Tissue expander breast reconstruction using prehydrated human acellular dermis.

INTRODUCTION: Human acellular dermal matrices help facilitate immediate tissue expander-implant breast reconstruction by providing support to the inferolateral pole, improving control of implant position, and enhancing early volume expansion. Although several freeze-dried human acellular dermal products have demonstrated reasonable safety and efficacy in immediate tissue expander-implant breast reconstruction, no dedicated studies have evaluated clinical outcomes of prehydrated human acellular dermal matrix (PHADM) in breast reconstruction. METHODS: The outcomes of 121 consecutive tissue expander reconstructions performed by the senior author using PHADM were evaluated. RESULTS: Mean intraoperative tissue expander fill volume was 256.6 ± 133 mL, 60% of final expander volume. Patients required an average of 3.2 additional expansions prior to tissue expander-to-implant exchange. Mean follow-up period after reconstruction was 44 ± 26.5 weeks. Complications occurred in 20 (16.5%) breasts, including 9 (7.4%) soft-tissue infections, 8 (6.6%) partial mastectomy flap necroses, and 2 (1.7%) seromas. Eleven (9.1%) breasts ultimately required explantation. Patients receiving radiation demonstrated a strong trend toward greater complications (30.8% vs. 13.7%, P = 0.0749). CONCLUSIONS: The outcomes and complication rates of PHADM tissue expander breast reconstruction are comparable to those reported with freeze-dried human acellular dermis.

Hybrid thoracoabdominal aortic aneurysm repair: visceral revascularization combined with endovascular abdominal and thoracic aneurysm repair.

Hybrid approaches for the treatment of thoracoabdominal aortic aneurysms (TAAAs) by using a combination of visceral revascularization followed by thoracic endovascular aneurysm repair (EVAR) have been reported with acceptable results. The authors present a case that required the addition of a bifurcated infrarenal EVAR to completely exclude a type III TAAA.

Acellular dermis-assisted breast reconstruction with the use of crescentric tissue expansion: a functional cosmetic analysis of 40 consecutive patients.

BACKGROUND: Crescentric tissue expanders have the potential to improve postoperative aesthetic results via selective lower pole expansion; however, limited data are available on their efficacy. OBJECTIVES: The authors assess postoperative functional and cosmetic outcomes of acellular dermis-assisted breast reconstruction with crescentric tissue expansion. METHODS: This study is a single-institution, retrospective review of 40 consecutive patients who underwent acellular dermis-assisted breast reconstruction with crescentric tissue expansion. Demographic data, operative details, and procedural outcomes were recorded and assessed. Cosmetic outcomes were assessed using the Breast Evaluation Questionnaire. RESULTS: Fifty-eight breasts representing 36 bilateral and 22 unilateral reconstructions were analyzed. Of these, 45 (78%) underwent tissue expander (TE) to implant exchange. The mean interval between stage 1 and stage 2 was 92 +/- 20 days, with a total follow-up time of 141 +/- 16 days. The average intraoperative expander fill volume was 213.5 mL, with an average final fill of 285 mL (range, 180-740 mL). The average number of expansions was 1.6. Overall, there were five complications (8.6%). Eighty-three percent of patients participated in the breast evaluation questionnaire. Answers to each question were reported using a qualitative five-point scale that ranged from 1 (very dissatisfied) to 5 (very satisfied). For the bilateral reconstructions, the average score in all contexts was 4.5 +/- 0.3, 4.33 +/- 0.5, and 4.36 +/- 0.33 for size, shape, and firmness, respectively. For unilateral reconstructions, the average scores were 4.0 +/- 0.58, 3.93 +/- 0.38, and 4.13 +/- 0.21, respectively. CONCLUSIONS: Crescentric expander-based reconstruction with acellular dermis assistance is well tolerated, especially in smaller breasted women. Functional and cosmetic outcomes were acceptable and comparable to previous reports of traditional expander-based reconstructions.

Arterial reconstruction with cryopreserved human allografts in the setting of infection: A single-center experience with midterm follow-up.

OBJECTIVES: Vascular reconstruction in the setting of primary arterial or prosthetic graft infection is associated with significant morbidity and mortality. Cryopreserved human allografts (CHA) may serve as acceptable alternatives when autogenous or extra-anatomic/in situ prosthetic reconstructions are not possible. METHODS: Between February 1999 and June 2008, 57 CHAs were placed in 52 patients (average age, 65 years) for abdominal aortic (n = 18) or iliofemoral/femoral-popliteal arterial or prosthetic infections (n = 39). Indications for arterial reconstruction included infected implanted prosthetic material (n = 39), mycotic pseudoaneurysms (n = 14), or intra-abdominal bacterial contamination or wound infection (n = 4). Wide local debridement and culture was followed by allograft interposition, bypass, or extra-anatomic reconstruction. Over a similar time period, 53 non-CHA extra-anatomical prosthetic or in situ autogenous tissue reconstructions were performed in 53 patients (average age, 65 years) for abdominal aortic (n = 18) or iliofemoral and femoral-popliteal (n = 35) prosthetic graft infections. Indications for arterial replacement in all cases included infected implanted prosthetic material. RESULTS: Thirty-day mortality for all CHA and non-CHA reconstructions was 5.2% and 7.5%, respectively. The 1-year procedure-related mortality for all CHA and non-CHA procedures was 7.0% and 13.2%, respectively. In the CHA cohort, 5 patients required re-exploration for hemorrhage or anastomotic disruption. In midterm CHA follow-up (20 months), there was 1 graft thrombosis, 2 graft stenoses, 1 recurrent ilioenteric fistula, and 1 non-related amputation. The remainder of the CHA reconstructions remained patent without evidence of aneurysmal change or reinfection. CONCLUSION: In the setting of infection, cryopreserved human allograft arterial reconstruction is a viable alternative to traditional methods of vascular reconstruction in patients without available autogenous conduit and when expedient reconstruction is required. In midterm follow-up, cryopreserved allografts appear to be resistant to subsequent reinfection, thrombosis, or aneurysmal dilatation. However, larger patient populations and longer follow-up are needed to determine if arterial reconstruction with CHA is the safest and most durable method of treatment for arterial infections.

Secondary infections of thoracic and abdominal aortic endografts.

PURPOSE: To review several cases of stent-graft infection with respective outcomes to identify clinical presentations and responses to treatment options. MATERIALS AND METHODS: The authors performed a single-center retrospective review of all secondary endograft infections from January 2000 to June 2007. Infections were identified from an institutional database containing all abdominal and thoracic endovascular aneurysm repairs (EVAR and TEVAR) performed at the treating hospital. RESULTS: From January 2000 to June 2007, 389 EVAR and 105 TEVAR were performed at the treating hospital. Ten endograft infections were identified (five EVAR and five TEVAR). Four infections occurred in grafts placed at outside institutions and six in grafts placed in-house. The in-house prevalence of EVAR and TEVAR infection is 0.26% and 4.77%, respectively. None were placed for a presumed pre-existing mycotic aneurysm. The mean time from the index procedure to the diagnosis of infection was 243.6 days +/- 74.5. Two patients who underwent EVAR presented with a contained rupture, and the remaining eight patients presented with constitutional symptoms and/or abscess formation on imaging studies. Microbiology cultures revealed Propionibacterium species (n = 3), Staphylcoccus species (n = 3), Streptococcus species (n = 2), and Enterobacter cloacae (n = 1). All EVAR patients underwent removal of the infected endograft and reconstruction with extraanatomic bypass (n = 3) or in situ homograft placement (n = 2). During a mean follow-up of more than 1 year, there were no recognized complications or recurrence of infection. Only one of the five TEVAR patients underwent removal and interposition grafting with an antibiotic-impregnated Dacron graft. The remaining four patients were medically managed--one patient survived and was placed in hospice care, two died of mycotic aneurysm rupture, and one died from multiorgan system failure secondary to sepsis. CONCLUSIONS: Graft-related septic complications following EVAR or TEVAR are rare but associated with significant mortality. Several surgical treatment options are available, each potentially equally successful. The effect of prophylactic antibiotic use during subsequent invasive procedures must be solidified.

Percutaneous Zenith endografting for abdominal aortic aneurysms.

A completely percutaneous approach to infrarenal abdominal aortic aneurysm (AAA) endografting has the theoretic benefits of being minimally invasive and more expedient. Our goal was to demonstrate the utility of this approach using a suprarenal fixation device and a suture-mediated closure system. We conducted a single-institution, retrospective review of 14 patients who underwent percutaneous AAA repair with the Zenith device between August 2003 and March 2007. Immediate and delayed access-related outcomes were examined over a mean follow-up of 12.1+/-2.0 months. Mean AAA size was 5.6 cm. Immediate arterial closure and technical success rate was 96% (27/28 vessels). One immediate hemostatic failure required open surgical repair. Over follow-up, one vessel required operative repair for new-onset claudication. No other immediate or delayed complications (thrombosis, pseudoaneurysm, infection, or deep venous thrombosis) were detected. A percutaneous approach for the treatment of AAA has several advantages over femoral artery cutdown but also has its own unique set of risks in the immediate and late postoperative period. Ultimately, the "preclose technique" can be safely applied for the Zenith device despite its large-bore delivery system.

Reconstruction of the zygomatic arch using a mandibular adaption plate.

Zygomatic complex fractures are one of the most common facial fractures treated by maxillofacial surgeons. Because of the importance of the zygomatic complex in midfacial skeletal orientation, comminuted zygomatic arch fractures can lead to significant morbidity and deformity. Common repair modalities include closed reduction via a Gilles approach, open reduction and internal fixation with screws and/or plating systems, primary bone grafting, and/or biosynthetics. In patients with significant comminution and arch defects, who are poor candidates for bone grafting, reconstruction can be difficult. In this clinical report, we present 2 patients with comminuted zygomatic arch fractures and significant bony defects, who were reconstructed with mandibular adaption plates alone without primary bone grafting. Over a mean follow-up period of 12.5 months, both patients healed well without any complications and had acceptable cosmetic outcomes.

Late Type III endoleak and graft failure of an Ancure stent-graft.

The authors report a case of a delayed type IIIb endoleak with sac expansion 6 years after an endovascular repair of an abdominal aortic aneurysm with an Ancure bifurcated stent-graft. The presumed etiology of the leak was secondary to erosion of the main body graft material by metal stents placed within the graft to correct kinking of the iliac limbs at the index operation. The endoleak was successfully treated by endovascular means with an aortouni-iliac device, contralateral iliac plug followed by a femoral-to-femoral bypass graft.

Breast implant procedures under conscious sedation: a 6-year experience in 461 consecutive patients.

BACKGROUND: Breast implant procedures are commonly performed using general anesthesia; however, patient apprehension, the potential for improved safety, lower costs, and faster recovery times have increased interest in the use of conscious sedation in plastic surgery. The authors examined the safety and efficacy of breast implant procedures performed under conscious sedation over a 6-year period using their standardized institutional protocol. METHODS: Between 2002 and 2008, 461 consecutive patients underwent breast implant procedures under conscious sedation using a protocol of preoperative intravenous diazepam along with intraoperative midazolam, fentanyl, and local anesthetic. All operative and follow-up data were recorded. Augmentation mammaplasty patients were further analyzed for conscious sedation medication dosing. RESULTS: The study population was divided into two groups (years 1 to 3 and years 4 to 6 of the study period) to analyze changes to the authors' regimen over time. In years 4 to 6, higher preoperative doses of diazepam (p = 0.01) allowed more effective local anesthesia administration, thereby reducing intraoperative fentanyl requirements (p < 0.0001). Midazolam doses and operating times did not differ significantly between groups. No patient required conversion to a deeper method of anesthesia. The overall complication rate was 4.34 percent. CONCLUSIONS: The authors' study demonstrates the safety and efficacy of conscious sedation in breast implant procedures. Higher preoperative doses of diazepam have significantly reduced fentanyl requirements, resulting in shorter recovery times, decreased postoperative nausea/vomiting, and elimination of unintended admissions. These benefits are obtained without increasing operative times or complications. The authors conclude that conscious sedation is the preferred method of anesthesia for most patients undergoing breast implant procedures.

Patient-subjective cosmetic outcomes following the varying stages of tissue expander breast reconstruction: the importance of completion.

INTRODUCTION: Tissue expander breast reconstruction consists of three major surgical steps: placement of the expander after mastectomy, exchange of the expander for an implant, and nipple-areola complex reconstruction. The evolution of patient satisfaction throughout this process has not been evaluated. Here we performed a stratified analysis of patient-subjective cosmetic outcomes during the stages of breast reconstruction. METHODS: Twenty-eight consecutive tissue expander-implant reconstructions were performed by the senior author using human acellular dermis. Cosmetic outcomes were assessed after each reconstructive stage using a validated Breast Evaluation Questionnaire consisting of questions related to breast size, shape and firmness in three separate contexts: intimate or sexual activities, leisure or social activities, and professional or job-related activities. RESULTS: Eighteen patients underwent unilateral reconstruction, while 10 underwent bilateral reconstruction. Satisfaction scores were statistically higher following Stage I and II procedures for bilateral reconstructions. For unilateral reconstructions, there was a statistically significant elevation in scores following Stage II. The addition of nipple-areola reconstruction resulted in the highest scores for both unilateral and bilateral reconstructions. These score elevations were significant (p < 0.05) in nearly every measured context for unilateral reconstructions and as such, the significant differences in scores between unilateral and bilateral cohorts after stages I and II were nearly eliminated after completion of the entire reconstructive process. CONCLUSION: Satisfaction with tissue expander reconstruction is significantly affected by the patients' stage during the reconstructive process. Completion of all three stages, including nipple-areolar complex reconstruction, achieves maximal patient satisfaction. For unilateral reconstructions, completion of the entire reconstructive process, including contralateral symmetry procedures and nipple-areolar complex reconstruction, results in cosmesis scores that are similar to those in bilateral cases.

Carotid stenting: risk factors for periprocedural stroke.

Carotid artery stenting is rapidly emerging as a minimally invasive alternative to carotid endarterectomy for the treatment of cervical carotid artery occlusive disease and stroke prevention. Periprocedural stroke risk still remains a concern despite improvements in technique and equipment. We will review technical, clinical and radiographic factors associated with an increased risk of stroke during carotid artery stenting. The primary focus will be on technical proficiency of the interventionalist, patient comorbid conditions (i.e., diabetes, coronary artery disease, renal failure and advanced age) and equipment (i.e., embolic protection systems and stent designs) that have been identified in the literature as predictors of poorer outcomes.