Anatomy of the Breast Fascial System: A Systematic Review of the Literature.

BACKGROUND: Understanding the anatomy of the fascial and ligamentous structures of the breast is important in both aesthetic and reconstructive breast surgery. Several structures have been identified that play a significant role in the aesthetic qualities and support of the breast warranting consideration in the context of breast reconstruction. METHODS: The authors performed a systematic review of anatomical, clinical, histologic, and radiologic studies that have described, characterized, and named these structures. The authors have summarized and critically appraised prior research to clarify and define the key fascial structures of the breast, their anatomical function, and their clinical significance in aesthetic and reconstructive breast surgery. RESULTS: Through their review, six distinct breast fascial structures were encountered consistently in the literature. The authors have organized them into intraglandular and extraglandular structures and have reviewed their significance in the context of reconstructive breast surgery. CONCLUSIONS: The primary fascial structures of the breast are important anatomical landmarks with numerous clinical applications. Cooper ligaments divide the breast parenchyma. The superficial and deep layers of the superficial fascia encase the breast in a "pocket," condensing into one thickened layer of fascia along the peripheral breast footprint. The inframammary fold supports and defines the inferior pole. The horizontal septum is a reliable neurovascular landmark. The vertical septum is a newly discovered fascial structure. There are certainly clinical implications that have yet to be described because of the relatively limited and disputed information on the fascia of the female breast and, ultimately, more research is warranted.

How to Minimize the Pain of Local Anesthetic Injection for Wide Awake Surgery.

After reading this article, the participant should be able to (1) almost painlessly inject tumescent local anesthesia to anesthetize small or large parts of the body, (2) improve surgical safety by eliminating the need for unnecessary sedation in patients with multiple medical comorbidities, and (3) convert many limb and face operations to wide awake surgery. We recommend the following 13 tips to minimize the pain of local anesthesia injection: (1) buffer local anesthetic with sodium bicarbonate; (2) use smaller 27- or 30-gauge needles; (3) immobilize the syringe with two hands and have your thumb ready on the plunger before inserting the needle; (4) use more than one type of sensory noise when inserting needles into the skin; (5) try to insert the needle at 90 degrees; (6) do not inject in the dermis, but in the fat just below it; (7) inject at least 2 ml slowly just under the dermis before moving the needle at all and inject all local anesthetic slowly when you start to advance the needle; (8) never advance sharp needle tips anywhere that is not yet numb; (9) always inject from proximal to distal relative to nerves; (10) use blunt-tipped cannulas when tumescing large areas; (11) only reinsert needles into skin that is already numb when injecting large areas; (12) always ask patients to tell you every time they feel pain during the whole injection process so that you can score yourself and improve with each injection; (13) always inject too much volume instead of not enough volume to eliminate surgery pain and the need for "top ups."

Management of Congenital Auricular Anomalies.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe normal ear anatomy and development, and evaluate the patient's ears for differences in shape, size, prominence, and symmetry. 2. Identify common congenital ear deformities, including prominent ear, macrotia, Stahl ear, cryptotia, constricted ear, and lobule anomalies. 3. Describe both early nonoperative management and operative techniques for correction of these ear deformities. 4. Be aware of advantages and disadvantages of common and emerging techniques for correction of pediatric ear deformities. SUMMARY: Whereas severe ear malformations such as microtia/anotia are rare, other ear deformities, such as prominent ear, Stahl ear, and cryptotia, are common. Although these ear deformities result in minimal physiologic morbidity, their psychological and cosmetic impact can be significant. Identifying these common deformities and understanding how they differ from normal ear anatomy is critical to their management. In cases where a deformity is identified in neonatal life, ear molding may obviate the need for surgery. Although various surgical techniques have been described for correction of common ear deformities, the surgeon should follow a careful stepwise approach to address the auricular deformity or deformities present. By using such an approach, complications may be minimized and predictable aesthetic outcomes achieved.

The Impact of Delaying Breast Reconstruction on Patient Expectations and Health-Related Quality of Life: An Analysis Using the BREAST-Q.

PURPOSE: An understanding of patient expectations predicts better health outcomes following breast reconstruction. No study to date has examined how patient expectations for breast reconstruction and preoperative health-related quality of life vary with time since breast cancer diagnosis. METHODS: Women consulting for breast reconstruction to a single surgeon's practice over a 13-month period were enrolled in this cross-sectional study. Patients were asked to prospectively complete the BREAST-Q expectations and preoperative reconstruction modules. A retrospective chart review was then performed on eligible patients, and patient demographics, cancer-related factors, and comorbidities were collected. BREAST-Q scores were transformed using the equivalent Rasch method. Multivariate linear regression models were constructed to assess the association between BREAST-Q scores and time since cancer diagnosis. RESULTS: Sixty-five patients met inclusion criteria for analysis and are characterized by a mean age of 53 ± 11 (34-79) years and a mean body mass index of 28 ± 6 (19-49). Most patients were treated by mastectomy (58%) or lumpectomy (23%). At the time of retrospective chart review, 29 (43%) patients had undergone reconstruction, most of which were delayed (59%). The mean latency from cancer diagnosis to reconstruction was 685 ± 867 days (range: 28-3322 days). Latency from cancer diagnosis to reconstruction was associated with a greater expectation of pain (ß = 0.5; standard error [SE] = 0.005; 95% confidence interval [CI]: 0.003-0.027; P < .05), and a slower expectation for recovery (ß = -0.5; SE = 0.004; 95% CI: -0.021 to -0.001; P < .05) after breast reconstruction. Latency from cancer diagnosis to reconstruction was associated with an increase in preoperative psychosocial well-being (ß = 0.578; SE 0.009; 95% CI: 0.002-0.046; P < .05). CONCLUSION: Delaying breast reconstruction may negatively impact patient expectations of postoperative pain and recovery. Educational interventions aimed at understanding and managing patient expectations in the preoperative period may improve health-related quality of life and patient-related outcomes following initial breast cancer surgery.

OBJECTIF: La compréhension des attentes des patientes est prédictive de meilleurs résultats cliniques après une reconstruction mammaire. Jusqu'à présent, aucune étude n'a porté sur la manière dont les attentes des patientes à l'égard de la reconstruction mammaire et de la qualité de vie liée à la santé avant l'opération varient dans le temps à compter du diagnostic de cancer du sein. MÉTHODOLOGIE: Les femmes qui ont consulté le cabinet d'un seul chirurgien en vue d'une reconstruction mammaire sur une période de 13 mois ont participé à la présente étude transversale. Les patientes ont été invitées à remplir de manière prospective les modules BREAST-Q sur les attentes préopératoires et la reconstruction. Les chercheurs ont ensuite procédé à un examen rétrospectif des dossiers des patients admissibles, puis ont colligé des données sur la démographie des patients, les facteurs liés au cancer et les morbidités associées. Ils ont transformé les scores BREAST-Q à l'aide du modèle de Rasch équivalent. Ils ont construit des modèles de régression linéaire multivariés pour évaluer l'association entre les scores BREAST-Q et la période écoulée depuis le diagnostic de cancer. RÉSULTATS: Soixante-cinq patientes respectaient les critères d'inclusion. Elles se caractérisaient par un âge moyen de 53 ± 11 ans (34 à 79 ans) et un indice de masse corporelle moyen de 28 ± 6 (19 à 49). La plupart des patientes ont été traitées par mastectomie (58 %) ou lumpectomie (23 %). Au moment de l'analyse rétrospective des dossiers, 29 (43 %) avaient subi une reconstruction, dont la plupart avaient été retardées (59 %). La latence moyenne entre le diagnostic de cancer et la reconstruction était de 685 ± 867 jours (plage de 28 à 3 322 jours). La latence entre le diagnostic de cancer et la reconstruction s'associait à une plus grande anticipation de la douleur (ß=0,5; ÉT=0,005; intervalle de confiance [IC] à 95 % de 0,003 à 0,027; P<0,05) et à des anticipations plus basses envers la convalescence (ß = -0,5; ÉT = 0,004; IC à 95 % de -0,021 à -0,001; P<0,05) après la reconstruction mammaire. La latence entre le diagnostic de cancer et la reconstruction était liée à une augmentation du bien-être psychosocial préopératoire (ß = 0,578; ÉT = 0,009; IC à 95 % de 0,002 à 0,046; P<0,05). CONCLUSION: Le report de la reconstruction mammaire peut avoir un effet négatif sur l'anticipation des patientes à l'égard de la douleur préopératoire et de la convalescence. Des interventions pédagogiques pour comprendre et gérer les attentes des patientes pendant la période préopératoire peuvent améliorer la qualité de vie liée à la santé et les résultats cliniques des patientes après la chirurgie initiale d'un cancer du sein.

Simple Effective Ways to Care for Skin Wounds and Incisions.

Plastic surgeons are medicine's wound experts. Many of the world's poor cannot afford expensive wound management programs. All humans suffer open and closed wounds at some point in their life and must look after them. The purpose of this paper is to provide basic information to the public in very simple terms on how to safely and inexpensively manage wounds. This paper is directed to all nonmedical people, medical students, and other doctors who may not be content experts in this field.

Effects of seasonal changes in temperature and humidity on incidence of necrotizing soft tissue infections in Halifax, Canada, 2001-2015.

OBJECTIVES: To explore weather seasonal variation in Necrotizing soft tissue infections (NSTI) in Halifax, Nova Scotia, Canada could be attributed to changes in environmental factors of temperature and humidity specifically. METHODS: A retrospective chart review of NSTIs between 2001 and 2015. Regional temperature and humidity data were obtained from the Environment Canada Agency, Halifax, Canada. Chi-square was used for categorical variables and continuous data was used for correlation analyses. Logistic regression was performed to analyze mortality. Results: Of 170 NSTI patients identified, more presented from March to July, especially when the temperature was greater than 10ºC. Higher incidence per 100,000 persons correlated with increased monthly temperatures (p less than 0.01). Monthly NSTI incidence was inversely related to mean humidity (p=0.005). Causative organism was associated with mean weekly temperature (p less than 0.01) but not humidity (p=0.66). Low body mass index, higher American Society of Anesthesiologists class, long intensive care unit stay, and shorter overall hospital stay were associated with mortality. No correlation was identified between temperature and humidity and mortality. CONCLUSION: This study demonstrates a tendency toward more frequent cases of NSTI with warmer, but less humid weather, without effect on severity or mortality.

Superior Extension of Upper Instrumented Vertebrae in Distraction-based Surgery: A Surrogate for Clinically Significant Proximal Junctional Kyphosis.

BACKGROUND: Proximal junctional kyphosis (PJK) is a reported complication of distraction-based growth-friendly surgery for early-onset scoliosis (EOS). A potential consequence of PJK is revision surgery with superior extension of the upper instrument vertebrae (UIV). The purpose of this study was to determine the risk of radiographic and clinically significant PJK during growth-friendly surgery. METHODS: This is a retrospective review of children treated with distraction-based growth-friendly surgeries from two EOS registries with minimum two-year follow-up. PJK is defined as clinically significant in this study if surgery with superior extension of the UIV was performed. RESULTS: Of 419 total patients, there was a 20% risk of developing clinically significant PJK (24% rib vs. 15% spine-based anchors, p = .03). These patients had a mean preoperative age of 5.6 years (5.2-year rib vs. 6.0-year spine, p < .001), scoliosis of 73° (69° rib vs. 77° spine, p < .001), and kyphosis of 51° (47° rib vs. 56° spine, p < .01). Regression analysis demonstrated that these differences in age, scoliosis, and kyphosis between anchor type did not account for a significant proportion of the measured variance. CONCLUSIONS: There was a 20% risk of developing clinically significant PJK, with a slightly higher risk for patients treated with rib-based proximal anchors (24%) than for those patients treated with spine-based proximal anchors (15%). LEVEL OF EVIDENCE: Level III.

Antibiotic Irrigation of Pocket for Implant-Based Breast Augmentation to Prevent Capsular Contracture: A Systematic Review.

BACKGROUND: In vitro and in vivo studies have described a number of different antibiotic solutions for irrigation of the pocket in implant-based breast augmentation in an attempt to prevent the formation of capsular contracture (CC). Our objective was to evaluate the evidence that antibiotic irrigation reduced the rate of CC. METHODS: A systematic search of MEDLINE, EMBASE, and CENTRAL was conducted from inception to January 2016. We included studies which examined the use of intraoperative antibiotic irrigation in women undergoing primary breast augmentation. Our primary outcome was the rate of CC. Included studies were assessed for methodological quality using validated tools. RESULTS: Seven studies were included in the final analysis: 1 randomized controlled trial (RCT) and 6 non-randomized studies. The mean follow-up ranged from 14 to 72 months. The rate of CC was less than 2% in 8 studies, between 3% and 6% in 4 studies, and 13.9% in 1 study. Included studies demonstrated significant clinical and methodological heterogeneity. The solitary low-quality RCT concluded that antibiotic irrigation was superior to saline irrigation. Three non-randomized studies demonstrated no significant difference in the rate of CC with the use of antibiotics. One non-randomized controlled study showed that the use of mixture of antibiotic and povidone-iodine significantly lowered the rate of CC. CONCLUSIONS: The available evidence on the use of antibiotic irrigation to prevent CC is weak and it is based on studies with high risk of bias. Methodologically robust studies are necessary to answer the question whether antibiotic breast pocket irrigation prevents CC.

HISTORIQUE: Des études in vitro et in vivo ont décrit plusieurs solutions antibiotiques pour irriguer la cavité en cas d'augmentation mammaire par implant afin de prévenir la formation de contractures capsulaires (CC). Les chercheurs voulaient évaluer les données selon lesquelles l'irrigation antibiotique réduisait le taux de CC. MÉTHODOLOGIE: Les auteurs ont effectué une recherche systématique dans MEDLINE, EMBASE et CENTRAL entre le début de l'étude et janvier 2016. Ils ont inclus des études sur l'examen de l'irrigation antibiotique intraopératoire chez des femmes qui avaient subi une augmentation mammaire primaire. Les résultats primaires étaient le taux de CC. Les chercheurs ont évalué la qualité méthodologique des études à l'aide d'outils validés. RÉSULTATS: Les auteurs ont inclus sept études dans l'analyse définitive, soit un essai aléatoire et contrôlé (EAC) et six études non aléatoires. Le suivi moyen a duré de 14 à 72 mois. Le taux de CC était inférieur à 2 % dans huit études, se situait entre 3 % et 6 % dans quatre études et correspondait à 13,9 % dans une étude. Ces études présentaient une hétérogénéité clinique et méthodologique marquée. Dans la seule EAC, qui était de mauvaise qualité, l'irrigation antibiotique était considérée comme supérieure à l'irrigation par un soluté physiologique. Trois études non aléatoires n'ont démontré aucune différence significative du taux de CC avec l'utilisation d'antibiotiques. Une étude non aléatoire et contrôlée a révélé que le mélange d'antibiotique et de polyvidone iodée réduisait le taux de CC de manière significative. CONCLUSIONS: Les données probantes sur l'utilisation de l'irrigation d'antibiotiques pour prévenir la CC sont faibles et fondées sur des études comportant un fort risque de biais. Des études robustes sur le plan méthodologique s'imposent pour déterminer si l'irrigation de la cavité mammaire par un antibiotique prévient la CC.

Adolescent interviewing skills: effect of feedback.

BACKGROUND: Communicating with adolescent patients can be challenging. Our study assessed the effect of structured feedback following a standardised patient (SP) encounter on postgraduate year-1 (PGY1) residents' adolescent-specific communication skills. Communicating with adolescent patients can be challenging METHODS: A two-group, prospective, double-blind randomised control study design was employed. Measures were taken before and after the intervention. PGY1 residents conducted a 30-minute interview with an SP adolescent-mother pair, who then individually scored the resident's performance using the validated Structured Communication Adolescent Guide (SCAG). PGY1s were randomised to receive either structured feedback following the interview (feedback group) or no feedback (no feedback group). All residents completed a second interview 4-6 weeks later. Scores were analysed using unpaired t-tests. RESULTS: Thirty-eight residents completed both interviews. The mean total-item and mean global scores for the first interview did not differ significantly between the feedback (n = 21) and no-feedback group (n = 17). The mean total-item scores for the feedback group [first interview: 34.19 ± 10.19 (adolescent); 36.33 ± 9.77 (mother)] improved significantly for the second interview [45.17 ± 6.22 (adolescent); 44.71 ± 6.72 (mother); p = 0.002 and 0.003, respectively]. The mean global scores also improved significantly from the first interview [27.00 ± 6.49 (adolescent); 27.47 ± 6.50 (mother)] to the second interview [34.05 ± 3.30 (adolescent); 31.19 ± 3.85 (mother); p = 0.001 and 0.03, respectively]. No significant improvement in the mean total-item or mean global rating was observed in the no feedback group. CONCLUSIONS: Structured feedback following a single adolescent and mother SP encounter resulted in significant improvement in the adolescent-specific communication skills of PGY1s in performing an adolescent interview.

Digital Myopericytoma: A Case Report and Systematic Literature Review.

A myopericytoma (MP) is an exceedingly rare perivascular tumor of unknown etiology. Given their potential for mimicry and malignancy, MP tumors pose a unique challenge for surgeons and may be overlooked on differential diagnosis. We present a case report of an otherwise healthy 33-year-old right-hand dominant male who presented to our outpatient clinic with a 2-month history of painless swelling and erythema of the pulp of his left index finger. Subsequent plain film X-ray showed near-complete bony destruction of his distal phalanx. Pathological evaluation of an incisional biopsy showed a benign variant of MP. The lesion was treated by excision with tumor shelling, and there was no evidence of recurrence 81 days postoperatively. A systematic literature review of the management and outcome of all known cases of hand and wrist MP is presented.

Skills for Interviewing Adolescent Patients: Sustainability of Structured Feedback in Undergraduate Education on Performance in Residency.

BACKGROUND: Effective adolescent (10 to 19 years) interviewing by physicians is an essential skill that many trainees can find challenging. OBJECTIVE: We assessed whether structured adolescent interviewing using standardized patients (SPs) and feedback in undergraduate medical education (UME) has a sustained effect on residents' skills. METHODS: Postgraduate year (PGY) 1 residents conducted interviews with a SP adolescent-mother pair. The SPs independently scored each PGY-1 interview using the structured communication adolescent guide (SCAG). Unpaired t tests were conducted comparing "Total-Item" and "Global" scores of PGY-1s who received structured SP adolescent interviewing with feedback in UME ("structured training" group) to those who had not ("no structured training" group). RESULTS: PGY-1s in the structured training group (n = 23) received significantly higher mean Total-Item scores from both the SP adolescent (40.78 ± 7.04 and 32.41 ± 10.12, respectively; P = .001) and the SP mother (40.48 ± 7.90 and 33.34 ± 10.90, respectively; P = .01) than those without structured training (n = 29). Statistically significant results favoring PGY-1s with prior training were also seen with the SP adolescent and mother total Global SCAG scores. CONCLUSIONS: Structured training in adolescent interviewing with SPs and feedback in UME appears to have a sustained effect on residents' adolescent interviewing skills. PGY-1s will interview adolescents and may benefit from structured adolescent SP interviewing with feedback, especially individuals who did not have this experience during their medical school training.