Immediate reconstruction of the chest wall by latissimus dorsi and vertical rectus abdominis musculocutaneous flaps after radical mastectomy for a huge pleomorphic liposarcoma.

We describe a 53-year-old woman who had a huge pleomorphic liposarcoma of the left breast. She had a left Halstead mastectomy, which left a huge defect in the chest wall. We did an immediate reconstruction of the chest wall with combined latissimuss dorsi musculocutaneous (for the upper half of the defect) and vertical rectus abdominis musculocutaneous flaps (for the lower half of the defect). She then had radiotherapy and chemotherapy during which time the flaps remained viable and provided satisfactory coverage for the irradiated area. Unfortunately four months later she was diagnosed with spinal cord and lung metastases and died seven months after the operation.

Acute esophageal dilation mimicking serious pulmonary complication after post-bariatric abdominoplasty.

UNLABELLED: Abdominoplasty is a frequent operative procedure among patients with massive weight loss following laparoscopic adjustable gastric banding (LAGB) surgery. After abdominoplasty, patients are carefully monitored and usually discharged from the clinic after overnight hospitalization. We report a case of acute esophageal dilation after abdominoplasty, following LAGB, mimicking a serious pulmonary complication. Three hours after a complete uneventful abdominoplasty, including reinforcement of the abdominal wall and removal of apron skin, a 39-year-old female patient developed cough and signs of respiratory distress. These symptoms were successfully treated by ventolin (salbutamol) inhalation. During the first night the patient required additional inhalation and was discharged from the hospital in good and stable condition. Three hours later she noticed respiratory distress and fever and was referred to the emergency room (ER). In the ER, a pulmonary embolism was suspected and the patient underwent CT angiography. On examination, acute severe esophageal dilation with fluid level was found. The esophageal diameter was 47 mm and the esophagus was compressing the mediastinum and trachea. The acute esophageal dilation was resolved after the gastric band was released by evacuation of saline solution from the subcutaneous port. The above-mentioned symptoms quickly disappeared during the next 2 h and the patient was discharged from the ER. We suggest complete gastric band release as a standard component of a bariatric surgery patient's preparation for abdominoplasty surgery. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Selectivity of a bromelain based enzymatic debridement agent: a porcine study.

BACKGROUND: Debridement of the burn eschar is a cornerstone of burn wound care. Rapid enzymatic debridement with a bromelain-based agent (Debriding Gel Dressing-DGD) has recently been investigated. The current study was designed to further investigate the selectivity of DGD to burned eschar in a larger number and more varied types of wounds. METHODS: A systematic animal experiment was conducted to determine the effects of DGD on normal, non-injured skin, burns, exposed dermis of donor sites, and skin punch biopsy wells. Partial thickness dermal burns and partial thickness skin graft donor sites were created on a pig and treated with a 4-h application of DGD or its control hydrating vehicle that does not have any activity except hydration. Punch biopsy samples were taken before and after treatment and microscopically assessed for evidence of tissue viability and its respective components thickness. RESULTS: Rapid dissolution of the burn eschar was noted in all DGD but not vehicle treated burns. There was no apparent damage to the underlying sub eschar dermis, donor sites, normal skin or punch biopsy wells after exposure to DGD. While the thickness of the treated tissues slightly increased due to edema, the increase in dermal thickness was similar after treatment with DGD or its vehicle. The increase in the cross section surface area of the treated punch biopsy wells was similar after treatment with DGD and its control vehicle. CONCLUSIONS: Exposure of the burn eschar to DGD results in its rapid dissolution. Exposure of normal skin or non-burned dermis to DGD has no effects demonstrating its selectivity to eschar.

[Axillary web syndrome--a variant of Mondor's disease, following excision of an accessory breast].

Cording, an unusual form of superficial thrombophlebitis, is a variant of the disease first described by Fage in 1870 and subsequently characterized by Henry Mondor in 1939 as sclerosing thrombophlebitis of the subcutaneous veins of the anterior chest wall. Similar lesions have also been found in the penis, groin, abdomen, arm, and axilla and have been reported under a variety of names. In the axilla the condition is termed axillary web syndrome (AWS) and is seen after axillary lymph node dissection and sentinel lymph node biopsy. A recent report suggests that pathophysiology of AWS is lymphatic in origin rather than venous. We report a unique case of unilateral AWS after excision of an axillary accessory breast and discuss the pathophysiology.

The role of frozen section histological analysis in the treatment of head and neck skin basal and squamous cell carcinomas.

BACKGROUND: Skin basal and squamous cell carcinomas together account for over half of all newly diagnosed cancer cases. Frozen section control of surgical margins is often required in the head and neck region. A paraffin permanent section does not always confirm the results of a frozen section. OBJECTIVES: To test the diagnostic accuracy of frozen section histopathological analysis in determining the free margins of excised tumors. METHODS: This was a retrospective study of 169 cutaneous basal and squamous cell carcinomas excised with surgical margins diagnosed by frozen section and confirmed by permanent paraffin sections. The data included patients' age, gender, clinical and histopathological diagnosis, as well as characteristics of the lesions. RESULTS: There were 149 (88%) basal cell carcinomas and 20 (12%) squamous cell carcinomas. False negative margins were found in 19 cases (11.2%) and false positive margins in 11 (6.6%). We did not find any correlation between false positive or false negative margins and patients' age, gender, tumor size, tumor location, or the presence of sun-damaged skin. A significantly lower rate of false negative results was found in the residual tumor group. CONCLUSIONS: Our findings support the use of frozen section margin control in selected patients suffering from non-melanoma skin cancer of the head and neck.

Escharotomy using an enzymatic debridement agent for treating experimental burn-induced compartment syndrome in an animal model.

BACKGROUND: In patients with deep circumferential burns, adequate resolution of burn-induced compartment syndrome (BICS) is achieved by surgical escharotomy. Surgical escharotomy is traumatic, may cause considerable blood loss, does nothing toward debridement of the burn wound, and entails possible morbidity and complications. Debridase is a Bromelain derived enzymatic preparation capable of lysing the burn eschar within 4 hours, obviating the need for surgical debridement. It has an affinity to burned necrotic tissue and does not damage healthy skin. In our clinical assessment of the Debridase efficacy, we found in several cases of deep burns of the limbs that the measured IC pressure subsided after 2-4 hours of Debridase application and none of the enzymatic escharotomy treated patients suffering from circumferential burns developed BICS. To confirm these observations we conducted this controlled study. AIM: to assess the efficacy of Debridase for treating BICS in an animal model. MATERIALS AND METHODS: A model for BICS was developed by making circumferential burns to pig legs and monitoring the anterior compartment the legs. BICS was induced in the legs of 5 pigs, 20 legs. 10 legs were treated with Debridase and 10 served as nontreated controls, treated by surgical escharotomy at the conclusion of the experiment. RESULTS: Debridase reduced BICS within 30 minutes from application. Debridase was as effective as a standard surgical escharotomy. CONCLUSION: Escharectomy using an effective enzymatic debriding agent is potentially an adequate, simple, fast and effective procedure to treat BICS, it has the added benefit of burn debridement without surgical escharotomy.

Risk factors for incomplete excision of squamous cell carcinomas.

OBJECTIVE: The aim of this study was to identify risk factors for incomplete excision of squamous cell carcinomas (SCCs). PATIENTS AND METHODS: A cross-sectional study of 369 patients who underwent a primary excision of SCCs was performed within an outpatient and a hospital plastic surgery department setting. RESULTS: Incomplete excision occurred in 25 of 369 primary excisions of SCC (6.8%). Location of the tumors on the forehead, temples, peri-auricular region, ears, cheeks, nose, lips or neck was significantly associated with incomplete excision of the tumors. In particular, high incomplete excision proportions were observed for tumors located on the ears (16.7%), neck (16.7%), temples (11.1%), nose (10.8%) or lips (7.1%). Incomplete excision of SCC was associated with the setting of the operation in the hospital as compared to ambulatory settings (p = 0.046) and was inversely associated with the specimen thickness (p = 0.002). There was no statistically significant association between incomplete excision of SCC and gender, age, clinical appearance of the lesion (suspected SCC vs other diagnoses), differentiation pattern, diameter of the tumor, length or width of the excised specimen, solar changes or ulceration. CONCLUSION: We recommend that in patients with SCCs located in the forehead, temples, periauricular region, ears, cheeks, nose, lips or neck surgeons should commence particular surgical measures to avoid inadequate excisions of the tumors. In particular, surgeons should use wider excisional margins in tumors located in the embryonic fusion planes (e.g. eyelids and naso-labial folds).

Safety and efficacy of a proteolytic enzyme for enzymatic burn debridement: a preliminary report.

A prospective, non-comparative study design was used to describe our experience with a bromelain-derived debriding agent, Debridase, in 130 patients with 332 deep second degree and third degree burns treated between 1984 and 1999. Debridase was applied after saturating the burns with a moist dressing for 2-24h. Debridase was applied for a period of 4h under an occlusive dressing. Mean patient age was 18.6 +/- 19.3, 42 (32.3%) were female, and 63 (48.5%) were children under age 18. Most burns were small. Debridase was applied once in 241 (72.6%) of the 332 wounds, twice in 67 (20.18%) cases, three times in 12 (3.61%) cases, and four times in 2 (0.6%) cases. The percentage debridement by number of applications was 89 +/- 21% for a single application, 77 +/- 27% for two, and 62 +/- 27% for three Debridase applications, respectively. There were no significant adverse events. The availability of a fast acting, reliable and complication-free enzymatic debriding agent may open new horizons and provide a new treatment modality for burns.

A randomized controlled trial of silver sulfadiazine, biafine, and saline-soaked gauze in the treatment of superficial partial-thickness burn wounds in pigs.

UNLABELLED: Silver sulfadiazine 1% cream (SSD) and biafine (an oil-in-water emulsion containing alginate) are used for the treatment of superficial partial-thickness burns, but comparative effectiveness studies are lacking. OBJECTIVES: To compare the uses of SSD, Biafine (Labortoires Medix, Houdan, France), and saline-soaked gauze in the treatment of superficial partial-thickness burns in pigs. METHODS: This was a randomized controlled trial in four anesthetized young pigs. Four equal sets of partial-thickness contact burns were inflicted on the pigs. Each burn was randomly assigned to treatment with biafine, SSD, or saline-soaked gauze with dressing changes every other day. Assessment of wound re-epithelialization was performed every other day, for a total of two weeks. The treatment groups were compared by univariable and multivariable analyses of variance (ANOVAs), controlling for the pig and the location of the burns on each pig. RESULTS: Thirty-two burns were inflicted on the pigs. Time to re-epithelialization of the burns was 13.5 days (SD +/- 0.9 days) in pigs treated with biafine, 13.3 days (+/-1.3 days) in pigs treated with SSD, and 13.5 days (+/-1.0 days) in pigs treated with saline-soaked gauze (p = not significant [NS]). The decreases in burn area from day 2 to day 12 were 21.4 cm(2) (+/-6.0 cm(2)) in pigs treated with biafine, 20.0 cm(2) (+/-6.3 cm(2)) in pigs treated with SSD, and 19.8 cm(2) (+/-5.9 cm(2)) in pigs treated with saline-soaked gauze (p = NS). A multivariable ANOVA showed a similar decrease in burn area between the treatment arms (p = NS) and a significant difference between the pigs (p = 0.015). CONCLUSION: Partial-thickness porcine burns treated with SSD, biafine, and soaked saline gauze re-epithelialize at similar rates.

Risk factors for incomplete excision of basal cell carcinomas.

Incomplete excision of basal cell carcinomas (BCCs) may be followed by recurrence of the tumor. In order to detect risk factors for incomplete excision of BCCs we performed a cross-sectional study of 1278 patients who underwent a primary excision of BCCs, during a four-year period, within an ambulatory and hospital plastic surgery department setting. Incomplete excision occurred in 159 of 1478 primary excisions of BCCs (10.8%) and was significantly associated with location of the tumors in the eyelids (OR 3.64, 95% CI 1.96-6.71), ears (OR 2.51, 95% CI 1.25-4.94), naso-labial folds (OR 2.26, 95% CI 0.99-5.04) and nose (OR 1.88, 95% CI 1.30-2.71). There was an inverse association with location of the tumors in the upper limbs (OR 0.44, 95% CI 0.21-0.90), back (OR 0.12, 95% CI 0.02-0.48) or chest (OR 0.09, 95% CI 0.00-0.57). Baso-squamous differentiation was associated with incomplete excision of BCCs (p = 0.03). No association was observed between incomplete excision of BCCs and gender, age, setting of the operation (ambulatory vs. hospital), clinical appearance of the lesion (suspected BCCs vs. other diagnoses) or diameter of the lesions. In conclusion, incomplete excision of BCCs was associated with location of the tumors in the eyelids, ears, naso-labial folds and nose. We recommend that in patients with BCCs located in these sites, surgeons should commence particular surgical measures to avoid inadequate excisions of the tumors.