Variance in the origin of the pectoralis major muscle: implications for implant-based breast reconstruction.

BACKGROUND: The pectoralis major muscle plays a crucial role in implant-based breast reconstruction. The goal of this study is to document variations of the origin of the pectoralis major muscle (PM). We hope to understand how many women have anatomy allowing for total submuscular coverage of an implant with the PM alone in immediate breast reconstruction. METHODS: Fifty patients undergoing mastectomy were recruited. Breast width and the costal origin of the natural inframammary fold (IMF) were measured preoperatively and intraoperatively. The PM width at its origin and the rib origin of the PM were measured intraoperatively. A ratio of the PM origin width to breast width was calculated. RESULTS: Forty-four percent of breasts studied had the IMF at the level of the seventh rib, 53% at the sixth rib, and 3% at the fifth rib. Twenty percent of PM muscles originated from the seventh rib, 68% from the sixth rib, and 12% from the fifth rib. Thirty-six percent of chests showed a PM originating one rib level above the IMF, 61% at the same level, and 3% one level below the IMF. Seventy-seven percent of chests showed a PM origin width to breast width ratio of <0.8. CONCLUSIONS: Overall, 72% of chests had either a high origin of the PM, a narrow PM relative to the breast width, or both. This anatomy is suboptimal for implant coverage using the PM alone. Surgeons performing implant-based breast reconstruction should be prepared to utilize wide dissection, alternative muscle recruitment, or supplemental acellular dermal matrix.

Recombinant activated protein C induces dose-dependent changes in inflammatory mediators, tissue damage, and apoptosis in in vivo rat model of sepsis.

BACKGROUND: Sepsis is the tenth leading cause of death in the U.S. and creates a $16.7 billion burden on the healthcare system every year. Sepsis is characterized by a severe uncontrolled inflammatory response to the infection. Various cells and mediators are activated, and the result is a complex interaction between the inflammation and coagulation cascades leading to capillary leakage and end-organ ischemia. Current therapeutic strategies, such as recombinant human activated protein C, focus on this interplay. However, this drug's precise mechanism of action is not well understood. The aim of this study was to assess cytokine production, tissue damage, and apoptosis in a rat model of sepsis in response to various doses of this drug. METHODS: Sprague-Dawley rats were divided into eight groups, including negative control, sham, sepsis only, and five treatment groups. The sepsis and treatment groups were given Escherichia coli. Each of the treatment groups received a different dose of recombinant activated protein C to complete 30-min or 270-min infusion times from the onset of sepsis. Serum and tissue samples were collected. Interleukin (IL)-6 concentrations were measured, and serum malondialdehyde (MDA) concentrations were determined to assess generalized tissue damage. Apoptosis in the lung was evaluated using a semi-quantitative ligation-mediated polymerase chain reaction assay. RESULTS: The physiologic effects of recombinant activated protein C are dose dependent and determined by the duration of infusion. Higher doses of the drug were associated with less inflammation, apoptosis, and generalized tissue damage. Sepsis increased the mean concentration of MDA (2.1 vs. 10.9 pmol/mg of protein) and IL-6 (0 vs. 10,763 pg/mL) compared with sham-treated animals, as well as the magnitude of apoptosis in lung (2,037 vs. 8,709 pixels) (all p < 0.05). Infusion of recombinant activated protein C attenuated these responses in a dose-response manner. Interleukin-6 and MDA concentrations were increased by lower-dose therapy, but attenuated significantly by the higher-dose infusion at 5 mg/kg/h. Apoptosis was attenuated by both the lower and the higher dose, but more so with the higher dose. CONCLUSIONS: These data can assist in establishing an optimal dose and infusion time of this drug for extrapolation to therapy of human beings. The goal now is to elucidate these findings further so that the maximum benefit of the drug may be achieved with the least possible harmful effects.

Abdominal injuries in pregnancy: a 155-month study at two level 1 trauma centers.

INTRODUCTION: Trauma in pregnancy is the leading cause of non-obstetrical maternal death and remains a major cause of fetal demise. The objective of this study was to examine the outcomes of pregnant patients sustaining abdominal injury. PATIENTS AND METHODS: This is a retrospective analysis of all pregnant trauma patients admitted to two level 1 trauma centers from February 1, 1996 to December 31, 2008. Patient data abstracted included mechanism of injury, physiologic parameters on admission, Injury Severity Score (ISS), abdominal Abbreviated Injury Scale (AIS), gestational age, diagnostic and surgical procedures performed,complications, and maternal and fetal mortality. Univariate analysis and logistic regression analysis were used. RESULTS: During the 155-month study period, 321 pregnant patients were included, of which 291 (91%)sustained a blunt injury, while 30 (9%) were victims of penetrating trauma. Of the penetrating injuries,22 (73%) were gunshot wounds, 7 (23%) stab wounds, and 1 (4%) shotgun injury. The overall maternal and fetal mortality was 3% (n = 9) and 16% (n = 45), respectively. Mean age was 22 6 year-old, and the mean ISS was 12 16. The overall mean abdominal AIS was 2 1.2. When adjusted for age, abdominal AIS,ISS, and diastolic blood pressure, the penetrating trauma group experienced higher maternal mortality [7%vs. 2% (adjusted OR: 7; 95% CI: 0.65­79), p = 0.090], significantly higher fetal mortality [73% vs. 10% (adjusted OR: 34; 95% CI: 11­124), p < 0.0001] and maternal morbidity [66% vs. 10% (adjusted OR: 25; 95% CI: 9­79)p < 0.0001]. CONCLUSIONS: Fetal mortality and overall maternal morbidity remains exceedingly high, at 73% and 66%,respectively, following penetrating abdominal injury. Penetrating injury mechanism, severity of abdominal injury and maternal hypotension on admission were independently associated with an increased risk for fetal demise following traumatic insult during pregnancy.

Endoscopic brow-lift in the male patient.

OBJECTIVE: To report our experience with the endoscopic brow-lift in male patients at a university-affiliated outpatient surgery center. METHODS: Retrospective case series. RESULTS: From 1995 to 2007, a total of 244 endoscopic brow-lift procedures were performed, 21 of which involved men. Thirteen of the male patients had receding hairlines or some degree of baldness. Two male patients had postoperative complications; 1 male patient had temporal branch neurapraxia that resolved; and 1 male patient had in-office scar revision. CONCLUSIONS: We have found that the endoscopic brow-lift procedure is well suited for male facial rejuvenation. Furthermore, our combined stair-step approach and suture suspension technique provides consistent results and high satisfaction regardless of the patient's hairline.