The effect of early arm exercise on drainage volume after total mastectomy and tissue expander insertion in breast cancer patients: a prospective study.

BACKGROUND: In prosthesis-based breast reconstruction patients, the drain tends to be kept in place longer than in patients who undergo only mastectomy. Postoperative arm exercise also increases the drainage volume. However, to preserve shoulder function, early exercise is recommended. In this study, we investigated the effect of early exercise on the total drainage volume and drain duration in these patients. METHODS: We designed a prospective randomized trial involving 56 patients who underwent immediate breast reconstruction following mastectomy using tissue expanders. In each group, the patients were randomized either to perform early arm exercises using specific shoulder movement guidelines 2 days after surgery or to restrict arm movement above the shoulder height until drain removal. The drain duration and the total amount of drainage were the primary endpoints. RESULTS: There were no significant differences in age, height, weight, body mass index, or mastectomy specimen weight between the two groups. The total amount of drainage was 1,497 mL in the early exercise group and 1,336 mL in the exercise restriction group. The duration until complete removal of the drains was 19.71 days in the early exercise group and 17.11 days in the exercise restriction group. CONCLUSIONS: Exercise restriction after breast reconstruction did not lead to a significant difference in the drainage volume or the average time until drain removal. Thus, early exercise is recommended for improved shoulder mobility postoperatively. More long-term studies are needed to determine the effect of early exercise on shoulder mobility in prosthesis-based breast reconstruction patients.

A prospective comparative study of radiotherapy effect upon scar quality.

INTRODUCTION: The effect of radiation on uncomplicated postoperative scars is unclear. This study aimed to analyze irradiated and non-irradiated scars in patients with unilateral breast cancer, who underwent oncoplastic breast reduction surgery and radiation therapy (RT), to identify how postoperative scar changes with radiation. METHODS: Twenty breast scars in 10 patients were analyzed after unilateral breast-conserving surgery, oncoplastic breast reduction, and RT. Scars were assessed using the Vancouver scar scale (VSS) by two independent blinded observers and three-dimensional scar analysis camera. Paired t-test between irradiated and non-irradiated scars in each patient and correlation of scar score differences with potential contributing factors were analyzed. RESULTS: The VSS was significantly lower for the irradiated scar than that for the non-irradiated contralateral scar (1.40 vs. 4.05, p = 0.001), although time interval from the last radiation to scar assessment had a negative correlation with paired differences of VSS (Spearman's correlation coefficient: -0.637, p = 0.048). Compared with the non-irradiated scar, the irradiated scar showed a significantly high level of hemoglobin (1.04 vs. 1.26, p = 0.017) and melanin (0.55 vs. 0.63, p = 0.03). CONCLUSIONS: Postoperative scars with radiation showed better results in objective and subjective assessments than scars without radiation. These findings suggest that radiation has a positive effect on general scar maturation.

Staged reconstruction of a chronically infected large skull defect using free tissue transfer and a patient-specific polyetheretherketone implant.

Reconstructions of extensive composite scalp and cranial defects are challenging due to high incidence of postoperative infection and reconstruction failure. In such cases, cranial reconstruction and vascularized soft tissue coverage are required. However, optimal reconstruction timing and material for cranioplasty are not yet determined. Herein, we present a large skull defect with a chronically infected wound that was not improved by repeated debridement and antibiotic treatment for 3 months. It was successfully treated with anterolateral thigh (ALT) free flap transfer for wound salvage and delayed cranioplasty with a patient-specific polyetheretherketone implant. To reduce infection risk, we performed the cranioplasty 1 year after the infection had resolved. In the meantime, depression of ALT flap at the skull defect site was observed, and the midline shift to the contralateral side was reported in a brain computed tomography (CT) scan, but no evidence of neurologic deterioration was found. After the surgery, sufficient cerebral expansion without noticeable dead-space was confirmed in a follow-up CT scan, and there was no complication over the 1-year follow-up period.

Sex-related and racial variations in orbital floor anatomy.

BACKGROUND: Repair of the orbital floor following trauma or tumor removal remains a challenge because of its complex three-dimensional shape. The purpose of the present study is to understand normal orbital floor anatomy by investigating its differences across four groups (Caucasian American and East Asian, males and females) via facial bone computed tomography (CT). METHODS: A total of 48 orbits in 24 patients between 20 and 60 years of age were evaluated. Although most patients underwent CT scanning following trauma, the orbital walls were intact in all patients. Linear and angular measurements of the orbital floor were obtained from CT images. RESULTS: Orbital floor width, length, angle between the orbital floor and medial wall, and distance from the inferior orbital rim to the lowest point of the orbital floor did not show a statistically significant difference between groups. Angles made by the infraorbital rim, the lowest point of the floor, and the anterior border of the infraorbital fissure were statistically significantly wider in East Asian females than in male groups. The floor depth in East Asian females was significantly smaller compared to all the other groups. CONCLUSION: East Asian female population had smaller curvature and depth of an orbital floor than the other groups, which means racial and sex-related differences should be considered in the orbital floor reconstruction.

Resorption of labial bone in maxillary anterior implant.

PURPOSE: The purpose of this study was to evaluate the amount of resorption and thickness of labial bone in anterior maxillary implant using cone beam computed tomography with Hitachi CB Mercuray (Hitachi, Medico, Tokyo, Japan). MATERIALS AND METHODS: Twenty-one patients with 26 implants were followed-up and checked with CBCT. 21 OSSEOTITE NT® (3i/implant Innovations, Florida, USA) and 5 OSSEOTITE® implants (3i/implant Innovations, Florida, USA) were placed at anterior region and they were positioned vertically at the same level of bony scallop of adjacent teeth. Whenever there was no lesion or labial bone was intact, immediate placement was tried as possible as it could be. Generated bone regeneration was done in the patients with the deficiency of hard tissue using Bio-Oss® (Geistlich, Wolhusen, Switzerland) and Bio-Gide® (Geistlich, Wolhusen, Switzerland). Second surgery was done in 6 months after implant placement and provisionalization was done for 3 months. Definite abutment was made of titanium abutment with porcelain, gold and zirconia, and was attached after provisionalization. Two-dimensional slices were created to produce sagittal, coronal, axial and 3D by using OnDemand3D (Cybermed, Seoul, Korea). RESULTS: The mean value of bone resorption (distance from top of implant to labial bone) was 1.32 ± 0.86 mm and the mean thickness of labial bone was 1.91 ± 0.45 mm. CONCLUSION: It is suggested that the thickness more than 1.91 mm could reduce the amount and incidence of resorption of labial bone in maxillary anterior implant.

Bladder reconstruction using bovine pericardium in a case of enterovesical fistula.

The use of graft materials in bladder mucosa has been examined in animal models, but debate exists over which materials are effective. Intestine has been used as a substitute in augmentation cystoplasty for patients with neuropathic bladder, but serious adverse effects of the operation have occurred in some instances. We report a case of a successful repair of an enterovesical fistula by use of bovine pericardium. The patient has remained well for 2.5 years. We suggest that bovine pericardium may be a suitable option as a bladder substitute.

Predictive factors of Gleason score upgrading in localized and locally advanced prostate cancer diagnosed by prostate biopsy.

PURPOSE: The Gleason score (GS) is an important factor that is considered when making decisions about prostate cancer and its prognosis. However, upgrading of the GS can occur between transrectal ultrasonography (TRUS) biopsy and radical prostatectomy. This study analyzed the clinical factors predictive of upgrading of the GS after radical prostatectomy compared with that at the time of TRUS biopsy. MATERIALS AND METHODS: We analyzed the medical records of 107 patients who had undergone radical prostatectomy. Patients were divided into two groups. Group 1 consisted of patients in whom the GS was not upgraded, and group 2 consisted of patients in whom the GS was upgraded. Associations between preoperative clinical factors and upgrading of the GS were analyzed. Preoperative clinical factors included age, prostate-specific antigen (PSA), prostate volume, PSA density, GS of TRUS biopsy, maximum core percentage of cancer, percentage of positive cores, number of biopsies, location of positive core with maximum GS, high-grade prostatic intraepithelial neplasia (HGPIN), inflammation on biopsy, and clinical stage. RESULTS: Among 85 patients, 42 (49%) patients had an upgraded GS after operation. TRUS biopsy core number of 12 or fewer (p=0.029) and prostate volume of 36.5 ml or less (p<0.001) were associated with upgrading of the GS. Preoperative clinical factors associated with nonupgrading of the GS were the detection of positive cores with a maximum GS at the apex (p=0.002) or in a hypoechoic lesion (p=0.002) in TRUS. CONCLUSIONS: If the positive cores with maximum GS are located at the apex or in a hypoechoic lesion in TRUS, we can expect that the GS will not be upgraded. In patients with the clinical predictive factors of a prostate volume of 36.5 ml or less and TRUS biopsy core number of less than 12, we can expect upgrading of the GS after radical prostatectomy, and more aggressive treatment may be needed.

Urachal actinomycosis mimicking a urachal tumor.

A 26-year-old man presented with lower abdominal discomfort and a palpable mass in the right lower quadrant. An abdominal computed tomography (CT) scan revealed an abdominal wall mass that extended from the dome of the bladder. Fluorine-18 fluorodeoxyglucose (FDG) positron-emission tomography/CT (PET/CT) showed hypermetabolic wall thickening around the bladder dome area that extended to the abdominal wall and hypermetabolic mesenteric infiltration. Differential diagnosis included a urachal tumor with invasion into adjacent organs and chronic inflammatory disease. Partial cystectomy with abdominal wall mass excision was performed, and the final pathologic report was consistent with urachal actinomycosis.