Complications after sternal reconstruction: a 16-y experience.

BACKGROUND: Unlike risk factors associated with sternotomy complications, those associated with sternal reconstruction have not been well elucidated. We sought to examine complication rates after sternal wound reconstruction and to identify perioperative risk factors associated with these complications. METHODS: We evaluated the records of 230 consecutive patients who underwent sternal reconstruction with muscle flaps after cardiac surgery. Patient demographics, clinical comorbidities, and operative procedure types were evaluated against two outcome variables-major complications and reconstructive failure. RESULTS: The mean age of our cohort was 62 y. Major complications (readmission, reoperation, or death) occurred in 76 patients (33%), including mortality rate of 3.5%. Obesity, chronic obstructive pulmonary disease, and type of reconstructive procedure correlated with an increased risk of major complications. Reconstructive failure occurred in 39 patients (17%) and was associated with female gender, obesity, previous coronary artery bypass graft procedure, and prior left internal mammary artery usage. Regression analyses demonstrated that obesity is independently associated with an increased risk of major complications and that women are at an increased risk of reconstructive failure. Reconstructions involving the rectus abdominis were correlated with an increased risk of major complications, but this difference was not significant in multiple regression analysis. CONCLUSIONS: Usual risk factors for sternal wound development after cardiac surgery include diabetes, age, obesity, tobacco use, history of stroke, bilateral left internal mammary artery harvest, and significant blood transfusion. In distinction, this study found that the risks independently associated with major complications and reconstructive failures after reconstruction of sternal wounds are limited to obesity and female gender.

Immediate, optimal reconstruction of facial lentigo maligna and melanoma following total peripheral margin control.

BACKGROUND: Peripheral margin control of lentigo maligna and melanoma on the head and neck can be problematic. Frozen sections are unreliable, and conventional histopathology cannot examine the entire margin. Customary treatment involves wide excision and dressing care or skin graft coverage until histopathologic evaluation is complete, as reexcision is frequently required because of positive margins. Wound contraction, donor-site morbidity, and additional procedures before reconstruction are inherent disadvantages to this approach. METHODS: After excisional biopsy of facial lentigo maligna and thin (<1 mm) lentigo maligna melanoma, peripheral margin control was performed in the office by means of excision of 2-mm-wide linear strips of skin, 5 to 10 mm from the biopsy site, combined with simple wound closure. Total margins were evaluated by means of permanent sections. Repeated margin excision was performed until clear. Definitive excision of the lesion was then performed and, with confidence of negative peripheral margins, the optimal reconstructive option was pursued immediately. RESULTS: Fifty-one lesions underwent "square" peripheral margin control, with lentigo maligna melanoma present in nine lesions (average Breslow depth, 0.65 mm). Margins required for clearance of lentigo maligna and lentigo maligna melanoma averaged 1.0 and 1.3 cm, respectively. No recurrences were identified with long-term follow-up. Reconstruction using the optimal procedure was performed immediately in all cases. CONCLUSIONS: Use of the square technique in the management of lentigo maligna and lentigo maligna melanoma improves the certainty of peripheral margin control before definitive excision. Immediate reconstruction can be performed, thereby avoiding temporizing procedures or open wounds and providing for optimal aesthetic and functional results.

Reevaluating resumption of oral intake after abdominoplasty.

BACKGROUND: Traditional postoperative management of patients undergoing abdominoplasty has involved withholding food until patients demonstrate evidence of bowel activity. No literature exists to support this practice, however, and with the expanding trend toward ambulatory abdominoplasty, early feeding may obviate, at least partially, the need for postoperative hospital admission for intravenous hydration, thereby allowing for faster discharge. OBJECTIVE: We sought to investigate whether early feeding of patients contributed to an increased incidence of postoperative nausea and vomiting (PONV), as well as impacted the return of bowel sounds or the usage of antiemetic medications. METHODS: Hospital records of the authors' patients who underwent full abdominoplasty with adjunctive suction-assisted lipoplasty were examined. The senior author (A.M.) held patients nil per os (NPO) until bowel sounds were auscultated (group I), whereas the other authors (S.S.J., M.J.O.) began a regimen of feeding immediately after surgery (group II). RESULTS: No significant differences in age, gender, or body mass index were present. Operative time was significantly shorter in group I. The incidence of PONV, use of antiemetic medications, and presence of audible bowel sounds on postoperative day 1 did not vary significantly between groups. None of the patients with inaudible bowel sounds in either group experienced PONV. CONCLUSIONS: Early feeding after abdominoplasty did not lead to an increased incidence of PONV, increased use of antiemetic medications, or delayed return of bowel sounds. In routine abdominoplasties, early feeding may permit patients to sustain adequate hydration and possibly allow for earlier discharge.

Aging increases the susceptibility of skeletal muscle derived satellite cells to apoptosis.

The mechanisms causing the impaired regenerative response to injury observed in skeletal muscle of old animals are unknown. Satellite cells, stem cell descendants within adult skeletal muscle, are the primary source of regenerating muscle fibers. Apoptosis may be a mechanism responsible for the depletion of satellite cells in old animals. This work tested the hypothesis that aging increases the susceptibility of satellite cells to apoptosis. Satellite cells were cultured from the extensor digitorum longus muscles of young (3-month-old), adult (9-month-old), and old (31-month-old) Brown Norway rats. Satellite cells were treated for 24h with the pro-apoptotic agents TNF-alpha (20 ng/mL) and Actinomycin D (250 ng/mL). Immunostaining for activated caspases and terminal deoxynucleotydil transferase-mediated dutp nick-end labeling (TUNEL) was performed to identify apoptotic satellite cells. Quantity of the anti-apoptotic protein bcl-2 was determined by Western blot analysis. Satellite cells from old animals demonstrated significantly higher percentages of cells with activated caspases and TUNEL-positive cells, and significantly lower amounts of bcl-2 compared to young and adult animals. These data support the hypothesis that aging increases satellite cell susceptibility to apoptosis. In old muscle, apoptosis may play a causative role in the depletion of satellite cells, impairing the regenerative response to injury.

Evaluation of plastic surgery information on the Internet.

The Internet allows vast access to medical information. Unlike most plastic surgery literature, the Internet is a quagmire of unfiltered information, not subject to peer review. To assess the accuracy of medical information on the Internet the authors studied one commonly performed elective procedure, classifying and defining the information retrieved. Using the keyword "breast augmentation," the authors compiled a list of the first 300 web sites, obtained from six distinct search engines, yielding 215 unique sites. They devised an instrument to evaluate each site for its accessibility, relevance, and accuracy. Of the 215 unique web sites evaluated, 20 were inaccessible, 24 were irrelevant, and 41 contained no medical information. Of the remaining 130 sites, almost 34% contained false or misleading information. Errors pertained most often to the technical details of the operation, potential benefits, and risks. In addition, exaggerated claims concerning alternative breast enhancement regimens, adverse sequelae of silicone breast implants, and potential effects on lactation were also seen commonly. A considerable amount of information regarding breast augmentation on the Internet was either misleading or inaccurate. Physicians can assist their patients with specific guidelines to allow them to process information discerningly, thereby diminishing the likelihood that medical decisions are based on misinformation.

Skeletal muscle denervation increases satellite cell susceptibility to apoptosis.

Peripheral motor nerve trauma severely compromises skeletal muscle contractile function. Satellite cells respond to denervation by dividing multiple times, ultimately fusing with other satellite cells or myocytes to form new muscle fibers. After chronic denervation, satellite cell numbers decline dramatically, impairing the ability to regenerate and repair myofibers. This satellite cell depletion may contribute to the mechanical deficit observed in denervated or reinnervated muscle. Apoptosis, an evolutionarily conserved form of cell suicide, is a potential mechanism for satellite cell depletion in denervated skeletal muscle. This work tested the hypothesis that skeletal muscle denervation increases satellite cell susceptibility to apoptotic cell death. Adult rats underwent sciatic nerve transection to denervate the distal hindlimb musculature; rats of similar age without the operation served as controls. Two, 6, 10, or 20 weeks after denervation (n = 6 each group), the gastrocnemius and soleus were excised, enzymatically digested, and plated for satellite cell culture. After reaching 95 percent confluence, satellite cells were treated for 24 hours with tumor necrosis factor-alpha (20 ng/ml) and actinomycin D (250 ng/ml), known pro-apoptotic agents. Immunostaining for activated caspases, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL), and hematoxylin and eosin staining were performed to identify apoptotic satellite cells. Percentages of apoptotic cells were quantified histomorphometrically. In addition, the presence or absence of bcl-2 and bax was determined by Western blot analysis of control, 6 weeks of denervation, and 10 weeks of denervation specimens. At 6 and 10 weeks after nerve transection, TUNEL and caspase activity were increased more than two-fold in satellite cells isolated from denervated muscle compared with those isolated from control muscle (p < 0.05). In all experimental groups, retention of adherence to the collagen-coated substrate was strongly associated with satellite cell survival. Western blot analysis revealed that adherent satellite cells from all groups expressed both bcl-2 and bax. These data support the authors' hypothesis that skeletal muscle denervation increases satellite cell susceptibility to apoptotic cell death. Apoptosis may play a causative role in the depletion of satellite cells in long-term denervated skeletal muscle.

The effect of two episodes of denervation and reinnervation on skeletal muscle contractile function.

Sensory or motor "baby-sitting" has been proposed as a clinical strategy to preserve muscle integrity if motion-specific axons must regenerate over a long distance to reach denervated target muscles. Denervated muscles are innervated temporarily by using axons from nearby sensory or motor nerves. After motion specific motor axons have reached the target, the baby-sitter nerve is severed and motion-specific axons are directed to the target. Although this strategy minimizes denervation time, the requisite second episode of denervation and reinnervation might be deleterious to muscle contractile function. This study was designed to test the hypothesis that two sequential episodes of skeletal muscle denervation and reinnervation result in greater force and power deficits than a single peripheral nerve injury and repair. Adult Lewis rats underwent either transection and epineurial repair or sham exposure of the left peroneal nerve. After a 4-month recovery period, the contractile properties of the extensor digitorum longus muscle of the sham exposure group (control, n = 9) and one of the nerve division and repair groups (repair group 1, n = 9) were evaluated with measurements of the maximum tetanic isometric force, peak power, and maximal sustained power. A third group of rats underwent a second cycle of nerve division and repair (repair group 2, n = 9) at this same time point. Four months postoperatively, contractile properties of the extensor digitorum longus muscles were evaluated. Maximum tetanic isometric force and peak power were significantly reduced in repair group 2 rats as compared with repair group 1 and control rats. Maximal sustained power was not significantly different between the groups. These data support our working hypothesis that skeletal muscle contractile function is adversely affected by two cycles of denervation and reinnervation as compared with a single episode of nerve division and repair.

A specific force deficit exists in skeletal muscle after partial denervation.

Skeletal muscle demonstrates a specific force deficit after repair of injured peripheral nerves, microneurovascular muscle transfer, and normal aging. Because atrophy cannot account for deficits in specific force, other, unknown, mechanisms are responsible for the resulting muscle contractile dysfunction under these circumstances. We tested the hypothesis that a subpopulation of denervated fibers is partially or completely responsible for the specific force deficit after partial denervation of the rat extensor digitorum longus muscle (EDL). Adult Fisher rats underwent either sham exposure or partial transection of 80% of the cross-sectional area of the left deep peroneal nerve. After a 2-week recovery period, maximum isometric force (F(0)) was measured in situ and maximum specific force (sF(0)) was calculated for EDL from both control (n = 8) and partial denervation (n = 7) groups. Innervated fiber cross-sectional area (CSA(inn)) was measured directly from whole EDL cross sections after immunohistochemical labeling for neural cell adhesion molecule (NCAM), a marker of muscle fiber denervation. A corrected specific force value (sF(0-inn)) was calculated by normalizing F(0) to CSA(inn). Partial skeletal muscle denervation resulted in significant reductions in muscle mass, F(0), and sF(0). The percentage of muscle fibers expressing NCAM in the extrajunctional sarcolemma increased from 1.0 +/- 0.8% in control to 49 +/- 15% in partially denervated EDL muscles. A 62.7% deficit in EDL specific force was observed after partial denervation. Denervated muscle fibers accounted for 59.3% of this deficit, but sF(0-inn) still differed significantly between control and partially denervated muscles, with a 25.5% difference between groups. In partially denervated muscles, the specific force deficit is partially but not fully explained by a subpopulation of noncontractile, denervated fibers.