Symptom outcomes following cranial vault expansion for craniosynostosis in children older than 2 years.

BACKGROUND: Most craniosynostosis cases are treated by cranial expansion before 1 year of age. Occasionally, patients present at a later age with nonspecific symptoms of increased intracranial pressure. The purpose of this study was to review the symptoms of patients undergoing late cranial vault expansion. In all cases, the indication for surgery was treatment of the cranial dysmorphology. METHODS: The authors performed a retrospective review of all patients (n = 17) undergoing cranial vault expansion from 2000 to 2007 aged older than 2 years (median, 7.4 years) for abnormal head shape who also reported preoperative symptoms consistent with increased intracranial pressure, including headaches, nausea or vomiting, or vision changes. Median follow-up was 30 months; 11 patients had nonsyndromic and six had syndromic craniosynostosis. RESULTS: Fourteen patients had headaches, nine had nausea and vomiting, and 11 had vision changes. Ten patients had signs of intracranial pressure elevation, such as a computed tomographic scan findings, papilledema, or both. Twelve of 14 patients had complete resolution of headaches following surgery and four had late mild recurrence. All patients with nausea and vomiting and nine of 11 patients with vision changes had resolution of symptoms. CONCLUSIONS: The diagnosis of increased intracranial pressure in older children with craniosynostosis is difficult in the absence of papilledema or computed tomographic findings. Clinical symptoms frequently associated with increased intracranial pressure are improved with late cranial vault expansion and demonstrate a possible benefit beyond improvement in head shape.

True incidence of all complications following immediate and delayed breast reconstruction.

BACKGROUND: Improved self-image and psychological well-being after breast reconstruction are well documented. To determine methods that optimized results with minimal morbidity, the authors examined their results and complications based on reconstruction method and timing. METHODS: The authors reviewed all breast reconstructions after mastectomy for breast cancer performed under the supervision of a single surgeon over a 6-year period at a tertiary referral center. Reconstruction method and timing, patient characteristics, and complication rates were reviewed. RESULTS: Reconstruction was performed on 240 consecutive women (94 bilateral and 146 unilateral; 334 total reconstructions). Reconstruction timing was evenly split between immediate (n = 167) and delayed (n = 167). Autologous tissue (n = 192) was more common than tissue expander/implant reconstruction (n = 142), and the free deep inferior epigastric perforator was the most common free flap (n = 124). The authors found no difference in the complication incidence with autologous reconstruction, whether performed immediately or delayed. However, there was a significantly higher complication rate following immediate placement of a tissue expander when compared with delayed reconstruction (p = 0.008). Capsular contracture was a significantly more common late complication following immediate (40.4 percent) versus delayed (17.0 percent) reconstruction (p < 0.001; odds ratio, 5.2; 95 percent confidence interval, 2.3 to 11.6). CONCLUSIONS: Autologous reconstruction can be performed immediately or delayed, with optimal aesthetic outcome and low flap loss risk. However, the overall complication and capsular contracture incidence following immediate tissue expander/implant reconstruction was much higher than when performed delayed. Thus, tissue expander placement at the time of mastectomy may not necessarily save the patient an extra operation and may compromise the final aesthetic outcome.

Breast implant capsules are partially composed of bone marrow-derived cells.

Capsular contracture is the most common complication following breast augmentation or reconstruction with implants. We recently demonstrated that bone marrow-derived cells provide fibroblasts to murine skin during wound healing. To determine if bone marrow-derived cells were the cellular source of periprosthetic capsules, we created chimeric C57BL mice containing bone marrow cells from isogeneic enhanced green fluorescent protein (EGFP) mice and implanted with a textured silicone shell implant. We found that none of the mice developed infection or capsular contracture, but day 30 capsules were composed of 26.4 +/- 6.1% EGFP cells, and day 60 capsules had 21.8 +/- 10.3% EGFP cells. Immunohistochemistry revealed a small population of EGFP cells in the capsules that were myofibroblasts. Thus, breast implant capsules are partially composed of bone marrow-derived cells and, given the potential of these cells to become myofibroblasts, may explain the cellular source of capsular contracture when it develops.