Image analysis comparison of nerve staining with food dye, methylene blue or tissue marker.

OBJECTIVE: Novel locoregional techniques use dye studies to confirm successful nerve targeting. The goal was to objectively quantify and compare nerve staining characteristics of dye mixtures commonly reported in the literature using image analysis software. STUDY DESIGN: Prospective, randomized cadaveric study. METHODS: Thirty-six brachial plexus nerves from unpreserved pig cadavers were randomized into three groups of 12: FD (1:10 mixture of blue food dye and bupivacaine 0.5%), MB (methylene blue 1%) and TM (0.1:10 mixture of blue tissue marker and lidocaine 2%). Nerves were immersed in dye for 1, 15, 30 or 60 minutes (n = 3 each). Images of nerves before immersion (baseline) and at each time point with epineurium intact (superficial staining) and after longitudinal bisection (deep staining) were processed using image analysis software. Color saturation values were divided into quartiles (dark, medium-dark, medium-light or light). Percentage of stained nerve area in each quartile was calculated and compared using two-way anova. RESULTS: Superficially, at minute 1, dark saturation covered 40% of nerve area in FD versus 19% in MB (p = 0.04) and 0% in TM (p < 0.0001). In bisected nerves, dark and medium-dark saturations occurred only in FD; medium-light saturation comprised anywhere from 4% to 22.5% over time in FD versus <1% at any time in MB (p = 1.000; p = 0.343; p = 0.383; p = 0.262). Deep staining was not found in TM at any point. CONCLUSION AND CLINICAL RELEVANCE: Food dye rapidly stains superficial and deep nerve layers. Based on these characteristics, investigators can choose the appropriate dye for their study.

Differences in autobiographical memories reported using text and voice during everyday life.

Autobiographical memories frequently occur during everyday life. One of the most common approaches to measuring memories in everyday life is a diary method: Participants record memories as they occur by writing down these memories in a paper diary or typing them on a smartphone. Conversely, many laboratory-based studies of autobiographical memory require participants to describe their memories out loud in a spoken manner. Here, we sought to directly compare memories recorded via typing to those spoken out loud in a smartphone diary study. Participants reported or, autobiographical memories that occurred over a period of four days either by typing (n = 43) or recording themselves orally describing memories (n = 39) using a smartphone app. Results indicated that the audio recording group reported memories more frequently and these memories contained a greater number of words, while the text group reported memories more promptly after they occurred. Additionally, the typing group reported memories that were episodically richer and contained a greater proportion of perceptual details. This work has important implications for future autobiographical memory studies in the lab, online, and using diary methods, and suggests that certain reporting modalities may be advantageous depending on the specific research focus.

A validation study of the International Trauma Questionnaire to assess post-traumatic stress disorder in treatment-seeking veterans.

BACKGROUND: Veterans with post-traumatic stress disorder (PTSD) typically report a poorer treatment response than those who have not served in the Armed Forces. A possible explanation is that veterans often present with complex symptoms of PTSD. ICD-11 PTSD and complex PTSD (CPTSD) have not previously been explored in a military sample. AIMS: This study aimed to validate the only measure of ICD-11 PTSD and CPTSD, the International Trauma Questionnaire, and assess the rates of the disorder in a sample of treatment-seeking UK veterans. METHOD: A sample of help-seeking veterans (N = 177) was recruited from a national charity in the UK that provides clinical services to veterans. Participants completed measures of ICD-11 PTSD and CPTSD as well as childhood and adult traumatic life events. Confirmatory factor analysis was used to assess the latent structure of PTSD and CPTSD symptoms, and rates of the disorders were estimated. RESULTS: The majority of the participants (70.7%) reported symptoms consistent with a diagnosis of either PTSD or CPTSD. Results indicated the presence of two separate disorders, with CPTSD being more frequently endorsed (56.7%) than PTSD (14.0%). CPTSD was more strongly associated with childhood trauma than PTSD. CONCLUSIONS: The International Trauma Questionnaire can adequately distinguish between PTSD and CPTSD within clinical samples of veterans. There is a need to explore the effectiveness of existing and new treatments for CPTSD in military personnel.

Nipple-Sparing Mastectomy Improves Long-Term Nipple But Not Skin Sensation After Breast Reconstruction: Quantification of Long-Term Sensation in Nipple Sparing Versus Non-nipple Sparing Mastectomy.

BACKGROUND: Changes in breast sensation after reconstruction are expected. Return of breast sensation after reconstruction and whether nipple-sparing mastectomy offers a substantial benefit in terms of sensation has been inconsistently documented in the literature. We conducted the current study using the pressure-specified sensory device to quantify postoperative breast sensation in patients undergoing nipple-sparing versus non-nipple-sparing mastectomy. METHODS: Consecutive adult women who underwent nipple-sparing (NSM) and non-NSM (NNSM) and were at least 18 months postreconstruction were included. Breast measurements were taken in 4 quadrants (upper/lower lateral, upper/lower medial) and nipple. Averaged skin cutaneous thresholds [(UL+LL+UM+LM)/4] and nipple sensation between NSM and NNSM were compared as the primary outcome measure. A generalized estimating equations model was used; univariate and multivariate variable analyses were done when appropriate. RESULTS: Forty-four patients (74 breasts) were examined (53 NNSM vs 21 NSM). The groups were further subdivided into autologous versus implant-based reconstruction. Averaged cutaneous skin thresholds for quadrants were better for the NSM, 51.8(±24.5) g/mm versus NNSM, 56.5(±25.7) g/mm, although this difference was not statistically significant. However, NSM breasts measured higher nipple or nipple area sensitivity, 44.5(±30.8) g/mm versus NNSM, 83.8(±27.4) g/mm (P < 0.001). In a multivariate regression analysis, a predictor of decreased sensation was the number of revision surgeries, especially after third revision. CONCLUSIONS: Breast sensation is decreased after reconstruction in both NSM and NNSM, but nipple sensation or nipple area is better preserved in NSM breasts. Number of revision surgeries (>3) was a predictor of decreased sensation.

Systematic Review of the Surgical Treatment of Extremity Lymphedema.

Background Although conservative management of lymphedema remains the first-line approach, surgery is effective in select patients. The purpose of this study was to review the literature and develop a treatment algorithm based on the highest quality lymphedema research. Methods A systematic literature review was performed to examine the surgical treatments for lymphedema. Studies were categorized into five groups describing excision, liposuction, lymphovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and combined/multiple approaches. Studies were scored for methodological quality using the methodological index for nonrandomized studies (MINORS) scoring system. Results A total of 69 articles met inclusion criteria and were assigned MINORS scores with a maximum score of 16 or 24 for noncomparative or comparative studies, respectively. The average MINORS scores using noncomparative criteria were 12.1 for excision, 13.2 for liposuction, 12.6 for LVA, 13.1 for VLNT, and 13.5 for combined/multiple approaches. Loss to follow-up was the most common cause of low scores. Thirty-nine studies scoring > 12/16 or > 19/24 were considered high quality. In studies measuring excess volume reduction, the mean reduction was 96.6% (95% confidence interval [CI]: 86.2-107%) for liposuction, 33.1% (95% CI: 14.4-51.9%) for LVA, and 26.4% (95% CI: - 7.98 to 60.8%) for VLNT. Included excision articles did not report excess volume reduction. Conclusion Although the overall quality of lymphedema literature is fair, the MINORS scoring system is an effective method to isolate high-quality studies. These studies were used to develop an evidence-based algorithm to guide clinical practice. Further studies with a particular focus on patient follow-up will improve the validity of lymphedema surgery research.

Effectiveness of Interventions for Children With Autism Spectrum Disorder and Their Parents: A Systematic Review of Family Outcomes.

This systematic review examined the literature published from January 2006 to April 2013 related to the effectiveness of occupational therapy interventions for children with autism spectrum disorder (ASD) and their parents to improve parental stress and self-efficacy, coping, and resilience and family participation in daily life and routines. From the 4,457 abstracts, 34 articles were selected that matched the inclusion criteria. The results were mixed and somewhat inconclusive because this body of literature is in its infancy. Studies of children with ASD do not routinely measure parental and family outcomes. Recommendations include an emphasis on family measures other than parental stress and a greater focus on measures of parental and family functioning in all future studies of pediatric interventions to more fully understand the impact of interventions in a wider context.

An effective method to access recipient vessels outside the zone of injury in free flap reconstruction of the lower extremity.

INTRODUCTION: A principle of microvascular surgery in lower extremity reconstruction is to identify recipient vessels and perform the anastomosis outside the zone of injury. Microsurgeons will often create an incision that extends from the wound several centimeters proximally to access the recipient vessels through healthy tissue. This iatrogenic wound, however, traverses the zone of injury and is susceptible to delayed healing and wound breakdown. These complications can be avoided by creating a unique incision proximal to the zone of injury through which the recipient vessels are dissected and the anastomosis performed. METHODS: In 13 consecutive patients with lower extremity wounds requiring free flap reconstruction, a remote incision was made in healthy tissue proximal to the defect to access the recipient vessels outside the zone of injury. The pedicle was tunneled in the subcutaneous plane from the wound to this site, and the anastomosis was performed. The flap was inset in the standard fashion, and the remote incision was closed in layers. RESULTS: There were 3 female and 10 male patients, and the median age was 65 years (18-85 years). Etiology of the wounds was traumatic (3 acute, 7 chronic), oncologic (2), and ischemic (1). Defects varied in size and were primarily located on the distal third of the extremity. Free flaps included radial forearm (4), anterolateral thigh (4), gracilis (2), vastus (1), latissimus dorsi (1), and parascapular (1). Postoperatively, there were no major complications related to the flap or any flap losses. There was 1 donor site hematoma requiring operative evacuation. There were no complications associated with the anastomotic incision. CONCLUSIONS: Accessing the recipient vessels via a separate proximal incision in lower extremity free flap reconstruction allows excellent exposure outside the zone of injury, avoids wound healing problems, and protects the pedicle from injury in the setting of multiple-staged procedures.

Comparison of irradiated versus nonirradiated DIEP flaps in patients undergoing immediate bilateral DIEP reconstruction with unilateral postmastectomy radiation therapy (PMRT).

INTRODUCTION: Patients with node positive or locally advanced breast cancer desiring deep inferior epigastric perforator (DIEP) flap reconstruction frequently require postmastectomy radiation therapy (PMRT). To avoid the deleterious effects of PMRT, surgeons will often delay reconstruction until after PMRT is complete. Drawbacks to this approach include additional surgery, recuperation, cost, and an extended reconstructive process. Even if a tissue expander is used to preserve the skin envelope during irradiation, the post-PMRT breast pocket is often distorted or constricted necessitating some skin replacement, resulting in a compromised aesthetic outcome. Therefore, a systematic approach to mitigate the deleterious effects of PMRT was developed, and primary DIEP flap reconstruction was offered to patients requiring PMRT. This study evaluates the outcome of this approach in a cohort of patients undergoing immediate bilateral DIEP flap reconstruction with unilateral PMRT, allowing comparison between irradiated and nonirradiated flaps. METHODS: One hundred twenty-five patients who underwent immediate DIEP reconstruction between 2009 and 2011 were identified. Eleven consecutive patients had bilateral DIEP reconstructions by a single surgeon and received unilateral PMRT. Preoperative, intraoperative, and postoperative steps were taken in all patients to ensure flap vascularity, prevent uncontrolled contracture, and limit radiation damage to the breast mound. Results were documented photographically and the irradiated and nonirradiated breasts were compared. The complication rates, incidence of clinically significant fat necrosis, and need for reoperation were examined. RESULTS: Median follow-up was 18 months (range, 8-21 months). Complications were minor and did not require readmission to the hospital or reoperation. There was no incidence of clinically significant fat necrosis in either the irradiated or nonirradiated DIEP flaps. Four operative revisions for breast symmetry were required in 3 of 11 patients. Aesthetic outcomes were deemed satisfactory in all patients. CONCLUSIONS: Primary reconstruction with DIEP flaps can be performed successfully in patients who require PMRT if steps are taken to ensure flap vascularity, minimize fibrosis, optimize contour, and modulate radiation dosing.

Identification and evaluation of medication-related issues relating to patient's own drugs by pharmacy students while on placement in a tertiary hospital.

Background Pharmacy students require knowledge of prescribing and supply of medicines; this is achievable through work-based learning. In UK hospitals, pharmacy technicians assess patient's own drugs (PODs) so medicines can be used as they would be at home. Student-led POD checks have not yet been considered as an opportunity for legitimate peripheral participation (LPP). Aim To evaluate an undergraduate pharmacy placement model using POD checking as a way of gaining LPP within a UK tertiary hospital. Method Students (n = 100) attended nine placements over academic year 2020-2021; they were supervised by a pharmacy technician to complete POD checks. Data were collected concerning student activities and resulting medication-related issues (MRIs); data were descriptively analysed. Results 1094 patients were seen by pharmacy students and 296 MRIs identified. Omitted (non-prescribed) medicines were the most common MRI (32.1%), followed by incorrect stock items (16.2%). Most MRIs were medium risk (65.5%). The most common actions/outcomes were handover to another ward member (41.6%) or medication removal (25.3%). Conclusion Clinically relevant MRIs relating to PODs can be identified by pharmacy students while experiencing LPP. These activities illustrate scalable work-based learning where pharmacy students can contribute to patient care in relation to the use and supply of medicines.

A Clinical Scoring Systems for the Evaluation of Corynebacterium bovis -associated Disease in NSG Mice.

Clinical signs of Corynebacterium bovis infections are well-known in athymic nude mice. However, C. bovis can also infect and cause clinical signs in many hirsute, immunocompromised mouse strains such as NSG (NOD. Cg-Prkdcscid Il2rgtm1Wgl/SzJ). Typically, the clinical assessment of C. bovis-infected mice begins when overt clinical signs are initially observed and thus the early course of infection has not been thoroughly described. The goal of this study was to characterize the clinical progression of C. bovis infection in NSG mice under experimental conditions and develop a quantifiable clinical scoring system. For the development and application of this clinical scoring system, 54 naïve NSG mice were exposed to soiled bedding from clinically ill C. bovis-infected NSG mice and the emergence of clinical signs was monitored and scored weekly for 8 wk. Overall, we identified 6 benchmark changes associated with C. bovis clinical infection. Four changes were the appearance of the eyes, ears, hair coat, and posture. Two behavioral changes were increased grooming activity and rapid head shaking. All clinical signs appeared consistently and progressed temporally with increasing clinical severity. Characterization of clinical signs and scoring of clinical disease will aid veterinarians in the assessment of C. bovis-infected NSG mice and may help in the evaluation of current and future clinical interventions used to prevent or treat C. bovis-infected immunodeficient mice.

Metaphylactic Antibiotic Treatment to Prevent the Transmission of Corynebacterium bovis to Immunocompromised Mouse Offspring.

Current methods for eradicating Corynebacterium bovis, such as depopulation, embryo transfer, and cesarean rederivation followed by cross fostering, are expensive, complex, and time-consuming. We investigated a novel method to produce immunocompromised offspring free of C. bovis from infected NOD. Cg-PrkdcscidIl2rgtm1Wgl/SzJ (NSG) breeding pairs. Adult NSG mice were infected with C. bovis, paired, and randomly assigned to either a no-antibiotic control group (NAB, n = 8) or a group that received amoxicillin-clavulanic acid (0.375 mg/mL) in their drinking water for a mean duration of 7 wk (AB group, n = 7), spanning the time from pairing of breeders to weaning of litters. The AB group also underwent weekly cage changes for 3 wk after pairing to decrease intracage C. bovis contamination, whereas the NAB mice received bi-weekly cage changes. Antibiotics were withdrawn at the time of weaning. All litters (n = 7) in the AB group were culture- and qPCR-negative for C. bovis and remained negative for the duration of the study, whereas all litters in the NAB group (n = 6) remained C. bovis positive. A single adult from each breeding pair was sampled at weaning and at 5 and 10 wk after weaning to confirm the maintenance of (NAB) or to diagnose the reemergence (AB) of C. bovis infection. By the end of the study, C. bovis infection had returned in 3 of the 7 (43%) tested AB adults. Our data suggest that metaphylactic antibiotic use can decrease viable C. bovis organisms from adult breeder mice and protect offspring from infection. However, using antibiotics with frequent cage changing negatively affected breeding performance. Nevertheless, this technique can be used to produce C. bovis-free NSG offspring from infected adults and may be an option for salvaging infected immunocompromised strains of mice that are not easily replaced.

Crystal structure of a ligand-free stable TSH receptor leucine-rich repeat domain.

The crystal structures of the thyroid-stimulating hormone receptor (TSHR) leucine-rich repeat domain (amino acids 22-260; TSHR260) in complex with a stimulating human monoclonal autoantibody (M22TM) and in complex with a blocking human autoantibody (K1-70™) have been solved. However, attempts to purify and crystallise free TSHR260, that is not bound to an autoantibody, have been unsuccessful due to the poor stability of free TSHR260. We now describe a TSHR260 mutant that has been stabilised by the introduction of six mutations (H63C, R112P, D143P, D151E, V169R and I253R) to form TSHR260-JMG55TM, which is approximately 900 times more thermostable than wild-type TSHR260. These six mutations did not affect the binding of human TSHR monoclonal autoantibodies or patient serum TSHR autoantibodies to the TSHR260. Furthermore, the response of full-length TSHR to stimulation by TSH or human TSHR monoclonal autoantibodies was not affected by the six mutations. Thermostable TSHR260-JMG55TM has been purified and crystallised without ligand and the structure solved at 2.83 Å resolution. This is the first reported structure of a glycoprotein hormone receptor crystallised without ligand. The unbound TSHR260-JMG55TM structure and the M22 and K1-70 bound TSHR260 structures are remarkably similar except for small changes in side chain conformations. This suggests that neither the mutations nor the binding of M22TM or K1-70TM change the rigid leucine-rich repeat domain structure of TSHR260. The solved TSHR260-JMG55TM structure provides a rationale as to why the six mutations have a thermostabilising effect and provides helpful guidelines for thermostabilisation strategies of other soluble protein domains.

A novel approach to T classification in tumor-node-metastasis staging of breast cancer.

BACKGROUND: The aim of this study was to examine the effect of measurement bias in breast cancer and to create a more rational T-size categorization in tumor-node-metastasis staging in response to smaller, screen-detected cancers and measurement bias. METHODS: From 1987 to 2003, 10,853 invasive nonmetastatic breast cancers enlisted in the Rhode Island Cancer Registry with a known dimension were reviewed. Data analyzed by proposed classifications included the rate of lymph node metastases and the mortality rate from breast cancer. RESULTS: The median diameter was 16 mm. Cancer measurements reflected the bias in pathologists' dimension recording, which is centered strongly about whole- and half-centimeter sizes. A new T classification is proposed with the following sizes and frequencies in the Rhode Island Cancer Registry: 1 to 2 mm = T1 mic (3% of registered cases); 3 to 7 mm = T1a (11%); 8 to 12 mm = T1b (23%); 13 to 17 mm = T1c (18%); 18 to 22 mm = T2a (17%); 23 to 27 mm = T2b (8%); 28 to 32 mm = T2c (8%); 33 to 42 mm = T3a (6%); 43 to 52 mm = T3b (3%), and greater than 52 mm = T3c (4%). The unadjusted odds ratio for the probability of node metastases was 1.43 (confidence interval, 1.40-1.46; P < .001) with each increase in proposed grouping. The range in the lymph node metastatic rate was 5.5% for tumors 1 to 2 mm to 64% for cancers greater than 52 mm. By Cox proportional hazard, the unadjusted hazard ratio for death from breast cancer for each increase in proposed grouping was 1.33 (confidence interval, 1.29-1.37; P < .001). The 10-year survival rate ranged from 98.3% for tumors 1 to 2 mm to 70.3% for cancers greater than 52 mm. CONCLUSIONS: A more rational T category for use in tumor-node-metastasis staging is presented to reflect the much smaller invasive breast cancers encountered by screening and to account for the dimension recording bias of pathologists. This new T category shows a clinically and statistically significant linear relationship for both incidence of lymph node metastases and hazard ratio of death.

Revisions in Implant-Based Breast Reconstruction: How Does Direct-to-Implant Measure Up?

BACKGROUND: Immediate direct-to-implant breast reconstruction is increasingly performed for breast cancer treatment or prevention. The advantage over traditional tissue expander/implant reconstruction includes the potential for fewer surgical procedures. METHODS: Retrospective, single-institution, three-surgeon review identified patients undergoing implant-based reconstruction from 2006 to 2011. RESULTS: Six hundred eighty-two reconstructions were performed in 432 women with an average follow-up of 5 years. Four hundred sixty-five were direct-to-implant reconstructions with acellular dermal matrix while 217 were tissue expander/implant reconstructions without acellular dermal matrix. The overall revision rate in direct-to-implant reconstruction was 20.9 percent. There was no difference in total revision rates between direct-to-implant and tissue expander reconstruction (20.9 percent versus 20.3 percent; p = 0.861). Subgroup analysis showed no difference in revision for malposition (3.4 percent versus 5.5 percent; p = 0.200), size change (6.7 percent versus 5.5 percent; p = 0.569), fat grafting (8.6 percent versus 9.7 percent; p = 0.647), or capsular contracture (4.5 percent versus 3.2 percent; p = 0.429). Multivariable logistic regression analysis showed complications were associated with higher rates of revision for malposition or size in both groups (OR, 2.8; 95 percent CI, 1.56 to 5.13; p = 0.001). Smoking, preoperative irradiation, skin necrosis, and one surgeon were associated with higher rates of fat grafting, whereas increasing body mass index was associated with lower rates. Postoperative radiotherapy and hematoma were predictive of revision for capsular contracture. CONCLUSIONS: The 5-year revision rate in this series of direct-to-implant reconstruction was approximately 21 percent and similar to the revision rate in tissue expander/implant reconstruction. Surgical complications, radiotherapy, and the surgeon influenced the rate of revision similarly in both groups. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Endovascular stent graft repair of thoracic aortic mural thrombus in a patient with polycythemia vera: a word of caution.

Thoracic aortic mural thrombus (TAMT) is a rare pathology and potential source of cerebral, visceral, and peripheral emboli. We present a 62-year-old male in a hypercoagulable state due to primary polycythemia vera (PV) developed TAMT and catastrophic thromboembolisms despite aggressive medical and surgical management. The outcomes and adverse events of endovascular exclusion of TAMT in the presence of PV are unknown. We would recommend proceeding with extreme caution when performing endovascular exclusion of TAMT, as PV may be a prohibitive risk.

Differences in Presentation and Management of Pediatric Facial Lacerations by Type of Health Insurance.

INTRODUCTION: Limited data are available regarding differences in presentation and management of pediatric emergency department (PED) patients based on insurance status. The objective of the study was to assess the difference in management of pediatric facial lacerations based on medical insurance status. METHODS: We conducted a retrospective cohort study with universal sampling of patients with facial lacerations who were treated in an urban PED (45K visits/year) over a one-year period. Demographic features and injury characteristics for patients with commercial (private) insurance and those with Medicaid or Medicare (public) insurance were compared. RESULTS: Of 1235 children included in the study, 667 (54%) had private insurance and 485 (39%) had public insurance. The two groups did not differ in age or gender, arrival by ambulance, location of injury occurrence, mechanism of injury, part of face involved, length or depth of laceration, use of local anesthetic, or method of repair but differed in acuity assigned at triage. Patients with public insurance were found less likely to have subspecialty consultation in bivariable (OR=0.41, 95% CI [0.24-0.68]) and multivariable logistic regression analyses (OR=0.45, 95% CI [0.25-0.78]). Patients with public insurance received procedural sedation significantly less often than those with private insurance (OR=0.48, 95% CI [0.29-0.76]). This difference was not substantiated in multivariable models (OR=0.74, 95% CI [0.40-1.31]). CONCLUSION: Patients with public insurance received less subspecialty consultation compared to privately insured patients despite a similarity in the presentation and characteristics of their facial lacerations. The reasons for these disparities require further investigation.

Aesthetic scrotal reconstruction following extensive Fournier's gangrene using bilateral island pedicled sensate anterolateral thigh flaps: A case report.

Achieving an aesthetic appearance of the scrotum after extensive Fournier's gangrene is a reconstructive challenge. Testicular coverage is often prioritized over scrotal cosmesis due to the comorbidities typically seen in this patient population. We describe our treatment of a young, healthy male with extensive Fournier's gangrene, with loss of the scrotum. Bilateral neurotized anterolateral thigh flaps were used to achieve a sensate and aesthetically acceptable result.

The efficacy of simultaneous breast reconstruction and contralateral balancing procedures in reducing the need for second stage operations.

BACKGROUND: Patients having unilateral breast reconstruction often require a second stage procedure on the contralateral breast to improve symmetry. In order to provide immediate symmetry and minimize the frequency and extent of secondary procedures, we began performing simultaneous contralateral balancing operations at the time of initial reconstruction. This study examines the indications, safety, and efficacy of this approach. METHODS: One-hundred and two consecutive breast reconstructions with simultaneous contralateral balancing procedures were identified. Data included patient age, body mass index (BMI), type of reconstruction and balancing procedure, specimen weight, transfusion requirement, complications and additional surgery under anesthesia. Unpaired t-tests were used to compare BMI, specimen weight and need for non-autologous transfusion. RESULTS: Average patient age was 48 years. The majority had autologous tissue-only reconstructions (94%) and the rest prosthesis-based reconstructions (6%). Balancing procedures included reduction mammoplasty (50%), mastopexy (49%), and augmentation mammoplasty (1%). Average BMI was 27 and average reduction specimen was 340 grams. Non-autologous blood transfusion rate was 9%. There was no relationship between BMI or reduction specimen weight and need for transfusion. We performed secondary surgery in 24% of the autologous group and 100% of the prosthesis group. Revision rate for symmetry was 13% in the autologous group and 17% in the prosthesis group. CONCLUSIONS: Performing balancing at the time of breast reconstruction is safe and most effective in autologous reconstructions, where 87% did not require a second operation for symmetry.

Bilateral breast reconstruction from a single hemiabdomen using angiosome-based flap design.

UNLABELLED: Performing bilateral autologous breast reconstruction using the abdominal donor site usually entails harvesting one flap from each hemiabdomen. However, the overlapping vascular territories of the superior epigastric, deep inferior epigastric, superficial inferior epigastric, and superficial circumflex iliac vessels make it theoretically possible to harvest two flaps based on vessels from one hemiabdomen. This may be useful in the obese patient, where one hemiabdomen may provide adequate tissue to reconstruct two breasts. The authors describe three clinical scenarios where they have used this principle, including the first reports in the literature of metachronous and synchronous bilateral breast reconstructions using two flaps based on pedicles from a single hemiabdomen. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Fibula osteo-adipofascial flap for mandibular and maxillary reconstruction.

BACKGROUND: The fibula free flap is a reliable method for reconstructing composite head and neck defects. However, its skin paddle has drawbacks, including its thickness, hair-bearing surface, desquamation, difficulty insetting it into maxillary defects, and the potential need for skin-grafting the donor site. The fibula osteo-adipofascial flap (FOAFF) is a modification of the fibula flap that overcomes these problems. METHODS: A retrospective study of 6 consecutive patients who underwent FOAFF reconstruction was evaluated for outcomes and complications. RESULTS: The mean follow-up was 22.6 months. All flaps survived, with complete oral mucosalization by 7 weeks. Four patients had dental implants placed at the time of reconstruction. Two patients received radiation therapy. Aside from loss of the labial sulcus in anterior maxillary reconstructions, complications were negligible. CONCLUSION: The FOAFF is useful for reconstructing defects requiring bone, soft tissue, and mucosal replacement without the disadvantages of the traditional fibula skin paddle.