Tissue Expander Complications Predict Permanent Implant Complications and Failure of Breast Reconstruction.

BACKGROUND: Two-stage tissue expander-based breast reconstruction is the most commonly used reconstructive modality following mastectomy. We sought to determine if patients who experienced complications during the expansion phase were at increased risk for complications or reconstructive failure after the exchange procedure. METHODS: A retrospective review of tissue expander-based breast reconstructions was performed from January 2007 through December 2011. Variables evaluated included age, presence of cancer, tobacco use, body mass index, comorbidities, use of acellular dermal matrix, chemotherapy, radiation, timing of reconstruction (delayed/immediate), intraoperative tissue expander fill, complications, and explantation or salvage of the reconstruction by means of debridement and closure or myocutaneous flap. RESULTS: A total of 196 patients underwent mastectomy with 304 tissue expander reconstructions. Tobacco use (active and remote), hypertension, and radiation were associated with complications. Patients with a salvaged tissue expander complication were 3 times more likely to have a complication after placement of a permanent implant and 9 times more likely to fail permanent implant reconstruction (ie, require explantation). CONCLUSIONS: Women with complications after placement of a tissue expander are at significantly increased risk for both complications and reconstructive failure after placement of a permanent implant. Consideration for earlier autologous reconstruction as a salvage should be strongly considered in patients with a tissue expander complication, particularly in smokers and those undergoing radiation therapy.

New Innovation: Custom Titanium Zygomaticomaxillary Complex (ZMC) Plate for Facial Reconstruction.

Zygomaticomaxillary complex (ZMC) fractures typically result from traumatic injuries, such as motor vehicle-related incidents, assaults, falls, and sports-related injuries. These fractures characteristically occur along suture lines where the zygomatic bone borders the frontal bone, maxilla, temporal bone, and sphenoid bone, resulting in a "tetrapod" fracture pattern that can be surgically fixated utilizing one, two, and three-point plate and screw fixation. However, fractures with complete loss of bone stock are less common, and standardized methods of fixation are not suitable for such complex fractures. Here, we present an interesting case of implantation of a custom-made alloplastic implant in a patient with complex ZMC fractures with loss of bone stock. A 52-year-old male sustained a traumatic gunshot wound to the face, resulting in significant destruction of bones involving the left orbital floor, left lateral orbital wall, and left zygomatic arch. Routine plating was not feasible, so a custom spanning plating system by DePuy Synthes (Synthes USA Products, LLC, West Chester, PA) was designed using the patient's CT scans. The patient recovered well with no complications. This case illustrates the successful application of patient-specific custom plates for complex ZMC fractures when standard plating methods are not suitable.

Surgical Marking Pen Contamination: Writing a Postoperative Infection Into Your Preoperative Plan.

Introduction Preoperative marking is an essential safety practice to prevent "never" events, including wrong site surgery. Moreover, the Joint Commission regulations of the Universal Protocol require that patients be marked to indicate the operative site. Marking typically occurs with a pen or marker, which may be disposable or reusable. Previous studies have demonstrated that methicillin-resistant Staphylococcus aureus (MRSA) can survive in the dark, moist, capped environment of the marking pen and thus could plausibly be a nidus for transmission from patient to patient. The Joint Commission has established no increased risk of postoperative infection with these markings. With this study, we aimed to determine the colonization of surgical marking pens in the plastic surgery population. Methods Two marking pens from five different attending plastic surgeons at a single institution were cultured in standard fashion for aerobic and anaerobic growth. All pens were used repeatedly in office settings for performing patient markings. Those same ten marking pens were then used to mark incision sites on mock patients. Standard povidone-iodine prepping was then performed in a paint-only fashion over the skin markings, and cultures were again taken. A control group consisted of cultures from five sterile pens from the operating room. Each sterile pen was opened, uncapped, and then swabbed. All twenty-five cultures were analyzed in the hospital laboratory in a blinded fashion. Results The five control pens revealed no bacterial growth. Of the 10 direct pen cultures, two samples grew coagulase-negative staphylococci and one culture contained Pseudomonas aeruginosa. The 10-patient marked and prepped specimens showed eight negative cultures and two with coagulase-negative staphylococci. Although Pseudomonas was detected on standard pen culture, no pseudomonal growth was present in any of the samples after patient marking and prepping with povidone-iodine. Conclusions Our findings reaffirm that marking pens may be vehicles for bacterial transmission and expand upon previous studies by describing the presence of bacterial colonization on marking pens even after surgical site preparation with povidone-iodine.

Sternectomy Reconstruction Using a Customized Three-Dimensional-Printed Polyetheretherketone Implant.

Complex sternal and chest wall reconstruction can be a challenging clinical situation, with the main objectives being restoration of chest wall rigidity, protection of intrathoracic organs, preservation of respiratory function, and reduction of pain and clicking. The treatment of choice is varied, with several different materials available to aid in adequate reconstruction. We present the case of a 60-year-old male with a post-sternectomy defect and debilitating symptoms who underwent reconstruction with a customized, three-dimensional (3D)-printed polyetheretherketone (PEEK) implant and pectoralis muscle flaps. There were no complications in the perioperative period, and the patient reported significant improvement in pain and subjective improvement in chest stability and respiration. The use of PEEK as a reconstructive material for cardiothoracic defects is a viable and safe method that has several important benefits over other utilized materials in the literature. The early success of this case in relieving patient symptoms opens the door for further exploration of PEEK as an alternative for cardiothoracic reconstruction.

Delayed diagnosis of hand injuries in polytrauma patients.

Trauma patients are at high risk for delayed diagnosis of injuries, including those to the hand, with reports in the literature as high as 50%. As a result, patients may have prolonged disability and longer hospital stays with associated increased costs. Our objective was to elucidate risk factors for the delayed diagnosis of hand injuries. A review was performed from 2000 through 2009, assessing for age, sex, blood alcohol level, Glasgow Coma Score (GCS), Injury Severity Score (ISS), mechanism, injury type, length of stay, and timing of hand injury diagnosis. In this study, 36,568 patients were identified; 738 meeting criteria; 21.7% of patients had delayed diagnoses with 91.3% of patients diagnosed by the day after admission. Delayed diagnoses were more than 2 times higher for severely injured patients. Patients with delayed diagnoses had a lower GCS and a higher ISS and length of hospitalization. With a decreased GCS and elevated ISS, patients are at risk for delayed diagnoses of hand injuries. A focused tertiary survey is mandatory, particularly in patients with an altered mental status or with multiple injuries.

A Severe Case of Siliconoma-induced Hypercalcemia due to Illicit Gluteal Silicone Injections.

Siliconoma-induced hypercalcemia is a rare complication of siliconoma, occurring secondary to a foreign body granulomatous process induced by the introduction of silicone into soft tissue. This is a case report of a woman presenting with sequelae of illicit silicone injections performed in an unknown woman's basement in Florida 20 years before presentation. A 39-year-old woman presented with a 2-month history of 20-pound weight loss, malaise, and intractable vomiting with a remote history of unregulated cosmetic injections to the bilateral gluteal and thigh regions. Her laboratory studies were consistent with severe hypercalcemia secondary to a foreign body granulomatous process. Initially, she was medically managed, with mild improvements in her symptomatic hypercalcemia and later underwent palliative debridement with siliconoma removal. Postoperatively, her course was complicated by delayed wound healing and graft failure, but the surgical defect was later closed successfully with split-thickness skin grafting after months of wound care. Although the procedure was not intended to treat her hypercalcemia, there were significant improvements in serum and ionized calcium in the months following her procedure. Severe hypercalcemia in the context of previous unregulated cosmetic injections or possible silicone implant rupture should prompt consideration of siliconoma-induced hypercalcemia as the underlying etiology. In addition to the established utility of IV fluids, bisphosphonates, and glucocorticoids, there may also be a role for surgical intervention in the management of this unique patient population's hypercalcemia.

Non-surgical Management of Complex Refractory Pyoderma Gangrenosum With Negative Pressure Wound Therapy With Instillation.

Pyoderma gangrenosum (PG) is a rare skin disorder primarily treated with immunosuppression medication. We report a case of a large, chronic PG wound treated with adjunct negative pressure wound therapy with instillation and dwell time (NPWTi-d) using nonadherent dressing (Mepitel) and reticular open-cell foam with through holes (ROCF-CC) with positive outcomes. The patient was a 62-year-old female with rheumatoid arthritis, Hashimoto's thyroiditis, lymphedema, and morbid obesity who presented with a 19.5 cm x 13.2 cm x 2.1 cm wound of three years duration on the right posterolateral lower extremity that successfully responded to a multimodality approach of immunosuppression and wound vac therapy. We conclude in our case that NPWTi-d with Mepitel and ROCF-CC enhanced the wound healing process, and we discuss NPWTi-d's potential role and benefit as an adjunctive therapy option for chronic and poorly controlled PG on patients taking concurrent immunosuppression.

Community-Acquired Methicillin-Resistant Staphylococcus aureus in the Suburban Hand Surgery Patient Population.

Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause for patients to present to a physician's office or emergency department. We observed increasing numbers of community-acquired MRSA infections in patients admitted to the hand surgery service at our suburban academic center. It is an important issue as unsuspected community-acquired MRSA hand infections can be admitted to the hospital, inadequately treated, and allowed for nosocomial spread. This study was performed to examine the trend in the incidence of community-acquired MRSA infections in patients admitted to the hand surgery service in order to sensitize practitioners to have a high index of suspicion for this entity and promote early recognition and treatment of this organism. A multihospital retrospective chart review was undertaken to compare the total number of community-acquired MRSA infections in our hospital as well as the number in patients admitted to the hand surgery service with community-acquired MRSA from 2000 through 2008. Statistical analysis was provided by linear regression. Two community-acquired hand MRSA infections were treated in 2000, as compared to three in 2001 and 2002, four in 2003, five in 2004, six in 2005, 14 in 2006, 13 in 2007, and ten in 2008. This increase was statistically significant (p = 0.038). This retrospective review documents a rapidly rising number of community-acquired MRSA hand infections in the suburban environment. The hand surgeon must be aware of the increased prevalence of this entity to adequately combat this organism and prevent prolonged hospital stays, expanded morbidity, and inflated treatment costs.