Postoperative Upper Extremity Function in Implant and Autologous Breast Reconstruction.

BACKGROUND: After mastectomy and breast reconstruction, many patients experience upper extremity complications, such as pain, restriction in motion, and lymphedema. Despite an aesthetically satisfactory outcome, these occurrences can diminish a patient's postoperative quality of life. Several studies have investigated the causes and incidence of these complications. However, there is currently a paucity of data comparing postoperative upper extremity function according to reconstruction technique. METHODS: A review was performed of patients enrolled in a physical therapy (PT) program after mastectomy and immediate breast reconstruction. PT initial encounter evaluations were used to gather data on patients' postoperative upper extremity function. Hospital records were used to gather surgical and demographic data. For each patient, data were collected for each upper extremity that was ipsilateral to a reconstructed breast. Data were then compared between patients who underwent implant-based versus autologous deep inferior epigastric perforator flap reconstruction. RESULTS: A total of 72 patients were identified, including 39 autologous and 33 implant-based reconstruction cases. Proportions of patients who underwent sentinel lymph node biopsies and axillary lymph node dissections were similar between the two groups. The autologous-based reconstruction patients had significantly higher arm pain at rest (p = 0.004) and with activity (p = 0.031) compared with implant patients. Shoulder range of motion and manual muscle test results were similar between groups, with the exception of elbow flexion, which was weaker in implant patients (p = 0.030). Implant patients were also more likely to report "severe difficulty" or "inability" to perform activities of daily living (p = 0.022). Edema/swelling, axillary cording, and lymphedema girth measurements were similar between the two groups. CONCLUSION: Different techniques of breast reconstruction can result in different postoperative upper extremity complications. These data show specific areas where postoperative care and PT can be customized according to reconstruction type. Investigation is currently underway to determine the effect of PT on upper extremity function in these patients.

Paramedian mandibular cleft: revisiting the Tessier classification.

Mandibular clefts are extremely rare, with less than 100 cases reported in the literature. Almost universally, these isolated cases of lower facial clefting have been noted to occur through the midline of the lip and/or mandible. The defect can vary, ranging from mild notching of the lower lip or mandibular alveolus to complete mandibular cleavage. The authors present a rare case of a paramedian mandibular cleft in a patient who also had Goldenhar syndrome and Tessier number 2/12 cleft. With its presentation, the authors revisit the Tessier classification of craniofacial clefts and the embryogenesis of lower facial clefts.

Not All Breast Explants Are Equal: Contemporary Strategies in Breast Explantation Surgery.

SUMMARY: Breast implant removal and replacement has been a common secondary breast procedure in the long-term maintenance of breast augmentation, but more recently growing concerns about silicone-related systemic illness, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), and changing perceptions of aesthetic beauty have seen breast implant removal without replacement become increasingly requested by patients. Explantation can be challenging, especially when performed with a total capsulectomy. Currently, there is no evidence regarding whether a partial or total capsulectomy has any effect on BIA-ALCL risk mitigation in patients that have textured implants without disease. Total capsulectomy with incomplete resection of a mass can contribute to hyperprogression of BIA-ALCL and death. There have also been cases of BIA-ALCL diagnosed years after removal of the textured device and "total capsulectomy." Therefore, the common practice of simple prophylactic capsulectomy in a textured implant to mitigate future disease has not been established and at the current time should be discouraged. In addition, aesthetic outcomes can be quite variable, and patients should have appropriate preoperative counseling regarding the indications and contraindications for explantation, associated risks, financial implications, and postoperative appearance. The authors review salient aspects related to the planning and management of breast implant removal.

The Public Face of Rhinoplasty: Impact on Perceived Attractiveness and Personality.

BACKGROUND: The authors assess the impact of rhinoplasty on public perception of a patient's appearance and personality. METHODS: A survey was created using standardized before-and-after photographs of 10 Caucasian women who had undergone primary rhinoplasty. Photographs of two additional women who had not undergone facial surgery were randomly included as controls, for a total of 12 survey items. Preoperative and postoperative photographs were placed side by side. The survey was administered by means of crowd-sourcing. Respondents were asked to evaluate which photograph better represented 11 traits of appearance or personality, according to a seven-point Likert scale. A score of 1 meant the preoperative photograph was much better, 7 meant the postoperative photograph was much better, and 4 meant no difference. T tests and analyses of variance were used to evaluate rating changes for each trait and differences between demographic groups. RESULTS: There were 264 responses received. Averaged scores across the 10 survey patients produced a value for each appearance or personality trait. In 10 of 11 categories (i.e., symmetry, youthfulness, facial harmony, likeability, trustworthiness, confidence, femininity, attractiveness, approachability, and intelligence), the postoperative photograph was significantly favorable compared with the preoperative photograph (p < 0.00001). The preoperative photograph was rated higher only in aggressiveness (p < 0.001). The same scores were calculated for the controls; no significant difference in any category was seen except confidence, where the right image was viewed as more confident (mean, 4.19; p < 0.005). CONCLUSION: Aesthetic rhinoplasty improves the public perception of a person's appearance and personality in multiple aspects.

The volume-outcome relationship for immediate breast reconstruction.

BACKGROUND: Efforts to improve the quality of surgical care in the United States have led many organizations to advocate the use of high-volume hospitals for complex surgical procedures and/or comprehensive multidisciplinary care. The benefits, if any, of selective referral to high-volume hospitals for immediate breast reconstruction are relatively unknown. It is this gap in knowledge that forms the basis for the current study. METHODS: Using California's Office of Statewide Health Planning and Development discharge database, all patients undergoing immediate breast reconstruction from January 1, 1998, to December 31, 1999, were identified. Information regarding demographic, comorbidity, complication, and hospital volume characteristics was obtained. Patient comorbidity was graded using a modified version of the Charlson score. Annual hospital volume was categorized into patient quartiles. Multivariate logistic regression was performed to identify predictors of surgical complications. RESULTS: A total of 2691 patients were included: 1271 had immediate autogenous tissue reconstruction and 1420 had immediate tissue expander placement. The complication rate was 11.6 percent among patients undergoing autogenous reconstruction and 2.4 percent among patients receiving tissue expanders. For autogenous reconstruction, complications were more likely in patients with comorbidities (odds ratio, 2.24) and in patients receiving care at very-low-volume (less than eight) and medium-volume (20 to 41) hospitals (odds ratio,1.81 and 1.90, respectively). For tissue expander reconstruction, patient comorbidity (odds ratio, 2.42) was the only significant predictor of complications. CONCLUSIONS: Hospital volume appears to be an important predictor of patient outcome with regard to autogenous reconstruction but not tissue expander reconstruction. Patient comorbidity predicts complications for both autogenous and tissue expander reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Hand dermatitis: review of etiology, diagnosis, and treatment.

Hand dermatitis is a common condition seen in the primary care setting. Occupational exposures and frequent hand washing often lead to symptoms that are irritating and may cause discomfort. Irritant dermatitis, atopic hand dermatitis and contact hand dermatitis account for at least 70% of all diagnoses. A unifying feature in most cases is an underlying disruption in the stratum corneum, altering its barrier function. Transepidermal water loss increases with barrier disruption and is exacerbated by additional exposure to water. Precise diagnosis and subsequent treatment present a considerable challenge, and hand dermatitis often becomes chronic. Initial treatment should be aimed at controlling inflammation and restoring the skin's natural barrier. Common management recommendations include the avoidance of irritants and potential allergens along with the use of emollients and topical corticosteroids to decrease inflammation. Simple petroleum-based emollients are very effective at restoring hydration and repairing the stratum corneum. Referral to a Dermatologist or an Allergist may be necessary for patients who require patch testing or those with refractory symptoms.

High septal osteotomy in rhinoplasty for the deviated nose.

When attempting to straighten a patient's healed, deviated bony nasal dorsum, deviation of the central structure (high dorsal septum and medial nasal bones) must be addressed following the completion of medial and lateral osteotomies. When hump resection is not performed, blunt fracture (digitally or with forceps) of the deviated central structure is not a reliable method of mobilization, often leading to postoperative nasal drift. An intranasal osteotomy technique to mobilize the central structure of the nose is described, called "high septal osteotomy." Review of 25 cases suggests high septal osteotomy, supplemented as needed by resection of overlapping septal elements, can be performed safely and efficaciously, permitting stable midline reduction of the nasal pyramid. The technique is not advocated when hump resection is performed, as it is unnecessary and could destabilize the dorsum. Even aggressive maneuvers to mobilize the bony dorsum may fail if not performed properly with meticulous attention to completion of all osteotomies.