Expression of a Secreted Fibroblast Growth Factor Binding Protein-1 (FGFBP1) in Angioproliferative Kaposi Sarcoma.

OBJECTIVE: Kaposi's sarcoma (KS) is an angioproliferative disease frequently seen in patients with the acquired immunodeficiency syndrome (AIDS). Previous studies suggest that the HIV-1 protein Tat and Fibroblast Growth Factor 2 (FGF-2) have synergistic angiogenic effects in AIDS-KS tumors. However, the mechanisms by which FGF-2 is released and activated in KS tumors are not clearly defined. We carried out this study to determine whether an FGF-binding protein (FGFBP1 or BP1) that enhances the angiogenic activity of FGF-2 is expressed in AIDS-KS tumors, and to define whether BP1, FGF-2, and HIV-Tat protein-protein interactions could play a potential clinically role in the pathogenesis of AIDS-KS. METHODS: BP1 was localized in AIDS-KS lesions by immunohistochemistry and in situ hybridization studies. The binding of radiolabeled FGF-2 to His-tagged BP1 or the FGF-receptor 1 was assessed in the presence and absence of HIV-Tat and other viral proteins. Mice carrying tetracycline-regulated BP1 transgene mice were used to determine whether activation of BP1 during wound healing induces KS-like lesions. RESULTS: BP1 expression was detected in AIDS-KS tumor keratinocytes, spindle cells, and infiltrating mononuclear cells. In addition, HIV-Tat competed for the binding of FGF-2 to immobilized BP1, but does not affect the interactions of FGF-2 with its high affinity receptor (FGFR-1). In contrast, two other HIV-proteins, Nef and gp120, did not affect the binding of FGF-2 to BP1 or to FGFR-1. Finally, up-regulation of BP1 expression in tetracycline-regulated -conditional BP1 transgenic mice subjected to skin wounds, induced KS-like skin lesions. CONCLUSION: Taking into consideration the results of previous studies showing that both HIV-Tat and BP1 enhance the mitogenic and angiogenic activity of locally-stored FGF-2, both in vitro and in vivo, our findings suggest a novel mechanism by which the release and activity of FGFs can be modulated in AIDS-KS tumors by HIV-Tat as well as BP1.

Applications of acellular dermal matrix in revision breast reconstruction surgery.

BACKGROUND: Acellular dermal matrix has been used for over a decade in primary breast reconstruction. Few articles have specifically examined its use in revision breast reconstruction for fold malposition, capsular contracture, rippling, and symmastia. METHODS: One hundred thirty-five revision breast reconstructive procedures using acellular dermal matrix (AlloDerm) in 118 patients (154 breasts) over a 5-year period were reviewed. Most procedures were revisions or part of the second stage of previous mastectomy reconstructions; three were revisions after reconstruction of congenital chest wall deformities. RESULTS: Fifty-seven revisions (37 percent) were for inferior fold malposition, followed by 40 (25.9 percent) for inferior pole support, 42 (27.2 percent) for capsular contracture, 10 (6.4 percent) for rippling, and five (3.2 percent) for symmastia. The overall complication rate was 5 percent. Revisions with acellular dermal matrix were successful in 147 of 154 breasts (95.5 percent). The most common complication was capsular contracture, occurring in five breasts (3.2 percent). There was one infection (0.6 percent), failure to lower the inframammary fold in one breast (0.6 percent), and one persistence of rippling (0.6 percent). The mean follow-up was 207 days. CONCLUSIONS: Acellular dermal matrix has proven to be a reliable tool for managing some of the most common and challenging problems in implant-based breast reconstruction. Although there are few published data on the success of more conventional solutions to fold malposition, lower pole support, and capsular contracture, the addition of acellular dermal matrix to buttress these repairs has been shown to provide a high likelihood of success with a low risk of complications.

Porcine acellular dermal matrix (strattice) in primary and revision cosmetic breast surgery.

BACKGROUND: Although acellular dermal matrix materials have been in use for over a decade in primary and secondary breast reconstruction and in some cosmetic breast surgery, little has been published on the outcomes of these materials for cosmetic applications. METHODS: A retrospective institutional review board-approved review was conducted of all patients who had a specific acellular dermal matrix, Strattice, used for cosmetic breast surgery performed by the senior author (S.L.S.). Patient demographics, indications, surgical findings, and postoperative course were collected and data analyzed using descriptive statistical tools. RESULTS: Between 2008 and 2012, Strattice was used in 43 cosmetic breast operations (75 breasts) performed by the senior author (S.L.S.). Sixty-nine of the 75 breasts (92 percent) were revision operations. Indications included inferior pole support [39 breasts (52 percent)], fold malpositions [28 breasts (37 percent)], capsular contracture [25 breasts (33 percent)], and rippling/palpability [six breasts (8 percent)]. Three patients (six breasts) had Strattice placed during primary augmentation/mastopexy. Seventy-four of the 75 breasts (98.7 percent) had successfully achieved the indication for which the Strattice was placed; one breast (1.2 percent) had some degree of relapse. The global complication rate for all patients in this study is 5.3 percent-two breasts (2.7 percent) had postoperative malposition, one breast (1.2 percent) had bottoming out, and one breast (1.2 percent) developed an infection that resulted in temporary device explantation. CONCLUSIONS: The use of Strattice is safe and may be helpful in the management of certain situations in cosmetic breast surgery, including needed lower pole support, capsular contracture, rippling, and implant malposition. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Repairing the high-riding nipple with reciprocal transposition flaps.

The high-riding nipple-areola complex is a clinical problem that can be encountered following cosmetic and reconstructive breast surgery. Because of the desire to avoid scars on the superior aspect of the breast and the limited availability of superior breast skin, it can be technically challenging to place the nipple-areola complex in a lower position. Multiple surgical strategies have attempted to lower it, and each has its advantages and disadvantages. Reciprocal rotation flaps have been used by the authors with success. They describe the surgical technique and outcomes in five breasts. The medical records of all patients who had reciprocal rotation flaps for high-riding nipple-areola complexes performed by the senior author (S.L.S.) were reviewed. The institutional review board-approved review included preoperative history and examination, surgical findings, surgical technique, and postoperative course. Five reciprocal rotation flap procedures were performed on four patients between 2005 and 2012 for high-riding nipple-areola complexes. The high-riding nipple-areola complexes were all iatrogenic, following reconstruction for nipple-sparing mastectomy or mastopexy. All nipple-areola complexes were successfully lowered with an average follow-up duration of 2.1 years. One breast that had undergone previous radiation therapy had a nipple-areola complex flap that appeared ischemic; the patient underwent hyperbaric oxygen therapy and the flap fully survived. Reciprocal rotation flaps are an effective strategy for management of the high-riding nipple-areola complex and can be safely performed with thoughtful planning and careful surgical technique. This technique is riskier in the irradiated breast but may be facilitated with hyperbaric oxygen therapy.

Classification and management of the postoperative, high-riding nipple.

BACKGROUND: Postoperative nipple malposition can be an aesthetically devastating problem for patients and a formidable challenge for surgeons. The authors' aim was to identify the common antecedent events leading to high-riding nipples, provide a classification system for these problems, and discuss management. METHODS: A retrospective review of medical records was conducted for patients who presented to the senior surgeon (S.L.S.) for management of a postoperative, excessively high nipple-areola complex over an 8-year period from January of 2004 to March of 2012. Demographic information, medical histories, operative details, and office records were reviewed for each patient. The high nipple-areola complex was classified as mild, moderate, or severe depending on the distance from the superior breast border to the top of the nipple-areola complex in relation to the vertical breast height. RESULTS: Twenty-five women met study criteria, with 41 breasts determined to have an excessively high nipple-areola complex. The average patient was aged 44.3 years and had undergone 2.5±1.3 operations before the development of a notably high nipple-areola complex, including nipple-sparing mastectomy (32 percent), augmentation/mastopexy (29 percent), augmentation (27 percent), mastopexy (10 percent), and skin-sparing mastectomy with nipple reconstruction (2 percent). Patients were classified as having mild (27 percent), moderate (56 percent), or severe (17 percent) nipple-areola complex displacement; surgical correction was attempted in 54 percent of cases. CONCLUSIONS: A high-riding nipple-areola complex can develop following aesthetic or reconstructive surgery. Although many patients may not need or choose correction, there are surgical options that may be helpful in improving the nipple-areola complex position.

Focus on technique: supporting the soft-tissue envelope in breast reconstruction.

Prosthetic-based breast reconstruction commonly involves device placement in either a total submuscular pocket or a partial subpectoral position for just superior pole coverage, with various possible strategies for inferior pole coverage. Historically, the pectoralis major muscle is managed either by suturing the muscle to the inferior flap or with marionette sutures; alternatively, the device is placed under total muscle/fascia coverage (under the pectoralis major, plus the serratus anterior and rectus abdominis muscles or fascia). For many plastic surgeons, acellular dermal matrix is now used instead to function as a sling or "hammock" supporting the periprosthetic pocket and thus covering the inferior pole of the device, attached to the pectoralis major muscle above and to the inframammary fold below. In addition to its added soft-tissue support in the inferior pole, acellular dermal matrix may help to stabilize the pectoralis major muscle along its inferolateral margin, create a well-defined inframammary fold, provide the opportunity to significantly increase intraoperative fill volume of the tissue expander, and reduce the incidence or severity of significant or symptomatic capsular contracture, particularly in a patient whose breast has been treated with radiation. In addition to its indications in primary breast reconstruction, acellular dermal matrix has been increasingly used in secondary revision reconstruction cases. It can be used to buttress capsulorrhapy and capsulotomy sites and it can be used to replace periprosthetic capsule following capsulectomy. While clinical experience is accruing for these indications, acellular dermal matrix continues to be used in primary and secondary breast reconstruction.

Late seromas after breast implants: theory and practice.

BACKGROUND: Late seromas surrounding breast implants are becoming an increasingly important issue in breast surgery. The authors report their experience with late seromas and describe their previous management options. METHODS: A multicenter retrospective review of patients who developed late seromas (clinically presenting seromas without evidence of overt or documented infection more than 1 year after implant operation) was performed. Management, surgical technique, outcomes, complications, culture findings, and cytology results were recorded. RESULTS: Between 2005 and 2010, 28 late seromas were identified in 25 patients. The average interval from the patient's last surgery to seroma onset was 4.7 years; 27 of 28 breasts (96 percent) had a Biocell textured device in place at the time of seroma development. The late seromas in the series were managed as follows: 15 (53.6 percent) by complete capsulectomy, seroma drainage, and new implant placement; three (10.7 percent) by seroma drainage and new implant placement but without capsulectomy; two (7.1 percent) by complete capsulectomy and seroma drainage but without implant replacement; five (17.9 percent) by only ultrasound-guided seroma drainage without the need for surgical intervention; and three (10.7 percent) by antibiotic therapy alone. All cultures and cytology studies were negative for malignancy or infection; 27 of 28 seromas (96 percent) were treated successfully by one of the described approaches. CONCLUSIONS: Biocell textured implants were more likely to be associated with late seromas than were smooth shell implants. The overwhelming majority of late seromas appear to be idiopathic, without clear evidence of infection or malignancy. A graduated approach, including several different management strategies, was used to successfully manage these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Nipple-sparing mastectomy for prophylactic and therapeutic indications.

BACKGROUND: Nipple-sparing mastectomy remains controversial and its adoption has been slow because of oncologic and surgical concerns. METHODS: A retrospective study evaluated all nipple-sparing mastectomies performed at a single institution for therapeutic or prophylactic indications for which records were available. RESULTS: Between 1989 and 2010, 162 nipple-sparing mastectomies were performed in 101 women. Forty-nine (30 percent) were performed for therapeutic purposes on 48 patients. A subareolar biopsy specimen was taken in 39 of 49 breasts (80 percent); four (10 percent) revealed ductal carcinoma in situ, and the nipple or nipple-areola complex was later removed. Four of 49 breasts (8 percent) in the therapeutic group had ischemic complications involving the nipple-areola complex, one of which (2 percent) was excised. With a mean follow-up of 2 years 6 months (range, 5 months to 9 years 5 months), no patients developed cancer in the nipple-areola complex. The remaining 113 mastectomies (70 percent) were performed prophylactically on 80 patients. The subareolar tissue was biopsied in 80 breasts (71 percent). One biopsy revealed lobular carcinoma in situ; none had ductal carcinoma in situ or invasive cancer. Two nipple-areola complexes (1.8 percent) were ischemic and excised. With a mean follow-up of 3 years 7 months (range, 5 months to 20 years 6 months), no patients developed new primary cancers in the nipple-areola complex. CONCLUSIONS: Nipple-sparing mastectomy can be safe in properly selected patients. A subareolar biopsy can effectively identify nipple-areola complexes that may harbor cancerous cells. Ischemic complications resulting in nipple loss can be minimized, and long-term follow-up suggests that this technique deserves further investigation in properly selected patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Perioperative complications in patients undergoing peripheral nerve surgery.

INTRODUCTION: With increasing indications for and volume of patients undergoing peripheral nerve surgery, it becomes imperative that complication rates are monitored. This study looks at complication rates in all types of peripheral nerve surgery, develops a complication classification system, and defines the most common variables associated with failures and complications. METHODS: All peripheral nerve procedures performed by the senior author during a consecutive 6-year period were retrospectively reviewed. Complications occurring within the first 30 postoperative days were recorded and classified into minor, intermediate, or major. RESULTS: A total of 5219 procedures were performed on 1819 patients in all areas of the body (head and neck, trunk, and upper and lower extremities). The total complication rate was 2.91%, with a minor complication rate of 2.47%, intermediate complication rate of 0.44%, and major complication rate of 0%. CONCLUSIONS: This study confirms that peripheral nerve surgery can be safely performed with a very low complication rate if patients are properly selected and the surgeon is appropriately trained. A classification system for complications after peripheral nerve surgery and the most common variables associated with failures and complications are presented.

Minimally invasive peripheral nerve surgery: a short scar technique.

INTRODUCTION: As peripheral nerve specialists can have a wide variety of training backgrounds, few standards of care exist with respect to necessary incision length, amount of dissection, and operative technique for common nerve decompressions. METHODS: Approaches for the following 12 common peripheral nerve surgeries were minimized using shorter incisions and a simple lighted retractor: zygomatico-temporal and auriculotemporal, greater occipital, brachial plexus, ulnar, radial, median, lateral femoral cutaneous nerve of the thigh, peroneal at the groin, fibular neck and lateral calf, and tibial and inner ankle. The new "minimal" incision length was recorded as was that of the "classical" approach as taught to the senior author and frequently represented in atlases. A Mann-Whiney analysis was independently performed to evaluate for significance between the lengths of incisions for each procedure. RESULTS: The average length of the "minimal" incisions was 3.9 ± 0.6 cm (range, 3.1-6.1 cm), with an average reduction in length of 51% as compared with the "classical" incisions (range, 30-75%; P < 0.001). There were no perioperative morbidities. CONCLUSIONS: Minimally invasive peripheral nerve surgery applied to the above procedures yields successful surgical outcomes while shortening incision lengths and maximizing patient satisfaction without sacrificing patient safety.

Chronic headaches/migraines: extending indications for breast reduction.

BACKGROUND: In patients with macromastia, the currently accepted indications for reduction mammaplasty are back pain, neck pain, shoulder grooving, and intertrigo in the inframammary fold. Occipital neuralgia and chronic headaches/migraines are not indications, but the authors noted anecdotally that numerous patients with macromastia complained of chronic headaches/migraines, and many of them reported headache improvement following surgery. Therefore, the authors conducted a retrospective review of their cases to evaluate this association. METHODS: A retrospective chart review of all patients undergoing reduction mammaplasty between 2003 and 2008 performed by the senior author (I.D.) was conducted. Patients were followed with clinic visits and telephone interviews. Collected data included preoperative symptoms, pain scores, and postoperative findings. Statistical analysis was conducted using the paired t test. RESULTS: Of the 84 patients who underwent reduction mammaplasty for macromastia between 2003 and 2008, 58 (69 percent) had chronic headaches preoperatively. Of these 58 patients, 31 (53 percent) reported a greater than 50 percent reduction in headache frequency and severity, with 12 (21 percent) stating that their headaches resolved completely after surgery. These patients reported a mean pain score of 7.2 (of 10) before surgery that dropped to 3.2 after reduction mammaplasty. Of all patients, 90 percent reported an improvement in their quality of life. CONCLUSIONS: The authors' data show that patients with macromastia who have occipital neuralgia and/or chronic headaches/migraines can experience headache relief following reduction mammaplasty. Future research should evaluate headaches as indications for reduction mammaplasty. Those patients whose headaches do not improve following breast reduction should consider further specialized evaluation and treatment.

Management of chronic leg and knee pain following surgery or trauma related to saphenous nerve and knee neuromata.

Patients who present with lower extremity pain following surgery or trauma can occasionally have the saphenous nerve as the offending anatomic cause of their pain. Consistent with its anatomic course, the saphenous nerve can be the source of pain that manifests anywhere along its sensory distribution.Patients who presented to the Georgetown Peripheral Nerve Institute with lower extremity pain were evaluated, and those patients whose pain was suspected to be of saphenous nerve origin were offered surgical treatment. The surgical intervention included excision of the neuroma and/or nerve decompression, as clinically indicated. Patients were followed clinically and evaluated for both their pain as well as recovery in their ambulation and quality of life.Forty-two consecutive patients underwent surgery for pain of saphenous nerve origin from 2003 to 2008; 69% of these patients had concomitant surgery on another involved lower extremity peripheral nerve. Follow-up was achieved in 35 patients (83% response rate), with an average follow-up duration of 34.7 months. Using a 10-point pain scale, patients reported their preoperative pain as an 8.0 and their postoperative pain as a 2.37 (P < 0.001). Of the 35 patients, 30 (86%) were able to ambulate at the last follow-up encounter. Patients were asked to report their quality of life on a 10-point scale, and reported a 77% recovery of their baseline quality of life as a result of peripheral nerve surgery performed. Of the 35 patients, 29 reported that the surgery effectively resolved their pain, yielding a success rate of 82.8%.The saphenous nerve can be a source of lower extremity and knee pain following trauma or surgery. Accurate clinical diagnosis followed by surgical intervention can result in clinical resolution in the majority of patients, with improvement in ambulation and quality of life. This study reports the largest series of surgically-corrected saphenous neuropathy in the literature.

Microvascular free flap failure caused by unrecognized hypercoagulability.

BACKGROUND: Microvascular free flap techniques have improved over the past two decades such that flap failure rates have dropped to under 3 percent in most large series of high-volume centers. However, despite technical and patient-selection advances, some components of free flap failure might be attributable to undiagnosed patient factors. METHODS: In this clinicopathologic conference article, the authors present four patients with major free flap microvascular complications who were later diagnosed with multiple risk factors for hypercoagulability and biochemical abnormalities, and present the characteristic associated findings. RESULTS: Previously undiagnosed hypercoagulability was present in four patients with major free flap microvascular complications. Hematologic consultation and laboratory investigation revealed the biochemical abnormalities. CONCLUSIONS: In certain patients undergoing microvascular free flap reconstruction, undiagnosed hypercoagulability risk factors can be a source of free flap failure that is independent of patient selection or technical factors. Diagnosis, management, patient counseling, and initiation of deep venous thromboembolism prophylaxis measures are critical clinical components of care of these patients.

Benign peripheral nerve tumors: treatment algorithm and reconstructive options.

Peripheral nerve tumors are mostly benign; however, their excision can result in profound deficits. Nerve reconstruction strategies offer techniques to minimize morbidity. In this prospective study, 20 consecutive patients with benign peripheral nerve tumors were treated using a single-stage surgical paradigm between 2003 and 2007. Nerve fascicles were microdissected off of the tumor; any fascicle that gave origin to the tumor (was inseparable from tumor) was reconstructed using nerve conduits. Patients were followed from 6 to 24 months. All patients had neuropathic pain before tumor excision; only 1 patient had pain persist postoperatively. Seventeen patients had complete functional recovery after nerve reconstruction. No perioperative complications occurred. Benign peripheral nerve tumors require highly specialized surgical care. Tumor excision with immediate nerve reconstruction, for fascicles inseparable from the tumor, optimizes outcomes. Nerve reconstruction with available conduits or allografts should be attempted to restore anatomic integrity to any killed fascicles, thereby minimizing possible deficits.

Anatomical variations of the occipital nerves: implications for the treatment of chronic headaches.

BACKGROUND: The anatomy of the greater and lesser occipital nerves has come under increased scrutiny with the increased appreciation of their role in the causation of chronic occipital headaches. Classic anatomical descriptions of their paths have differed from some recent published reports. METHODS: Measurements of the courses of the greater and lesser occipital nerves were conducted bilaterally in 125 individuals, consisting of 112 live intraoperative measurements and 13 cadaver specimens. In addition to nerve width and trajectory in the occiput, measurements of the distance of the nerves from the occipital protuberance were performed. RESULTS: The greater occipital nerve had a diameter of 3.8 +/- 1.6 mm, and emerged from the semispinalis capitis muscle 14.9 +/- 4.5 mm lateral to the midline and 30.2 +/- 5.1 mm inferior to the occipital protuberance. The nerve almost always (98.5 percent) pierces the body of the semispinalis capitis muscle, and in 6.1 percent of individuals it is split by fibers of this muscle or in the trapezial tunnel. The nerve then travels in a superolateral course. In 43.9 percent of patients, the nerves were asymmetric on the two sides. The lesser occipital nerve had a diameter of 1.2 +/- 1.6 mm and was often located along the posterior border of the sternocleidomastoid muscle. CONCLUSIONS: The course of these two nerves differs in several critical aspects from that described in classic anatomical reports. These findings have direct implications for application of nerve blocks and surgical decompression of these nerves.

The role of the neuropeptide Y2 receptor in liporemodeling: neuropeptide Y-mediated adipogenesis and adipose graft maintenance.

BACKGROUND: Neuropeptide Y is a signaling molecule that was recently found to stimulate adipose tissue growth in vitro by means of a peripherally acting mechanism involving the neuropeptide Y2 receptor found on adipocytes and endothelial cells. This study aims to evaluate the translational applications of a neuropeptide Y2 receptor agonist for autologous fat grafting in plastic surgery. METHODS: Murine and primate animal models were used to investigate the proliferative effects of neuropeptide Y on adipose tissue. The effect of applying neuropeptide Y to subcutaneous tissues in mice and monkeys was assessed by magnetic resonance imaging, histology, and immunohistochemistry. The effect of neuropeptide Y on human fat xenograft survival and vascularity in athymic mice was measured by ultrasonography and immunohistochemistry. Six animals per group were used in murine experiments, and two animals were used in the pilot primate study. RESULTS: Neuropeptide Y stimulated growth of adipose tissues when applied subcutaneously in mice and monkeys, and increased human fat xenograft survival and vascularity in athymic mice at 3 months. CONCLUSIONS: These data provide in vivo evidence for a critical role for neuropeptide Y/neuropeptide Y2 receptor interactions in adipogenesis, and suggest neuropeptide Y2 receptor as a potential target for agonist compounds that can be used to enhance fat graft survival or stimulate de novo adipogenesis.

Prophylactic mastectomy and reconstruction: clinical outcomes and patient satisfaction.

BACKGROUND: The purpose of this study was to evaluate both clinical outcomes and satisfaction in patients who have undergone prophylactic mastectomy and breast reconstruction. METHODS: A 5-year retrospective analysis of the senior author's (S.L.S.) experience with breast reconstruction following prophylactic mastectomy was performed. Timing, type of mastectomy and reconstruction, complications, and cancer occurrence/recurrence were examined. Patients reported their level of satisfaction and willingness to undergo the procedure again. Aesthetic outcomes were graded by an independent and blinded group of surgeons. RESULTS: There were 101 breast reconstructions performed in 74 patients following prophylactic mastectomy. With a mean follow-up of 31 months, there were three breast-site complications in this group (3 percent). Forty-seven patients in the study had a unilateral prophylactic mastectomy; on the contralateral side with cancer, there were five breast-site complications in reconstructions following therapeutic mastectomy (10 percent). Aesthetic outcome ratings by surgeons were higher in the bilateral prophylactic mastectomy and reconstruction patients compared with the cancer patients who had undergone a therapeutic mastectomy and reconstruction along with a contralateral prophylactic mastectomy; however, this difference did not reach statistical significance. Patient satisfaction was higher in the bilateral prophylactic group, with all of the patients completing the survey stating they would undergo the procedure again. CONCLUSIONS: Breast reconstruction following prophylactic mastectomy was as safe as or more safe than that following therapeutic mastectomy, which has been shown in other studies to result in a high percentage of patient satisfaction. Although not statistically significant, the results from reconstruction after prophylactic mastectomy trended toward improved aesthetic outcome with a lower complication rate compared with reconstruction after therapeutic mastectomy.

The role of peripheral nerve surgery in the management of painful chronic wounds: indications and outcomes.

BACKGROUND: Patients with chronic wounds caused by healing problems often present with chronic pain at the site. Proper wound care with or without appropriate reconstruction usually addresses both the wound and its associated pain. However, wounds occasionally remain painful despite successful reconstruction, particularly when they are complicated by an underlying condition. These patients frequently develop a disabling chronic pain condition despite the application of current treatment modalities. The authors used a novel approach to manage this difficult clinical situation, by addressing the sensory nerve supply to the affected wound region. METHODS: Five women and two men with intractable chronic pain despite wound reconstruction underwent surgery and were followed for a mean period of 27 months (range, 8 to 40 months). The involved sensory nerve was identified preoperatively by physical examination, confirmed by nerve block, and then surgically excised and implanted into adjacent muscle. Each patient's pain reduction, ambulation status, and quality-of-life improvement were evaluated. RESULTS: The involved nerves included the ilioinguinal, lateral femoral cutaneous, sural, saphenous, superficial peroneal, and deep peroneal nerves, and the genital branch of the genitofemoral nerve. All seven patients reported significant pain reduction (p < 0.0001), improved ambulation (p < 0.0001), and improved quality of life (p < 0.0001), as evaluated at last follow-up (mean, 27 months). CONCLUSIONS: This study suggests that an additional treatment modality in the management of chronic wounds can be considered for patients with disabling pain. As an adjunct to other interventions, this novel application of peripheral nerve surgery can critically improve symptoms in selected patients with intractable chronic wound pain.

Algorithm for treatment of postoperative incisional groin pain after cesarean delivery or hysterectomy.

OBJECTIVE: Despite the low mortality and morbidity of major obstetric and gynecologic surgeries (including hysterectomy and cesarean delivery), women undergoing these procedures occasionally suffer from intractable postoperative suprapubic and groin pain. We present seven patients whose intractable pain lasted longer than 6 months and was not due to gynecologic disease or other obvious pathology. METHODS: Neuromas of the ilioinguinal, iliohypogastric, and/or genitofemoral nerves were suspected clinically and confirmed intraoperatively. RESULTS: After neuroma resection, all patients reported complete and durable pain relief. CONCLUSION: Intractable pain after obstetric or gynecologic surgery can be due to neuroma formation, and resection is therapeutic. We suggest an algorithm for the management of women with chronic intractable suprapubic or groin pain after major obstetric and gynecologic surgery. LEVEL OF EVIDENCE: II-3.