Long-term clinical and patient-reported outcomes in free flap reconstruction of the weight-bearing heel pad and non-weight-bearing Achilles tendon regions.

BACKGROUND: The non-weight-bearing (NWB) Achilles tendon and weight-bearing (WB) heel pad regions are technically challenging to reconstruct with distinct functional and aesthetic considerations that have not been previously considered in the literature. This study is the first to characterize the long-term clinical and patient-reported outcomes of these components to better inform patients about the postreconstruction period. METHODS: A retrospective review of medical records and phone-based survey of adult patients who underwent free flap reconstruction of the heel/ankle with 6-month minimum clinical follow-up was performed. RESULTS: Forty-three patients, with 31 (72.1%) NWB and 12 (27.9%) WB defects, treated from January 1, 2000 to February 28, 2017 were included. Muscle flaps were more common than fasciocutaneous flaps (N = 36 [83.7%] vs. 7 [16.3%]). Flap survival rate was 95.3% and limb salvage rate was 93.0% at median follow-up of 12.0 months (interquartile range [IQR] 6.2, 25.5). Flap ulceration occurred more frequently in the WB region (41.7 vs. 6.5%, p = .0123). The survey response rate was 63.6%. The majority of patients complete daily tasks with no/little impairment (76.2%), walk half a mile or more (85.7%), returned to work (86.6%), and fit shoes "fair" or "well" (71.4%). Most patients were "very satisfied" with heel/ankle function (71.4%) and would "very likely" undergo the same procedure if needed (76.2%). CONCLUSIONS: Free flap reconstruction in both the NWB Achilles tendon and WB heel pad has excellent limb salvage and flap survival rates. Patients were satisfied with heel/ankle function, but additional counseling is recommended for variance in appearance and higher ulceration rates in WB defects.

Mucocele-Like Lesions of the Breast: Rate of Upstaging and Cancer Development.

BACKGROUND: Breast mucocele-like lesions (MLLs) are rare breast lesions. There is a paucity of literature on the rate of pathologic upstaging of MLL to in situ or invasive breast cancer. We sought to review our experience with MLL at a tertiary care center and review published literature. METHODS: A retrospective review was undertaken of all patients with breast MLL at the Mayo Clinic, Rochester, from 1998 to 2016. Descriptive statistics were performed. RESULTS: Overall, 30 patients were diagnosed with MLL, with a mean age of 54.6 years (range 51-58). Calcifications on screening mammogram were the most common method of MLL detection (n = 26, 86.7 %), with core needle biopsy (CNB) being performed in 29/30 patients. MLL with atypia was identified in 14 patients (48 %), and surgical excision was performed in 26 patients. Disease was upstaged to invasive disease in one patient (3.8 %) who presented with a palpable mass. With a median duration of follow up of 3.5 years [interquartile range 1-7.1], two patients developed contralateral invasive breast cancer (both patients had a remote history of invasive breast cancer on that side), and one patient developed contralateral in situ disease. Review of the literature demonstrates a 2.9 % upgrade rate of MLL without atypia on excisional biopsy. CONCLUSIONS: The upstage rate of MLL identified on CNB to invasive disease at surgical excision in this series was 3.8 %. In cases with MLL presenting as calcifications, no cases were upstaged in this series. Across the literature, upstage rates of MLL without atypia on CNB are low, indicating excisional biopsy may be avoided in these cases.

A new, simple operative approach for bilateral inguinal hernia repair in girls: A single transverse supra-pubic incision.

BACKGROUND: Inguinal hernia repair remains one of the most common operations performed by pediatric surgeons. We described a new surgical approach for treating bilateral inguinal hernias in girls through a small single transverse supra-pubic incision. MATERIALS AND METHODS: A new approach was performed on female children 12-years-old and younger with bilateral inguinal hernias between January 2005 and April 2012. TECHNIQUE: A single transverse suprapubic incision (1-1.5 cm) was made. Using sharp and blunt dissection bilateral hernias were exposed and repaired using a standard high ligation. RESULTS: Ninety-nine girls with a preoperative clinical diagnosis of bilateral inguinal hernia were included. Median age was 2 years (range: 1 month to 12 years). All patients underwent general anesthesia. Median operative time was 12 minutes (range 5-22). There were no intra-operative complications or misdiagnosis. Two patients had bilateral sliding hernias and the remainder had indirect hernias. Post-operatively two patients developed non-expanding small hematomas, both treated non-operatively without sequelae. There were zero hernia recurrence and median follow-up was 5 years (range: 1-8 years) on 99% of patients. CONCLUSION: We described a new, safe, simple, and rapid approach for bilateral inguinal hernia repair in female pediatric population. A single transverse suprapubic skin incision was adequate for exposing both inguinal regions with excellent postoperative results.

Mastectomy and Immediate Breast Reconstruction for Cancer in the Elderly: A National Cancer Data Base Study.

BACKGROUND: Mastectomy with immediate breast reconstruction (M+IBR) is performed increasingly for breast cancer treatment, but whether this trend extends to the growing number of women diagnosed at age 65 or older is unknown. We studied the effects of age and comorbidities on the use and outcomes of M+IBR. STUDY DESIGN: Patients undergoing mastectomy for breast cancer were ascertained from the National Cancer Data Base 2004 to 2012. Performance of M+IBR and outcomes were compared by age group (<65 years vs ≥65 years) and other patient and tumor factors. RESULTS: There were 364,767 patients who underwent mastectomy, of whom 127,501 (35.0%) had IBR. Among M+IBR patients, 10.3% were age 65 or older, including 1.5% who were 75 or older. From 2004 to 2012, M+IBR increased from 6.7% to 18.1% in women 65 or older (p < 0.001), paralleling the increase in women less than 65 years (32.9% to 57.3%; p < 0.001). Contralateral prophylactic mastectomy rates in M+IBR patients were lower in patients 65 or older (27.4%) than in those less than 65 (45.9%), p < 0.001. A Charlson-Deyo score > 0 (any comorbidity) was more frequent in patients 65 or older having mastectomy alone (27.0%) vs M+IBR (18.4 %) (p < 0.001). Among M+IBR patients, the Charlson-Deyo score was >0 in 18.4% of patients 65 or older vs 9.8% among patients less than 65 (p < 0.001). Thirty-day unplanned readmission rates were higher for older patients: 3.7% vs 2.9% for M+IBR patients 65 or older vs less than 65, respectively, even those with a Charlson-Deyo score = 0, 3.5% vs 2.8% (both p < 0.001). CONCLUSIONS: Rates of M+IBR rates are increasing, with 10% of M+IBR patients now age 65 or older. Higher 30-day unplanned readmission rates in elderly M+IBR patients with or without comorbidities suggest the need to establish criteria for safe M+IBR in these patients.

Safety and yield of muscle biopsy in pediatric patients in the modern era.

BACKGROUND: Muscle and skin biopsies are commonly used diagnostic procedures in the evaluation of pediatric neuromuscular and genetic disorders. However, few modern reports have documented their diagnostic yield and clinical utility. We reviewed our experience at a tertiary care center. METHODS: We retrospectively studied consecutive pediatric patients who underwent muscle biopsy at our institution between January 2008 and April 2012. RESULTS: Of 169 patients, 97 (57%) were male, and the median (range) age was 7years (9days to 18years). In 101 patients (60%), a pathologic diagnosis was made. Histologic results of biopsy were completely normal in 45 patients (27%). Minimal abnormalities not sufficient to make a definitive pathologic diagnosis were reported in 23 patients (14%). Sensitivity and specificity of preoperative electromyography in detecting muscle pathology were 58% and 56%, respectively. No complications occurred from the use of general anesthesia. The only complication was a right femoral vein laceration when the right vastus medialis muscle was chosen as a biopsy site. CONCLUSION: Muscle biopsy in children is safe and useful in establishing the best management plan for patients with suspected neuromuscular disorders. This finding contradicts those of previous studies.