Comparing patient satisfaction in bilateral and unilateral breast reconstruction.

BACKGROUND: Current literature in breast reconstruction continues to provide answers to questions regarding patient satisfaction in the areas of autologous vs alloplastic reconstruction and silicone vs saline implants. There are no studies, however, that specifi cally address patient satisfaction with bilateral vs unilateral breast reconstruction. Our goal was to assess patient satisfaction with bilateral compared with unilateral breast reconstruction. METHODS: Over a 4-year period, 108 patients completed either unilateral or bilateral breast reconstruction from a single surgeon. Patient satisfaction in these patients was assessed using a questionnaire developed focusing on clinical outcome measures of aesthetic and functional satisfaction. RESULTS: A total of 72 anonymous surveys were returned. Statistically significant differences were seen with respect to overall symmetry, aesthetics without clothing, and overall satisfaction between unilateral and bilateral reconstructions. In each of these categories, the average patient satisfaction score was higher for bilateral reconstructions. Furthermore, when comparing unilateral vs bilateral reconstruction in the different reconstruction types, parallel differences in patient satisfaction were noted. CONCLUSION: The results of this study suggest that patients were more satisfied with bilateral reconstruction because of improved symmetry, superior aesthetic appearance without clothing, and overall satisfaction with the reconstructive process. Future studies with larger subsets of patients are needed.

Targeted Muscle Reinnervation for a Symptomatic Neuroma in a Traumatic Transmetatarsal Amputee: A Case Report.

CASE: An overall healthy 48-year-old man suffered a left foot mangled crush injury resulting in a post-transmetatarsal amputation and subsequently developing a painful neuroma on the plantar surface of the foot. To avoid the zone of injury, targeted muscle reinnervation was used to treat the neuroma by coapting the tibial nerve to the motor point of the flexor hallucis longus (FHL) muscle. At 1-year follow-up, the patient reported no pain at rest, returned to work, and could ambulate with an orthosis for 30 minutes. CONCLUSION: Rare tibial nerve coaptations to the FHL could serve as a treatment option for patients with neuromas in traumatic postmetatarsal amputation.

Management of thoracic aortic graft infections with the omental flap.

BACKGROUND: Infection of thoracic aortic grafts occurs infrequently; however, once present, it is associated with high patient morbidity and mortality. We report our successful experience in the treatment of 11 patients who developed infection of their thoracic aortic graft. METHODS: This is an institutional review board-approved retrospective review of 11 patients who had documented thoracic aortic graft infections with associated mediastinitis or empyema. After diagnosis, plastic surgery consultation was obtained, and the patients underwent formal operative debridement with cardiovascular service. Intraoperative cultures were obtained, and the patients were placed on specific antibiotic regimens. After the wound bed was adequately prepared, the omentum was harvested and was based on the right gastroepiploic vessels. The flap was circumferentially wrapped around the aortic graft and simultaneously used to fill the mediastinal dead space. In a certain subset of patients, a cryopreserved homograft replaced the synthetic graft before omental flap reconstruction. RESULTS: The infections were eventually controlled in all surviving patients. Ten of 11 patients were discharged either to a rehab or to a nursing facility. There was 1 perioperative death secondary to multisystem organ failure. Mean follow-up period was 36 months and revealed a greater than 90% survival rate. Serial imaging reported no suture-line complications. CONCLUSIONS: We report our series on the treatment of patients with infection of thoracic aortic grafts. Debridement and tissue coverage with an omental flap provided these patients with successful recovery and survival.

Intramedullary Free Gracilis for Dead-Space Obliteration and Stump Resurfacing in a Transfemoral Amputee With Recurrent Osteomyelitis.

Background: A 72-year-old man with a history of delayed presentation for severe right lower extremity burns underwent through-knee amputation complicated by periprosthetic distal femur osteomyelitis. Subsequent transfemoral amputation was complicated by Stage IVB Cierny-Mader osteomyelitis despite appropriate medical and surgical treatment. Methods: Due to the presence of threatened proximal femur intramedullary nail from prior intertrochanteric femur fracture, inability to further shorten femur, and lack of local soft-tissue options, we performed soft tissue reconstruction with free gracilis flap. The free gracilis flap was pulled proximally through the femoral canal to obliterate intramedullary dead space and provide distal femoral stump coverage. Results: The stump was fully healed upon 6-month follow-up with computerized tomography demonstrating continued presence of gracilis flap within the femoral canal and no evidence of osteomyelitis. At 1-year follow-up, the patient was ambulatory using a prosthetic without recurrence of osteomyelitis. Conclusions: Previous descriptions of intramedullary free muscle flaps for the treatment of osteomyelitis are limited in number, with its function being limited to dead-space obliteration. This report presents intramedullary free gracilis flap to be a viable option in above-knee amputees for combined dead space obliteration and stump resurfacing in the context of recurrent osteomyelitis.

Single Center Oncoplastic Experience and Patient Satisfaction Reported via Patient Reported Outcomes.

Oncoplastic breast surgery (OPS) is gaining in popularity compared with traditional breast conserving surgery due to wider resections and better satisfaction with cosmetic outcomes. This study analyzed OPS versus traditional breast conserving surgery outcomes: wound complications, reoperations for margins or fat necrosis, and ipsilateral recurrence. Methods: This retrospective review compared 191 OPS and traditional breast conserving surgery patients on patient-related factors, primary outcomes, and patient reported outcome measures results. A propensity score method analysis using 1:1 to nearest neighbor was also performed. Results: OPS patients were younger, less likely to be smokers, more likely to be ER+ and PR+, and had larger specimen volumes than did traditional breast conserving surgery patients (P < 0.05). There were also differences in distribution of invasive ductal carcinoma and noninvasive disease (P < 0.05). After the propensity score method, the differences observed between the cohorts disappeared. No differences were observed between groups for wound complication, reoperation for positive margins or fat necrosis, or ipsilateral recurrence. Results of patient reported outcome measures showed greater satisfaction with breast surgery in OPS patients (P < 0.01). Conclusions: We showed that OPS is a noninferior technique that should be discussed with appropriate patients. Operative planning should involve patient preferences in optimizing long-term cosmetic outcomes.

Assessing the safety and efficacy of combined abdominoplasty and gynecologic surgery.

BACKGROUND: Combined surgery is an attractive option for both patients and surgeons. Unfortunately, it remains unclear to patients whether plastic surgery can be combined safely and efficaciously with other surgeries, particularly gynecologic surgery. The goal of this study was to determine the safety and efficacy of combined abdominoplasty and gynecologic surgery. METHODS: A case-control study of 25 patients undergoing combined abdominoplasty and intra-abdominal gynecologic surgery was performed. These combined patients were compared with control group patients undergoing abdominoplasty alone and gynecologic surgery alone. Demographic data, operative time, estimated blood loss, pre- and postoperative hemoglobin, length of hospitalization, and complications were compared between combined and control groups. RESULTS: Statistically significant reductions were seen in operative time, estimated blood loss, and total days of hospitalization when comparing the combined group to the sum of the control groups. In this study, no major complications, including the need for blood transfusion or pulmonary embolus, were noted in any of the patients. CONCLUSIONS: These results demonstrate success in performing abdominoplasty with gynecologic surgery, which may be an acceptable option for patients.

Impact of mandibular condyle preservation on patterns of failure in head and neck cancer.

OBJECTIVE: To determine the role of native condyle preservation in local recurrence after segmental mandibulectomy in patients with head and neck squamous cell carcinoma. METHODS: Retrospective chart review with main outcome measuring local control of cancer. RESULTS: Between 1994 and 2003, 72 patients (48 men, 24 women) with an average age of 73.5 years without previous treatment underwent segmental mandibulectomy. Fifty-four cases (n = 54) involved the mandible posterior to the mental foramen and are the subject of this review. In 36 patients, the condyle was preserved and mandibular continuity was restored. In 18 patients, condyle and ramus were resected without mandibular reconstruction. Reconstructive modalities included primary closure (3), split-thickness skin graft (3), pedicle flap (19), and free tissue reconstructions (29). Overall local-regional recurrence rate was 22 percent (12 of 54); no recurrences were identified in patients who underwent condylar resection. Recurrences were observed in patients with mandibular reconstruction by both plate and pedicle flap (5 of 9) or (osteo) myocutaneous free flap (7 of 27). CONCLUSION: Condylar preservation may predispose patients to local recurrence after segmental mandibulectomy. This does not translate into overall reduction in survival.

Facial paralysis associated with glomus jugulare tumors.

OBJECTIVE: To review the intraoperative findings and facial nerve management in nine patients who presented with facial paralysis associated with glomus jugulare tumors. STUDY DESIGN: A retrospective analysis of patient medical records. SETTING: Tertiary care academic medical center. PATIENTS: All patients who presented with facial paralysis and a glomus jugulare tumor who underwent surgical resection of their tumors at our institution. INTERVENTION: A postauricular infratemporal fossa approach for tumor removal and greater auricular interposition neural repair. MAIN OUTCOME MEASURE: Intraoperative facial nerve findings and long-term facial recovery. RESULTS: One hundred two patients underwent a postauricular infratemporal approach for resection of glomus jugulare tumor from July 1988 through July 2005. Nine of these patients presented with ipsilateral facial paralysis. The medial surface of the vertical segment was invaded by tumor in all nine cases. Facial recovery at 2 years was House-Brackmann Grade III in eight patients and Grade IV in one individual. Facial recovery did not significantly change after 2 years (mean follow-up of 7.4 years). DISCUSSION: Facial nerve invasion of the vertical segment occurred in 9 (9%) of 101 patients in our series. Facial nerve resection with interposition grafting resulted in House-Brackmann Grade III in eight (89%) of nine patients. Facial nerve dissection and preservation was not possible when preoperative facial paralysis was evident.

Facial reanimation according to the postresection defect during lateral skull base surgery.

The vast majority of benign tumors of the cerebellopontine angle, temporal bone, and parotid gland can be successfully resected without permanent injury to the facial nerve. Malignant tumors or recurrent disease may require facial nerve sacrifice, especially if preoperative facial paresis is present. This article will present case examples of the various methods to reconstruct facial animation after lateral skull base resections that require sacrifice of cranial nerve VII, and the associated mimetic facial musculature. Facial mimetic outcome after reanimation was graded using the House-Brackmann scale. Primary neurorrhaphy or interposition grafting may be performed when both the proximal and distal portions of the facial nerve are available and viable facial musculature is present. If only the distal facial nerve and viable facial musculature are available, a split hypoglossal to facial nerve anastomosis is used. A proximal facial nerve to microvascular free flap is performed when the proximal facial nerve is available without distal nerve or viable musculature. A cross-facial to microvascular free flap is performed when the proximal and distal facial nerve and facial musculature are unavailable. The above methods resulted in a House-Brackmann score of III/VI in all case examples postoperatively. The method of facial reanimation used depends on the availability of viable proximal facial nerve, the location of healthy, tumor-free distal facial nerve, and the presence of functioning facial mimetic musculature.

Heads-up 3D Microscopy: An Ergonomic and Educational Approach to Microsurgery.

Traditional microsurgery can lead surgeons to use postures that cause musculoskeletal fatigue, leaving them more prone to work-related injuries. A new technology from TrueVision transmits the microscopic image onto a 3-dimensional (3D) monitor, allowing surgeons to operate while sitting/standing in a heads-up position. The purpose of this study was to evaluate the feasibility of performing heads-up 3D microscopy as a more ergonomic alternative to traditional microsurgery. A feasibility study was conducted comparing heads-up 3D microscopy and traditional microscopy by performing femoral artery anastomoses on 8 Sprague-Dawley rats. Operative times and patency rates for each technology were compared. The 8 microsurgeons completed a questionnaire comparing image quality, comfort, technical feasibility, and educational value of the 2 technologies. Rat femoral artery anastomoses were successfully carried out by all 8 microsurgeons with each technology. There was no significant difference in anastomosis time between heads-up 3D and traditional microscopy (average times, 34.5 and 33.8 minutes, respectively; P = 0.66). Heads-up 3D microscopy was rated superior in neck and back comfort by 75% of participants. Image resolution, field of view, and technical feasibility were found to be superior or equivalent in 75% of participants, whereas 63% evaluated depth perception to be superior or equivalent. Heads-up 3D microscopy is a new technology that improves comfort for the microsurgeon without compromising image quality or technical feasibility. Its use has become prevalent in the field of ophthalmology and may also have utility in plastic and reconstructive surgery.

Closure of complex lateral skull base defects.

OBJECTIVE: To discuss surgical reconstructive options and complications in patients with extensive lateral skull base defects. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Eligibility criteria included patients seen between July 1999 and July 2003 with malignant neoplasms of the lateral skull base requiring surgical therapy, with resultant surgical defect not amenable to primary closure. INTERVENTION: Surgical extirpation of malignant skull base neoplasm requiring free tissue transfer or rotational flap closure. MAIN OUTCOME MEASURE: Closure and healing of surgical defect, intraoperative and postoperative complications, patient survival. RESULTS: There were 11 patients, 8 males and 3 females, with an average age of 65 years. Eight patients required trapezius flap reconstruction, whereas one patient required temporalis rotational flap closure, and two patients required rectus abdominus free tissue transfers. There was one perioperative death secondary to cardiac disease. There were no immediate wound complications. One patient developed a delayed partial trapezius flap failure successfully treated with a rectus abdominus flap. CONCLUSIONS: The trapezius rotational flap is a reliable means of closing complex lateral skull base defects with minimal morbidity.

The influence of reconstructive modality on cost of care in head and neck oncologic surgery.

OBJECTIVE: To determine the differential costs of 3 reconstructive modalities in patients undergoing head and neck oncologic surgery. DESIGN: Cost-identification analysis. SETTING: Academic tertiary care medical center. METHODS: Retrospective review of 104 major head and neck resections involving primary tumors of the upper aerodigestive tract requiring a tracheotomy (primary hospital discharge, diagnosis related group 482 from the International Classification of Diseases, Ninth Revision, Clinical Modification) from July 2, 1999, through June 30, 2000. Patients were stratified by reconstruction modality: (1) microvascular free tissue transfer (MFFT), (2) pedicle myocutaneous flaps (PMF), and (3) primary reconstruction and/or skin graft (PR). Dependent variables included length of hospitalization, direct and indirect hospital costs, total hospital costs, the percentage of total costs attributable to direct costs, and the percentage of total costs attributable to indirect costs. RESULTS: No significant age differences existed among the 3 patient groups. Significant differences (Kruskal-Wallis) were observed for all variables. The PR group was compared with the PMF and MFFT groups. Total patient charges were greatest in the MFFT group (mean, $22 821.04) and least for the PR group (mean, $13 125.70). Length of stay was greatest in the PMF group (mean, 7.53 days) and shortest in the PR group (mean, 5.53 days). CONCLUSIONS: Intricate reconstructions are frequently more times consuming than primary closure, and the additional surgical procedures are more likely to use more hospital resources. Efforts at providing superior functional outcomes must be balanced against increasing restrictions on the use of health care dollars. Careful evaluation of functional outcomes and quality of life will be required to justify the increased expenditure incurred when providing complex reconstructions.

Posterior marginal mandibulectomy in the management of cancer of the oral cavity and oropharynx.

OBJECTIVE: To review a single institution's experience with posterior marginal (ramus) mandibulectomy for mandibular preservation in the management of patients with squamous cell carcinoma of the retromolar trigone or oropharynx. To review the history and surgical technique with emphasis on functional as well as oncologic outcomes. STUDY DESIGN AND SETTING: Retrospective review at a tertiary care academic referral center from 1996 to 2002. RESULTS: Between 1996 and 2002, 382 patients with squamous cell carcinoma of the oral cavity and oropharynx were surgically treated at the Loyola University Medical Center. Medical records were reviewed and 152 patients were identified who had some form of mandibular procedure (segmental resection, marginal resection, or mandibulotomy) performed in conjunction with their tumor resection. Eighteen posterior marginal mandibulectomies were performed for primary cancers of the retromolar trigone, tonsillar fossa, and/or base of the tongue. All patients received adjuvant radiotherapy. Bone invasion of the marginal mandibulectomy specimens by squamous cell carcinoma was observed in 2 cases, neither of which developed a local recurrence. Mean and median overall survivals were 41.4 and 37.5 months, respectively. Functional outcomes were determined by administering the University of Washington Quality of Life instrument administered at 12 months. Patients reported significant alterations in chewing, but all were able to maintain satisfactory oral intake and no patient required a gastrosotomy tube. CONCLUSIONS: A posterior osteotomy of the mandibular ramus is a useful adjunct in the surgical treatment of cancer of the retromolar trigone or oropharynx. Negative surgical margins can be obtained even with focal invasion of mandibular bone. The loss of bone in this area does not significantly affect patients' appearance. Patients report deterioration in chewing following this procedure but are able to maintain a diet of solid food.

Management of malignant tumors of the anterior and anterolateral skull base.

OBJECT: Malignant tumors of the skull base represent a group of diverse and infrequent lesions. Comprehensive oncological management requires a multidisciplinary team of neurological surgeons, otolaryngologists, radiation oncologists, plastic surgeons, and medical oncologists. The authors describe an institutional experience in performing 54 combined anterior-anterolateral cranial base resections for malignant disease. METHODS: The technical considerations for preoperative workup, surgical approach, resection, and reconstruction are outlined and illustrated. Considerations for complication management and avoidance are detailed. CONCLUSIONS: Overall mortality (0%) and morbidity rates (18%) are acceptable. The influence on the natural history of the disease process is an ongoing study.

Incidence of intercostobrachial nerve injury after transaxillary breast augmentation.

BACKGROUND: Although many studies on transaxillary breast augmentation (TBA) have been published, none has examined the incidence of intercostobrachial nerve (ICBN) injury after aesthetic surgery. OBJECTIVE: This study was designed to measure the incidence of ICBN injury after endoscopic and non-endoscopic TBA, and to determine anatomic guidelines for the avoidance of iatrogenic injury to the ICBN. METHODS: A questionnaire was distributed nationally to 1000 plastic surgeons selected randomly from the roster of the American Society of Plastic Surgeons. The questionnaire sought information on the surgeons' experience, technique, and complication rate with regard to TBA. Anatomic dissections of 6 unpreserved axillae were also performed. RESULTS: Our survey response rate was 50%; of those responding, 26.8% of surgeons (134) performed TBA. Of the 134 surgeons performing TBA, 72 (53.7%) used an endoscope. The overall complication rate was 62.7%, which included upper-arm and shoulder pain, numbness, sensory loss, and tingling, and upper-arm fibrous banding. No significant differences were seen between the complication rates for the endoscopic (66.7%) and open (58.1%) TBA groups. With few exceptions, all symptoms resolved in 3 to 6 months. The dissection study confirmed the location of the ICBN as being immediately subcutaneous in the axilla. CONCLUSIONS: TBA is associated with a high incidence of injury to the ICBN. Our findings indicate that the use of an endoscope with the transaxillary approach does not significantly affect the rate of injury to the ICBN. The dissection study performed helped to confirm that an immediately subcutaneous plane of dissection in the axilla is safest with regard to avoiding injury to the ICBN. (Aesthetic Surg J 2002;22:26-32.).

Can't have one without the other: component separation plus mesh for repairing difficult incisional hernias.

BACKGROUND: Incisional hernia recurrence after repair continues to be a persistent complication. The purpose of this study was to investigate the association between patient-specific factors, surgeon-specific factors, and hernia recurrence in patients undergoing repair of an incisional hernia in whom the component separation technique was used. METHODS: All patients undergoing incisional herniorrhaphy with component separation from October 2006 to May 2013 were reviewed. Data collected included demographics, comorbidities, postoperative complications, and factors related to mesh implantation. Computed tomography images were used to evaluate the size of the hernia and dimensions of the linea alba. RESULTS: The 85 patients were followed for a mean of 14.4 months, and 12 (14.1%) recurrent hernias were diagnosed. More than 91% of the herniorrhaphies were performed after a previous repair failed. The recurrence rate decreased to 11.1% when, in addition to the component separation, a mesh was used to reinforce the repair. There were no differences between the group who developed a recurrence and those who did not in terms of sex, age, race, body mass index, preoperative comorbidities, or type of mesh used. CONCLUSION: In this case series of complex abdominal wall herniorrhaphies using component separation, the recurrence rate was 14.1% overall and 11.1% when a mesh was used to reinforce the repair. Recurrent hernia was not associated with patient demographics, comorbidities, thickness or width of the linea alba, presence of a contaminated wound, or postoperative surgical-site occurrences.

A comparison of full and split thickness skin grafts in radial forearm donor sites.

To formally evaluate the functional and aesthetic outcomes between full versus split thickness skin graft coverage of radial forearm free flap donor sites. A retrospective chart review of 47 patients who underwent pedicled or free radial forearm free flap reconstruction from May 1997 to August 2004 was performed. Comparisons were made between patients who had donor site coverage with split thickness skin grafts (STSG) or full thickness skin grafts (FTSG). There was no statistically significant difference between the STSG and FTSG in the number of post-operative dressings, incidence of tendon exposure, time to healing at the skin graft donor site, and time to healing at the skin graft recipient site. The questionnaire data showed there was a trend toward higher scores with the radial forearm scar aesthetics and satisfaction in the FTSG group. Full thickness skin graft coverage of radial forearm free flap donor site is superior to split thickness skin graft coverage in terms of aesthetic outcome, and has no statistically significant difference in terms of tendon exposure, time to healing at the skin graft donor site, time to healing at the skin graft recipient site, or post operative pain.

Intermeshing breast reconstruction and postmastectomy radiation.

In women with advanced breast cancer or those with early-stage cancer for whom there is a contraindication for breast-conserving therapy, mastectomy is the primary surgical treatment. This is often followed by breast reconstruction in either an immediate or delayed fashion. There is a great psychological and emotional benefit for the patient to have immediate reconstruction at the time of initial mastectomy. Recently, evidence has demonstrated that postmastectomy radiation therapy (PMRT) administered in conjunction with systemic therapy improves not only locoregional control but also survival. This has increased the number of women receiving PMRT and resulted in much debate in the literature regarding the timing of radiation therapy and the types of reconstructive options. In this article, the authors review the literature for controversies and currently accepted practices for intermeshing PMRT and breast reconstruction following mastectomy. We also summarize the key issues related to the integration of breast reconstruction with PMRT and detail the experience and complications arising from this integration.

Use of human acellular dermal matrix for hernia repair: friend or foe?

BACKGROUND: Surgeons continue to search for the ideal prosthetic material to repair complex abdominal wall hernias. Recently, a new biologic material was introduced into the surgeon's arsenal. The purpose of this study is to review a single institution's experience with the use of human acellular dermal matrix (HADM [AlloDerm]) for repair of hernias. METHODS: This was a retrospective review of all patients who received HADM for repair of an abdominal wall hernia. Patient demographics, comorbidities, wound contamination, operative technique, complications, and hernia recurrence were analyzed. RESULTS: Between May 2004 and October 2007, HADM was implanted in a total of 46 patients undergoing repair of a ventral hernia. The average age was 54 years (range, 26-77), with an average American Society of Anesthesiologists classification of 2.5 (range, 1-4). Indications for use of HADM included complex ventral hernia repair (n = 34), mesh infection/enterocutaneous fistula (n = 10), and peritonitis (n = 2). The incidences of comorbidities were hypertension in 47%, diabetes mellitus in 16%, and coronary artery disease in 11%. The majority (87%; n = 40) of the procedures were performed on an elective basis. Seventeen procedures were performed in contaminated wounds. The HADM was placed as reinforcement to the hernia repair in 26 patients and as a "bridge" between the fascial edges in 20 patients. The average follow-up was 12.1 months. Wound complications were frequent at 54%. There were 6 recurrent hernias and 8 patients with eventration of the bioprosthesis so that the recurrent hernia rate was 30%. None of the recurrences were associated with a postoperative wound infection. The majority (88%) of patients who developed eventration of the HADM had a repair using the bioprosthesis to "bridge" an abdominal wall defect. Hernia recurrence and eventration were not associated with use of HADM in a contaminated/infected wound. CONCLUSIONS: HADM is a suitable prosthesis for repair of complex and routine abdominal wall defects. This bioprosthesis can incorporate into contaminated tissue without becoming infected. Eventration occurs when HADM is utilized as a fascial replacement rather than as a reinforcement.