Autologous mastectomy reconstruction: Communication among the breast surgery team to maximize aesthetic and oncologic outcome.

Mastectomy breast reconstruction with autologous tissue is challenging. Oncologic and aesthetic goals face previous surgical scars, radiation, chemotherapy, or other comorbidities. We describe a simple approach for autologous mastectomy reconstruction so that breast and plastic and reconstructive surgeons can maximize aesthetic outcomes and minimize wound complications. A retrospective chart review was done on patients who underwent mastectomy and autologous reconstruction. The surgical flight plans were reviewed to delineate an approach, and pre- and postoperative photographs were examined to create a step-by-step process. The most encountered mastectomy and autologous flap reconstruction scenarios were categorized to create a step-by-step process. Successful autologous mastectomy reconstruction to optimize aesthetic outcome and minimize complications requires team communication. Creation of a surgical flight plan using information from the physical examination, MRI and adjunctive imaging, and preoperative photographs is imperative. Thoughtful incision choice and exposure approach are paramount.

Facial reanimation by staged, split masseter muscle transfer.

BACKGROUND: Facial paralysis of the lower face presents severe functional and aesthetic disturbance to patients. The gamut of facial paralysis correction is diverse and must be tailored to the patient. When nerve repair or free functional muscle transfer is unavailable, regional muscle transfer has become a staple in surgical management of facial paralysis. Previous masseter transfers relied on orbicularis oris attachment, which may be atrophic, adhered, or lengthened. Using fascia lata grafts, we describe the senior author's method of staged, split masseter transfer as a reliable method for reanimating the lower third of the face in appropriate candidates. METHODS: The staged, split masseter muscle transfer is a 3-part repair. The first stage places a hemioral fascia lata graft to act as an anchor reinforcement. The second stage transfers the split masseter muscle, suturing to the fascia lata reinforced oral commissure. The third stage, a reefing procedure, is performed 6 to 10 months later under local anesthesia to reinforce attachments. RESULTS: Six patients underwent the staged, split masseter muscle transfer. Mean age was 43 (15-67) years. Mean time to surgery from onset of deficit was 174 months (3 months to 65 years). All patients had significant improvement over preoperative symptoms. Symmetry was restored in repose. On movement, commissure excursion went from 0 to 6.67 mm in the superolateral vector. Of the 6 patients, 5 required an average of 1.5 outpatient revisions to achieve satisfactory results on average of 4.67 (4-127) months after the final stage. CONCLUSIONS: The staged, split masseter transfer is useful for restoring subtle reanimation in patients presenting with facial paralysis. The staged, split masseter transfer provides bulk and restores both static and dynamic function. We present a case series demonstrating excellent long-term functional results.

Approaching revisional surgery in augmentation and mastopexy/augmentation patients.

BACKGROUND: Breast augmentation and mastopexy augmentation procedures are becoming more common. The young plastic and reconstructive surgeon is often challenged revisional surgery operations in these patients. These cases are challenging, require significant operative time, and can be associated with a high revision rate. It is important for the young surgeon to have an approach to deal with these common and difficult scenarios. METHODS: A retrospective chart review was conducted on all patients who underwent a revision augmentation or revision mastopexy augmentation procedure between 2008 and 2010 by the authors. The most commonly encountered mitigating circumstances in the revision augmentation or revision mastopexy augmentation populations were identified and an algorithm was created on how to address these difficult problems. RESULTS: Between July 1, 2008 and July 1, 2010, 264 patients underwent revision augmentation or revision mastopexy augmentation procedures. The most commonly encountered patient scenarios were recurrence of ptosis, recurrent capsular contracture, implant malposition, rippling, and desiring a reduction in implant size. We encountered many mitigating circumstances that complicated the revisions. We devised a stepwise algorithmic approach to address these problems based on the following factors: (1) blood supply to the nipple-areola complex, (2) need to change implant plane, (3) patient desire to reduce or increase in breast implant volume, (4) need for total en bloc capsulectomy or capsulorrhaphy, (5) incision approach used to perform the capsulectomy, and (6) patient-related factors that need to be medically optimized or treated before, during, and after surgery. By adhering to these steps, outcomes can be accomplished more reliably and safely. CONCLUSION: Specialized preoperative planning is necessary to consistently deliver safe and aesthetic revision augmentation and revision mastopexy augmentation results. It is important for the operative surgeon to carefully consider the potential adverse effect of implants and prior mastopexy or reduction incisions and patterns on the blood supply to the nipple-areola complex. With educated planning, successful results can be achieved in most cases, and the risk of serious complications can be minimized.

Reconstruction of an entire metacarpal and metacarpophalangeal joint using a fibular osteocutaneous free flap and silicone arthroplasty.

Radical resection of the entire ring finger metacarpal for a giant cell tumor resulted in a bony defect extending from the distal surface of the hamate to the proximal surface of the proximal phalanx. We reconstructed the metacarpal with a custom-contoured free fibular osteocutaneous flap and maintained motion at the new fibulophalangeal joint using a silicone arthroplasty. At 4.5 years postoperatively, the patient has shown no signs of recurrence of the giant cell tumor. The silicone arthroplasty has maintained 15° to 85° of motion at the new joint. Because of its similar shape to a metacarpal and because it allows faster bony healing compared with a nonvascularized fibular bone graft, a free vascularized fibular bone graft is an ideal candidate for reconstruction of extensive defects of the metacarpals, and placement of a silicone spacer in its distal medullary cavity can preserve motion at the new metacarpophalangeal joint.

Split, temporalis muscle flap for repair of recalcitrant cerebrospinal fluid leaks of the anterior cranial fossa.

Cerebrospinal fluid repair after dural disruption is critical in preventing morbidity and mortality in trauma and cancer patients. Among reconstructive options, coverage with the temporalis muscle has been a staple in many surgeons' armamentarium. However, the donor-site morbidity has been a major drawback in the use of this technique. Here, we present our method of split, temporalis harvest for anterior cranial base reconstruction, which seeks to regain dural integrity, while maintaining aesthetic and functional elements of the donor site. We present 2 patients, demonstrating the ease of harvest, fulfillment of both cosmetic and reconstructive goals, widespread applicability, and versatility of our split, temporalis muscle flap.

Preoperative MRI to Improve Aesthetic Outcomes in Secondary Mastopexy Augmentation: A Step-by-Step Approach.

Background: Secondary mastopexy augmentation is challenging because of compromised blood supply to the nipple areola complex (NAC). The operating surgeon often relies on clinical judgment and may perform a more conservative elevation of the NAC to minimize the risk of nipple necrosis. Despite this, the danger of necrosis persists. In our experience, MRI with contrast has enhanced preoperative planning in both cosmetic and reconstructive cases. Objectives: The goals of this article are to describe our use of preoperative MRI in identifying the blood supply to the NAC, evaluating dermo glandular thickness, decreasing surgical complications, and improving outcomes in secondary mastopexy augmentation. Methods: A consecutive series of secondary mastopexy augmentation procedures performed in 2021 were reviewed. In each case, preoperative maximum intensity projection (MIP) and/or high-resolution T1-weighted contrast enhanced MRI imaging was reviewed to elucidate the blood supply to the NAC and quantify the dermo glandular thickness. The imaging was used to formulate the operative plan. Preoperative and postoperative photographs were compared. Results: Eight cases were performed, four of which were selected to demonstrate our method using breast MRI with contrast in step-by-step approach. Patient satisfaction was high. The NAC survived in all cases. Conclusions: Surgeons can utilize preoperative breast MRI for strategic operative planning when performing secondary mastopexy augmentation. Visualization of the blood supply to the NAC and dermo glandular flap thickness are vitally important when performing a more aggressive lift of the breast.

Temporalis fascia for lip augmentation.

BACKGROUND: The pervasiveness of the desire for beautiful lips persists today, with women in the United States spending almost 2.9 billion dollars annually on cosmetics and lip products. The lips occupy the central feature of the lower third of the face and are of paramount importance to facial beauty. Various surgical approaches and methods are used in lip augmentation. METHODS: We reviewed the charts of 7 patients who underwent temporalis fascia lip augmentation to evaluate the temporalis fascia as a safe and effective means for lip augmentation. RESULTS: The average follow-up was 5 years (range, 4-6 years). All patients who underwent lip augmentation were female. The average age of the patients was 47 years old with a range of 36 to 67 years. All patients were very satisfied with the results of their surgical lip augmentation postoperatively and no patients required any revision operations. CONCLUSION: Temporalis fascia is a safe method of lip augmentation and is durable and long lasting. Lip augmentation with temporalis fascia can easily be performed in conjunction with other procedures.

Successful salvage of venous thrombosis of a free flap by creation of a venocutaneous fistula.

This report describes the creation of a venocutaneous fistula to salvage a free fibular osteocutaneous flap compromised by extensive venous thrombosis. This technique has previously been described for salvage of digital replants, but this is the first report of a venocutaneous fistula being used to salvage a free flap. A 21-year-old woman underwent a 9-cm resection of the distal left tibia for an aneurysmal bone cyst. A contralateral right fibular osteocutaneous free flap was used for reconstruction. On postoperative day 2, the skin paddle showed evidence of venous congestion. Reexploration demonstrated extensive thrombosis throughout the entire venous system of the flap. The venae comitantes were transected as far back as possible and brought to the surface of the skin through two small stab wounds to allow venous egress. After a short course of heparin and dextran, the skin flap healed uneventfully and both osteosynthesis sites consolidated. A venocutaneous fistula provides a path of relatively low resistance for venous outflow, improving the arterial inflow-venous outflow balance for a short time until neovascularization and collateral venous channels develop. The venocutaneous fistula technique may be considered for salvage of free flaps compromised by extensive venous thrombosis.

Lateral breast flap with superomedial pedicle breast lift.

BACKGROUND: Single-stage, durable aesthetic contouring of the volume-depleted and ptotic breast remains a challenge for plastic and reconstructive surgeons. These challenges are often even more difficult in the patient who has undergone massive weight loss (MWL). OBJECTIVES: The authors describe their technique of reshaping the breasts of MWL patients with laterally-based breast flaps during a superomedial pedicle breast lift. METHODS: A total of 20 patients were treated in a private clinic by one of the authors between April 2006 and January 2010 were included in this study. Each patient underwent breast reshaping with mastopexy, lateral breast autoaugmentation, and implant insertion. A laterally-based breast flap was developed to augment the involuted and ptotic breast and was dissected in conjunction with the superomedial pedicle breast lift to maintain the implant position, prevent bottoming out, and provide tissue coverage between the skin and breast implant in the advent of wound breakdown. RESULTS: Mean follow-up for this patient series was 19.5 months (range, two to 47). The average patient age was 41 years (range, 21 to 56), and the majority of patients had Grade 2 ptosis (14 out of 20). The average volume of the implants in this study was 350 cc (range, 275 to 600). There were no instances of seroma or wound infection. Five patients had minor instances of wound breakdown, but none required surgical revision. One patient developed early capsular contracture and required revision. That same patient developed a small hematoma. Patient self-evaluation revealed a high level of satisfaction; all 20 patients reported being happy with their results. CONCLUSIONS: The laterally-based breast flap, in combination with the superomedial pedicle mastopexy, is a powerful tool for use in the postbariatric or postpartum patient in whom the majority of the breast parenchyma is needed to fill the skin envelope. This flap serves to improve overall breast shape by providing added tissue along the deficient inferior pole, relieving some of the unaesthetic lateral chest wall excess and providing an additional layer of support inferiorly along the fold.

Uncovering the socioeconomic facets of human mobility.

Given the rapid recent trend of urbanization, a better understanding of how urban infrastructure mediates socioeconomic interactions and economic systems is of vital importance. While the accessibility of location-enabled devices as well as large-scale datasets of human activities, has fueled significant advances in our understanding, there is little agreement on the linkage between socioeconomic status and its influence on movement patterns, in particular, the role of inequality. Here, we analyze a heavily aggregated and anonymized summary of global mobility and investigate the relationships between socioeconomic status and mobility across a hundred cities in the US and Brazil. We uncover two types of relationships, finding either a clear connection or little-to-no interdependencies. The former tend to be characterized by low levels of public transportation usage, inequitable access to basic amenities and services, and segregated clusters of communities in terms of income, with the latter class showing the opposite trends. Our findings provide useful lessons in designing urban habitats that serve the larger interests of all inhabitants irrespective of their economic status.

Nasopharyngeal encephalocele: report of transcranial and transpalatal repair with a 25-year follow-up.

BACKGROUND: : Encephaloceles are an extension or protrusion of any intracranial matter through a cranial bone defect. The sphenoethmoidal encephalocele is often fatal. For those who survive long enough, expeditious repair is critical. We report a case that was repaired successfully via a combined transcranial and transpalatal approach, and because of successful repair, the patient underwent multiple secondary reconstructions resulting in a 25-year follow-up. CLINICAL REPORT: : A 3960-g, term male infant from a normal gestation was delivered via cesarean delivery for breech position. Initial examination revealed a 2 x 3-cm gray intraoral nasopharyngeal mass with smooth mucosal covering extruding through a midline palatal cleft. At 4 weeks of life, extradural and intradural exploration of the encephalocele was performed via a bifrontal craniotomy. At 15 months of age, the patient underwent median cleft lip repair. At 6 years of age, hypertelorism was corrected by wedge resection of the frontal and nasal bones and medial mobilization of the orbits. Follow-up was continued until 25 years of age, which revealed excellent maintenance of correction. CONCLUSION: : Sphenoethmoidal encephalocele is a rare sporadic congenital cranial floor defect associated with typical facial and cerebral anomalies. Encephaloceles extending into the nasopharynx may cause airway obstruction and feeding difficulty and present a potential pathway for central nervous system infection. Repair of the encephalocele should then be performed as soon as possible. Care of patients with nasopharyngeal encephaloceles requires a lifetime of reconstructive surgery. Care of these patients can be rewarding to both families and surgeons.

Reconstruction of total laryngopharyngectomy defects with deep inferior epigastric perforator flaps.

Laryngopharyngectomy reconstruction with microvascular free flaps remains challenging. Current methods of reconstruction include anterolateral thigh, radial forearm, and jejunal flaps, all of which have substantial donor site morbidity. We present a novel approach for total laryngopharyngectomy reconstruction using deep inferior epigastric perforator (DIEP) flaps. A retrospective review of head and neck reconstruction cases performed at Harbor-UCLA from 2006 to 2007 was performed. Those undergoing DIEP flaps were identified; management and postoperative course were analyzed. Two patients underwent successful reconstruction of total laryngopharyngectomy defects using DIEP flaps. Flaps up to 10 x 30 cm were harvested. Average donor vessel diameters were 2.5 cm and 3.0 cm for the artery and vein, respectively. The abdominal wounds were closed primarily. Flap survival was 100% with no emergent reexplorations. There were no postoperative bulges or hernias, and no leaks were detected on postoperative swallow evaluation. The DIEP flap is a useful addition to the armamentarium for reconstruction of total laryngopharyngectomy defects. Pedicle length is abundant, and donor vessel caliber is excellent. Large surface-area flaps can be harvested; excess flap can be deepithelialized or utilized for external skin. Primary closure of the donor site can be routinely achieved, negating the need for skin grafts.

Hierarchical organization of urban mobility and its connection with city livability.

The recent trend of rapid urbanization makes it imperative to understand urban characteristics such as infrastructure, population distribution, jobs, and services that play a key role in urban livability and sustainability. A healthy debate exists on what constitutes optimal structure regarding livability in cities, interpolating, for instance, between mono- and poly-centric organization. Here anonymous and aggregated flows generated from three hundred million users, opted-in to Location History, are used to extract global Intra-urban trips. We develop a metric that allows us to classify cities and to establish a connection between mobility organization and key urban indicators. We demonstrate that cities with strong hierarchical mobility structure display an extensive use of public transport, higher levels of walkability, lower pollutant emissions per capita and better health indicators. Our framework outperforms previous metrics, is highly scalable and can be deployed with little cost, even in areas without resources for traditional data collection.

Bilateral lower extremity gangrene requiring amputation associated with heparin-induced thrombocytopenia: a case report.

Heparin is a common cause of thrombocytopenia in hospitalized patients. Between 10% and 15% of patients receiving therapeutic doses of heparin develop thrombocytopenia. Heparin-induced thrombocytopenia (HIT) can cause severe bleeding and thrombosis owing to intravascular platelet aggregation. HIT must be distinguished from other causes of thrombocytopenia. Importantly, heparin use is often associated with an early fall in the platelet count that usually occurs within the first 4 days of initiation and recovers without cessation of heparin treatment. This nonimmune heparin-associated thrombocytopenia has not been found to be associated with thrombosis and does not necessitate discontinuation of heparin. The authors present a case report of a 70-year-old man who received heparin therapy following aortic tissue valve replacement and aortic root repair with graft and developed bilateral lower extremity arterial clots 6 days postoperatively in the setting of positive heparin antibody titers. Ultimately the patient required bilateral above-knee amputations.

Bilateral lower extremity gangrene requiring amputation associated with heparin-induced thrombocytopenia--a case report.

Heparin use, both prophylactically and therapeutically, is prevalent among hospitalized patients. Patients on heparin may develop a thrombocytopenia that is self-limited. Fewer patients develop a heparin-induced thrombocytopenia that can cause severe bleeding and thrombosis owing to intravascular platelet aggregation. The authors present a case report of heparin-induced thrombocytopenia in a patient who underwent aortic arch and aortic valve replacement that resulted in bilateral above-knee amputations. The patient developed limb ischemia related to heparin-associated thrombosis, but had a delay in antibody seroconversion. Early and accurate diagnosis of heparin-induced thrombocytopenia requires a high clinical suspicion and may be present despite the absence of serum antibodies.

Community incidence of hepatitis B and C among reincarcerated women.

BACKGROUND: The incarceration rate has increased 239% in the United States over the past 2 decades. This increase in incarceration has been fueled by the movement towards a criminal, rather than medical, response to the problem of drug dependence. For women in particular, incarceration and drug use are interdependent epidemics. Given that incarceration is common among drug-dependent persons, infectious diseases--including hepatitis B virus (HBV) and hepatitis C virus (HCV) infection--are prevalent among incarcerated persons. We sought to determine the incidence of HBV and HCV infection among recidivist women prisoners. METHODS: From 1996 through 1997, excess from serum samples collected during HIV testing of female admittees to a state Department of Corrections facility were tested for HBV and HCV. Multiple samples obtained from women incarcerated multiple times during the study period were compared for incidence. RESULTS: Baseline prevalences of markers of HBV and HCV were 36% and 34%, respectively. Incidence rates for HBV and HCV infection among reincarcerated women were 12.2 and 18.2 per 100 person-years, respectively. The majority of the time spent between serial intakes was not spent in the correctional facility; thus, incident infections likely occurred in the community. CONCLUSIONS: Incidences of HBV and HCV infection among reincarcerated women were high. Prisons and jails can be efficient locations for the diagnosis, treatment, and prevention of hepatitis B and C through programs such as testing, counseling, education, vaccination, and linkage to medical and drug treatment services.

Gender Differences in HIV Risk Behaviors among Young Adults and Adolescents Entering a Massachusetts Detoxification Center.

We examined gender differences in HIV risk behaviors among young substance abusers 17 through 25 years of age. A voluntary and confidential survey inquiring about HIV-related risk behaviors was administered to clients (N = 200 respondents) on intake at a drug detoxification center in Massachusetts. Female respondents were more likely than males to report having shared their needles (p < 0.01), having had sex in exchange for drugs or money (p < 0.01), sex with an HIV-infected partner (p < 0.01), and sex with an injection-drug user (p < 0.01). They were also more likely to report having been diagnosed with an STD (p < 0.01). Nineteen percent of females (compared to 32% of males) reported always having used condoms for vaginal sex (p = 0.08), and 16% of females compared to 35% of males reported always having used condoms for anal sex (p = 0.06). In our cohort of substance-abusing youth, adolescent and young adult females were more likely than males to report unsafe injection-drug use and sexual practices. The results of this study suggest that programs designed to decrease HIV risk among high-risk substance abusers in detoxification centers should be gender specific.

Difficulties with subpectoral augmentation mammaplasty and its correction: the role of subglandular site change in revision aesthetic breast surgery.

BACKGROUND: Difficulties that arise with subpectoral breast implant placement include the following: malpositioning of the implant; improper superior contouring; and unnatural movement with chest muscle contraction. Correction of these deformities is easily achieved by removal of the subpectoral implant, resuspension of the pectoralis major muscle to the chest wall, and reaugmentation with a new implant in the subglandular plane. This study defines a correction modality for the adverse results of subpectoral implant placement in augmentation mammaplasty. METHODS: Pectoralis major resuspension was performed in 36 patients undergoing revision aesthetic breast surgery from 1995 to 2006. All patients had previously placed subpectoral breast implants performed elsewhere with unwanted movement, malposition, and/or capsular contracture. All patients underwent explantation of the breast implant, modified capsulectomy, pectoralis major resuspension, and reaugmentation of the breast in the subglandular position. In cases of symmastia, medial capsulodesis and sternal bolster sutures were used. Patients were evaluated for resolution of symptoms, satisfaction, and complications. RESULTS: Malposition (62 percent), capsular contracture (53 percent), and symmastia (10 percent) were the most common indications for revision, but 100 percent of patients were dissatisfied with abnormal breast movement. The average follow-up time was 20 months. The silicone implants were commonly used, with an average volume change decrease of 27 cc. Unwanted implant movement was eliminated completely (100 percent), symmastia was corrected (100 percent), and capsular contraction was significantly decreased in each respective group. Patient satisfaction with this procedure was high, with a low complication rate. CONCLUSIONS: Pectoralis major resuspension can be performed successfully in aesthetic breast surgery. It can be applied safely to correct problems of unwanted implant movement, symmastia implant malposition, and capsular contraction. The use of silicone gel implants in a novel tissue plane may be beneficial in this diverse, reoperative patient population.

Functional limb salvage following muscle rigor in a pediatric patient.

Acute limb-threatening ischemia is a vascular surgical emergency. Traditionally, 4 to 6 hours are usually available from the onset of acute ischemia to successfully revascularize before irreversible damage occurs. The presence of ischemic rigor traditionally represents irreparable local damage to muscle in the adult population and is an indication for limb amputation. Although the literature is scarce on this topic, few authors have reported superior limb salvage rates in pediatric patients despite the presence of severely impaired arterial perfusion. We present a case of a 10-year-old girl with rigor of the left lower extremity, who underwent surgical reperfusion for acute ischemia approximately 14 hours after the initiation of symptoms. The patient presented with an insensate and paralyzed limb. Pulsatile flow was restored to her lower extremity. She regained protective sensation and suffered no significant sequelae of systemic reperfusion syndrome.