imaging in partial face CTA harvest. METHODS: We created hemifacial CTAs (n = 8) using an established porcine model. This included ear cartilage, nerve, lymphoid tissue, muscle, and skin with perfusion by the carotid artery and external jugular vein. We injected animals systemically with indocyanine green and obtained NIR fluorescence images simultaneously with color video. In addition, we assessed the elevated hemifacial flaps using standard of care (i.e., clinical examination and Doppler). RESULTS: Flap design was facilitated by NIR imaging with localization of perforators to the hemifacial CTA flap. In particular, an arterial and venous phase could be clearly identified. We assessed perfusion of the flap by NIR fluorescence intensity after injection of indocyanine green. Sequential clamping of the artery and vein confirmed correlation of perfusion deficits with NIR imaging as well as with clinical examination and Doppler. CONCLUSIONS: Evaluation and assessment of perfusion are important in facial transplantation. The results from our pilot study indicate that NIR imaging has the capability to assess perfusion of partial facial CTAs. This emergent technology shows promise in assessing tissue perfusion in a composite flap.

Intercostal neuroma as a source of pain after aesthetic and reconstructive breast implant surgery.

The development of persistent post-operative pain after implant placement for aesthetic or reconstructive breast surgery can lead to significant patient morbidity. Although there are many etiologies for post-operative pain, the diagnosis of an intercostal neuroma is important as this can be treated surgically. We describe three cases of an intercostal neuroma in patients with breast implants. A Tinel's sign can be elicited along the lateral chest wall and a local anesthetic block temporarily alleviates this pain. Surgical management with identification and clipping of the intercostal neuroma and burying into the underlying muscle significantly decreases post-operative pain long term. In patients with persistent pain after breast implant placement, plastic surgeons must be aware of this treatable cause of pain.

Complications following expander/implant breast reconstruction utilizing acellular dermal matrix: a systematic review and meta-analysis.

BACKGROUND: The recent increase in popularity of acellular dermal matrix assistance in immediate expander/implant breast reconstruction has led to variety of viewpoints. Many studies are published indicating an increase in complications with the use of acellular dermal matrix, while others indicate there is no increase in complications. METHODS: This meta-analysis utilizes information from available studies that directly compare one specific type of acellular dermal matrix with traditional methods of immediate expander/implant breast reconstruction. Eight studies were found through a meticulous literature search that met these criteria. RESULTS: There was more than a 2-fold increase in the number of infections and explanations in the acellular dermal matrix group compared to the control. There was a 3-fold increase in seroma formation in the acellular dermal matrix group compared to the control. There was a significant difference of intraoperative fill volumes between the acellular dermal matrix group compared to the control. CONCLUSIONS: This study illustrates that after pooling all available date regarding the use of acellular dermal matrix in immediate expander/implant breast reconstruction there appears to be an increased rate of complications. However, the increased intraoperative fill volume may lead to ultimately greater patient satisfaction.

Analysis of comprehensibility of patient information regarding complex craniofacial conditions.

PURPOSE: Health care consumers are increasingly turning to the Internet for information regarding medical and surgical procedures. When an elective procedure is under consideration, the Internet is often the first resource used by a patient. Caregivers of craniofacial patients are typically overwhelmed during the surgical planning process. A firm understanding of craniofacial condition and the associated procedures is crucial to obtain satisfactory outcomes. Furthermore, health care providers are increasingly referring their patients to on-line sources of patient education material. Currently, the National Institutes of Health suggests the information be at the fourth- to sixth-grade reading level to maximize comprehension. Much of the information available regarding health care targeted at patients is written at a 10th-grade reading level or higher. The purpose of this study was to evaluate readily available on-line patient education information for readability; being aware of this information will aid craniofacial surgeons in appropriately educating their patients. METHODS: Texts were extracted from commonly used craniofacial educational Web sites regarding reconstructive procedures. Three objective and accepted methods (SMOG, Flesch-Kincaid, and Dale-Chall) were used to assess readability of each condition and its corresponding procedure's text. RESULTS: The results from all 3 of the methods used were higher than the recommended seventh-grade reading level. The mean reading level for eMedicine was 13.8, 15.2, and 15 for the Flesch-Kincaid, SMOG, and Dale-Chall methods, respectively. Likewise, the mean reading levels for FACES were 7.5, 10.7, and 8.3; and for World Craniofacial Foundation, the levels were 11.9, 13.8, and 13. CONCLUSIONS: Patient education and understanding is a critical factor in planning for surgery; this is especially true of reconstructive craniofacial procedures. Craniofacial surgery is a diverse field, and its surgeons have correspondingly diverse practices. It is up to each individual surgeon to determine what is appropriate for his or her patients. Our results show that on-line educational material is at a level that is substantially higher than the national reading average. The ultimate impact of this fact will vary from practice to practice, but all surgeons should be aware of the possible conflicts between information distributed and the patient's ability to comprehend that information. This may assist surgeons in preoperative evaluations by discussing conditions with more level appropriate means.

Virginal mammary hypertrophy: a meta-analysis and treatment algorithm.

BACKGROUND: Virginal mammary hypertrophy, a rapid enlargement of one or both breasts that usually presents in the adolescent years, is a rare condition that has been reported sporadically in the medical literature. Currently, there are no patient- or disease-oriented evidence-based guidelines for the treatment of this condition. This meta-analysis examines the published case reports and presents a cumulative algorithm for the diagnosis and treatment of this uncommon condition. METHODS: A literature search was performed using PubMed, with multiple keywords. Information regarding patient age, menarchal state, mass of excision, surgical technique, number of operations, pharmacologic intervention, and recurrence was extracted from each case report and analyzed using SPSS 15.1 statistical software. RESULTS: A significant relationship was found (p < 0.01), as was an odds ratio of 7.0, for the likelihood of recurrence using a reduction mammaplasty as opposed to a mastectomy. CONCLUSIONS: Based on the evidence presented in this article, certain interventions are more effective for the treatment of virginal mammary hypertrophy. On diagnosis of virginal mammary hypertrophy, tamoxifen therapy may be considered based on previous literature, barring any medical contraindications. A subcutaneous mastectomy with complete removal of breast tissue is the procedure least likely to lead to recurrence but is more deforming. Reduction mammaplasty gives an improved aesthetic breast, but it is important to counsel the patient on the likelihood of increased recurrence. Tamoxifen therapy following surgery may decrease the recurrence rate.

Perils of diagnosis and detection of subungual squamous cell carcinoma.

Subungual squamous cell carcinoma often presents with atypical clinical manifestations, which can lead to delays in diagnosis. The presence of a tumor can be masked by the presence of infections or other misleading pathological conditions. The authors report on techniques for adequate biopsy and excision of such tumors. A case of subungual squamous cell carcinoma with invasion into the underlying bone is presented. Clinical histopathological evidence is reviewed along with human papillomavirus typing. Accurate diagnosis requires a high index of suspicion and appropriate tissue sampling.

Localization and quantification of intact, undamaged right-handed double-stranded B-DNA, and denatured single-stranded DNA in normal human epidermis and its effects on apoptosis and terminal differentiation (denucleation).

Quantification of two types of nucleic acids [double-stranded (ds-) and single-stranded (ss-) DNA] was performed to understand the distribution of DNA within the epidermal strata and to examine the effects of DNA structure on gene expression, viz., apoptosis and terminal differentiation. In addition, we examined the precise starting point of cell death within the epidermis (suprabasal layer); examined how DNA structure affects gene expression of melanocytes; and characterized the "transitional cells" located between the stratum granulosum and stratum corneum, viz., epidermal phase transition zone (EPTZ). Ultrasensitive anti-DNA antibody probes (ds-DNA, ss-DNA), the Feulgen reaction, histological stains (morphological characterization) and the terminal deoxyribonucleotidyl transferase (TUNEL) assay (apoptosis) were used to characterize cell death in normal human epidermis. This study characterized, for the first time, the deterioration of right-handed ds-B-DNA and the increase in denatured ss-DNA during epidermal maturation. For the first time, this approach also allowed for the quantitative and qualitative characterization of DNA content and structure in all epidermal strata, using anti-ds-B-DNA and anti-ss-DNA antibodies. In order to improve the retention and quality of DNA, a novel histotechnological processing procedure was used. The results indicate that the largest decline in DNA occurred within the stratum granulosum, followed by the EPTZ, and the stratum spinosum. Not all epidermal nuclei lost DNA, indicating two differentiating keratinocyte pathways, viz., apoptotic and non-apoptotic. Both pathways united in the stratum granulosum. These results suggest that keratinocyte terminal differentiation and apoptosis are distinct cellular events, cell death begins earlier than expected, and molecular epidermal events take place in a gradual and orderly manner within keratinocytes. During maturation, ds-B-DNA decreases as ss-DNA increases. Therefore, during differentiation of keratinocytes, both DNA content and DNA structure are altered.

Topical antimicrobials in pediatric burn wound management.

Burn trauma continues to injure an estimated 1 million children each year in the United States alone, with many more injuries suffered worldwide. Several decades ago, advances in acute burn wound management, including development of topical antimicrobials, dramatically improved outcomes in pediatric burn injuries. However, infection remains the leading cause of burn wound mortality. With increasing antibiotic resistance in many medical centers, precise selection of topical antimicrobial therapy has grown in importance for pediatric burn management. Effective choice and application of topical antimicrobials require correct classification of burn wounds, appropriate understanding of the process of burn wound sepsis, and accurate identification of pathogens for individual patients as well as for their surrounding environment. This article examines the current and evolving role of topical antimicrobials in pediatric burn wound management. Burn wound classification, the biologic process of burn wound sepsis, wound cultures with pathogen profiling, and evaluations of commonly used topical antimicrobials are reviewed. Newer biologically active occlusive (bio-occlusive) and hybrid products are examined in the context of topical antimicrobial therapy and their increasing role in pediatric burn wound management.