Comparison of Allergan, Mentor, and Sientra Contoured Cohesive Gel Breast Implants: A Single Surgeon's 10-Year Experience.

BACKGROUND: Contoured cohesive gel breast implants have been recently approved in the United States. These implants have been available for premarket approval studies for selected surgeons. The purpose of this study was to assess a single surgeon's outcomes in three specific clinical situations-breast augmentation, secondary augmentation, and breast reconstruction-using implants of all three contoured cohesive gel implant manufacturers (Allergan, Mentor, and Sientra) over a 10-year period. METHODS: The authors performed a prospective study of contoured cohesive silicone gel breast implants. Demographic and outcomes data were recorded. Complication rates were compared among the three implant manufacturers. RESULTS: From 2001 to 2013, 695 patients were included from U.S. Food and Drug Administration clinical trials. Mean age at implantation was 42.7 years (range, 18 to 82 years), and mean time enrolled was 5.3 years (range, <1 to 10 years). One hundred sixty-four patients (24 percent) received Allergan implants, 245 (35 percent) received Mentor implants, and 286 (41 percent) received Sientra implants. Three hundred eighty-four patients (55 percent) underwent primary augmentation, 198 (29 percent) underwent secondary augmentation, and 113 (16 percent) underwent breast reconstruction. The total complication rate was the lowest for primary augmentation of the Mentor group compared with the Allergan and Sientra groups (p < 0.05). There were no significant differences in complication rates when used for secondary augmentation and reconstruction. There was no statistically significant difference between implant group reoperation, explantation, or capsular contracture rates. Overall implant rupture and rotation rates were low (0.7 percent and 1.3 percent, respectively). Patient and surgeon satisfaction was high. CONCLUSIONS: Contoured cohesive gel breast implants overall have low complication rates and high patient and surgeon satisfaction. The authors believe these implants to be safe and effective in breast augmentation and reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Upper extremity deep vein thrombosis with tourniquet use.

INTRODUCTION: Upper extremity deep vein thrombosis is an increasingly important clinical finding with significant morbidity and mortality. The condition may be under-diagnosed in trauma and surgery settings. PRESENTATION OF CASE: We present a case of upper extremity thrombosis with venous congestive symptoms secondary to the use of an operative tourniquet. A literature review and discussion of the causes of upper extremity deep vein thrombosis and the pathophysiological disturbances seen with tourniquet use are presented. DISCUSSION: Upper extremity deep venous thrombosis is uncommon. In this case the likely cause was operative tourniquet use. CONCLUSION: Operative tourniquet may be a risk factor in upper extremity deep vein thrombosis.

Amnion-derived cellular cytokine solution promotes macrophage activity.

Activated macrophages play a significant role in wound healing and infected tissue repair. In this study, we investigate the recruitment of macrophages into the wound, and the effects on the bactericidal/phagocyte activity after exposure to amnion-derived cellular cytokine solution (ACCS). To evaluate the influence of ACCS on the migratory behavior of macrophages, cell migration was assayed quantitatively using a Boyden chamber. Chemotactic migration activity of macrophages through the membrane determined the influence of ACCS. In the presence of ACCS, macrophages demonstrated a statistically significant (P < 0.05) increase in migration as compared with controls. Subsequently, groups of macrophages were exposed to different concentrations of ACCS solution. The killing and phagocytic activity of each group was compared with the control after exposure to Escherichia coli. Macrophage activity following activation by higher concentrations of ACCS demonstrated significantly increased phagocytosis as well as a trend correlation between percentage ACCS concentration and bactericidal activity. These cell types, critical to normal wound healing, may be influenced by ACCS to accelerate migration and enhance bactericidal/phagocytic activity in wounds.

Clinical challenge: cutaneous Kaposi's sarcoma of the lower extremity.

Kaposi's sarcoma (KS) typically presents as multiple bilateral cutaneous patches or plaques of the lower extremities. This malignancy, however, can evolve with atypical presentation masquerading as a chronic wound. Lesions can mimic venous stasis ulcers, arterial insufficiency, vascular ulcers or chronic-infected wounds. With acquired immune deficiency syndrome (AIDS)-associated KS, lesions are even more widespread, and can affect the respiratory tract, lymph nodes, gastrointestinal tract, spleen, liver and, rarely, bone. As the initial diagnosis of KS is generally determined clinically, a high index of suspicion is necessary for all patients with a known or suspected history of HIV/AIDS. Tissue biopsy with histological analysis is essential for all wound types in this patient subset, regardless of wound presentation. The purpose of this report is to review the pathogenesis as well as the typical and atypical presentations of KS with an example of a diagnostic dilemma.

Individualized, targeted wound treatment based on the tissue bacterial level as a biological marker.

BACKGROUND: The use of biologic markers to aid in individualizing wound treatment may help improve outcomes. A biologic marker that has been demonstrated to be predictive of healing in both chronic and acute wounds is wound tissue bacterial level. The objective of this study was to determine whether tissue bacterial level can be used to individualize wound treatment regimens with a stem-like cell-derived product. METHODS: Amnion-derived cellular cytokine solution (ACCS) was topically applied to rat chronic wounds, and healing rates were measured. RESULTS: Experimental wounds treated with ACCS demonstrated accelerated healing regardless of the tissue level of bacteria, compared with saline. As the level of tissue bacteria increased, the frequency of ACCS application required to obtain optimal results increased. CONCLUSIONS: It appears that the biologic characteristic of tissue bacterial level can serve as a marker to predict the response of open granulating wounds treated with ACCS.

Primary breast lymphoma after mastectomy with reconstruction.

Primary breast lymphoma accounts for only 0.05%-1.1% of all breast malignancies, and less than 1% of all cases of non-Hodgkin lymphoma. Although primary breast lymphoma may present clinical similarities to breast carcinoma, the majority of cases lack the typical features of breast malignancy or lymphoma. We describe a case of primary breast lymphoma in a reconstructed breast, 8 years after a mastectomy for breast cancer. To the best of our knowledge, this is the first reported case in the worldwide literature of primary breast lymphoma in a reconstructed breast. We will discuss the diagnostic and treatment strategies involved in the management of primary breast lymphoma, and the effect of breast reconstruction on the detection of recurrent breast cancer.

Amnion-derived cellular cytokine solution (ACCS) promotes migration of keratinocytes and fibroblasts.

Amnion-derived Multipotent Progenitor cells appear to be useful as adjuvants in wound healing. Amnion-derived multipotent progenitor cells secrete a unique combination of cytokines and growth factors, known as amnion-derived cellular cytokine solution (ACCS). In the skin, a cytokine communication network between mesenchymal and epithelial cells tightly controls keratinocyte and fibroblast migration, proliferation and differentiation-key determinants of wound healing. To evaluate the influence of ACCS on the migratory behavior of keratinocytes and fibroblasts, cell migration was assayed quantitatively using a Boyden chamber. Chemotactic migration activity of fibroblasts or keratinocytes through the membrane determined the influence of ACCS. In the presence of ACCS, fibroblasts and keratinocytes demonstrated a statistically significant (P < 0.05) increase in migration when compared with controls. These cell types, critical to normal wound healing, may be influenced to accelerate migration in wounds, thus accelerating wound repair/healing.

Treatment of eccrine carcinoma of the chin via submental island flap.

BACKGROUND: The submental artery island flap is a reliable reconstructive option for lower face defects. Advantages of this flap include suppleness of tissue, excellent color and texture match to facial skin, a wide arc of rotation, prominent blood supply, and a well-hidden donor site scar. METHODS: This article describes a 61-year-old man with eccrine carcinoma of the chin necessitating extensive excision. A submental artery island flap was used for the reconstruction of the extended chin subunit. RESULTS: The operation resulted in excellent aesthetic outcome and maintenance of oral competence. CONCLUSION: The submental artery island flap utilizes loose tissue of the submental area to effectively and reliably reconstruct the soft tissue subunits of the chin and is a superb option for sizable defects. The flap is sufficiently well vascularized to tolerate postoperative radiation therapy without significant fibrosis or retraction.

An algorithmic approach to breast reconstruction using latissimus dorsi myocutaneous flaps.

BACKGROUND: Innovative surgical techniques developed by surgical oncologists have changed the landscape of mastectomy defects. Latissimus dorsi myocutaneous flap-based breast reconstruction provides a reliable foundation for breast reconstruction. The purpose of this study was to evaluate differential skin island designs with latissimus dorsi myocutaneous flap breast reconstruction, and to develop an algorithmic approach to breast reconstruction that is applicable to a broad spectrum of mastectomy defects. METHODS: In this study, the authors retrospectively reviewed data of patients who underwent latissimus dorsi myocutaneous flap reconstruction following unilateral or bilateral mastectomies between February of 2001 and April of 2005. Patients were selected to undergo reconstruction under the following circumstances: (1) previously irradiated tissue, (2) body mass index greater than 30, (3) current tobacco use, (4) previous abdominopelvic surgery, and (5) patient preference. Patients were divided into three groups based on defect present: intact inframammary fold with skin deficit, intact inframammary fold without skin deficit, and absent inframammary fold with or without skin deficit. Differential skin island design was customized to the presenting mastectomy defect to optimize results and minimize donor-site scaring. RESULTS: Fifty-four patients underwent 64 latissimus dorsi myocutaneous flap reconstructions. Aesthetic outcomes and donor-site scar placement differed between groups. CONCLUSIONS: The authors have developed an algorithmic approach to latissimus dorsi myocutaneous flap breast reconstruction. Through critical evaluation of mastectomy defects, reconstructive breast surgeons can tailor skin island orientation, minimize donor-site scarring, enhance cosmetic outcomes, and provide a durable and natural aesthetic outcome in breast reconstruction with the latissimus dorsi myocutaneous flap.