Does concurrent gynaecological surgery affect infectious complications rate after mastectomy with implant-based reconstruction?

BACKGROUND: Women who undergo breast cancer surgery often have an indication for gynaecological procedure. The aim of our study was to compare infectious complications rate after mastectomy with implant-based reconstruction in patients with and without concurrent gynaecological procedure. PATIENTS AND METHODS: We retrospectively reviewed clinical records of 159 consecutively operated patients after mastectomy with implant-based reconstruction. The patients were divided in 2 groups: 102 patients without (Group1) and 57 with (Group 2) concurrent gynaecological procedure. Infectious complications rates between the groups were compared using χ2-test. Logistic regression was performed to test for association of different variables with infectious complications. RESULTS: There were 240 breast reconstructions performed. Median follow-up time was 297 days (10-1061 days). Mean patient age was 47.2 years (95% CI 32.8-65.9); 48.2 years (95% CI 46.1-50.3) in Group 1 and 45.8 years (95% CI 43.2-48.3) in Group 2; p = 0.002). Infectious complications rate was 17.6% (17.6% vs. 17.5%, p = 0.987), implant loss occurred in 5.7% (4.9% vs. 7.0%, p = 0.58). Obesity (body mass index [BMI] > 30 kg/m2), age, previous breast conserving treatment (BCT) with radiotherapy (RT) were identified as risk factors for infectious complications in univariate analysis. Obesity (adjusted odds ratio [aOR] 3.319, 95% CI 1.085-10.157, p = 0.036) and BCT with RT (aOR 7.481, 95% CI 2.230-25.101, p = 0.001) were independently associated with infectious complications in multivariate model. CONCLUSIONS: Concurrent gynaecological procedure for patients undergoing mastectomy with implant-based reconstruction did not carry an increased risk for infectious complications.

A Unique Method for Total Nasal Defect Reconstruction - Prefabricated Innervated Osteocutaneous Radial Forearm Free Flap.

A 52-Year-old woman underwent a two-stage total nose reconstruction for complete nasal defect due to skin cancer. In the 1st stage, innervated osteocutaneous radial forearm flap ("Neo nose") was raised with the help of a 3D template. In the 2nd stage, well vascularised "Neo-nose" was transferred to the face and covered with pre-expanded forehead flap.

Anatomical Considerations to Optimize Sensory Recovery in Breast Neurotization with Allograft.

BACKGROUND: Breast numbness is a recognized problem following mastectomy and subsequent reconstruction. Contemporary literature acknowledges the positive role of breast neurotization, but it is characterized by a variety of technical approaches and substantial heterogeneity with respect to the degree of recovered sensibility that remains suboptimal in comparison with other sensory nerve reconstructions. This study's purpose was to provide an anatomical basis for observed inconsistencies and therein provide a principle that can be used to develop a technical approach that will optimize sensory recovery. METHODS: Anatomical dissections on 6 fresh cadavers, that is, 12 hemi-abdominal flaps and 12 hemi-chest dissections, were performed. The technical aspects of harvesting the abdominal flap with a nerve target, that is, inclusion of a sensory nerve branch only, recipient nerves in the chest, and the applications of allograft for acquired nerve gap reconstruction were investigated. RESULTS: Abdominal flaps that include sensory-only intercostal nerve 10-12 segments and identification of recipient chest wall intercostal nerves 2-4 could be consistently performed. The dissection and extraction of the donor sensory nerve target allowed preservation of the motor rectus innervation. The acquired nerve gap was easily bridged by an interposing allograft, allowing free arch of rotation for flap inset, suitable for either single or dual neurotization. CONCLUSIONS: We provide a likely anatomical explanation for suboptimal sensory recovery after deep inferior epigastric perforator (DIEP) flap breast neurotization, as mixed intercostal autograft is prohibitive to maximal sensory recovery. Breast neurotization with allograft that bridges sensory donor intercostal nerves to sensory recipient intercostal nerves should anatomically optimize restoration of breast sensibility.

Does a continuous local anaesthetic pain treatment after immediate tissue expander reconstruction in breast carcinoma patients more efficiently reduce acute postoperative pain--a prospective randomised study.

BACKGROUND: Immediate breast reconstruction with an expander is a reasonable option for properly selected patients. After reconstruction, patients have severe postoperative pain, which responds poorly to opioids. Our aim was to evaluate if continuous wound infusion of a local anaesthetic into the surgical wound reduces postoperative pain, consumption of opioids and incidence of chronic pain compared to standard intravenous piritramide after primary breast reconstruction in breast carcinoma patients. METHODS: Altogether, 60 patients were enrolled in our study; one half in the group with wound infusion of a local anaesthetic, and the other half in the standard (piritramide) group. Parameters measured included: pain intensity (visual analogue scale), drug requirements, alertness, hospitalisation, side-effects and late complications. A p-value of < 0.05 was considered statistically significant. RESULTS: In the recovery room, the test group reported less acute pain at rest (P = 0.03) and at activity (P = 0.01), and on the day of the surgical procedure they reported less pain at activity (P = 0.003). Consumption of piritramide and metoclopramide was lower in this group (P < 0.0001), but their alertness after the surgical procedure was higher compared to the standard group (P < 0.001). After three months, the test group reported less chronic pain (P = 0.01). CONCLUSIONS: After primary tissue expander breast reconstruction, wound infusion of a local anaesthetic significantly reduces acute pain and enables reduced opioid consumption, resulting in less postoperative sedation and reduced need for antiemetic drugs. Wound infusion of a local anaesthetic reduces chronic pain.

The use of 3D laser imaging and a new breast replica cast as a method to optimize autologous breast reconstruction after mastectomy.

Aesthetically pleasing and symmetrical breasts are the goal of reconstructive breast surgery. Sometimes, however, multiple procedures are needed to improve a reconstructed breast's symmetry and appearance. In order to avoid additional corrective procedures, we have developed a new method that uses a reverse engineering technique to produce what we call a new breast replica cast (NBRC). The NBRC is a mould of the contralateral healthy breast, designed according to preoperative laser 3D images. During surgery, the mould is used to help shape the new breast. With this method, we are able to achieve breast symmetry in terms of volume, projection, contour, and position on the chest wall more accurately, more quickly, and more safely than before.

Evaluation of surgical treatment in mandibular condyle fractures.

AIM: In the past, fractures of the mandibular condylar process were, as a rule, treated conservatively. At the Department of Maxillofacial and Oral Surgery of the University Medical Centre Ljubljana, Slovenia, our doctrine was changed in 2002 on the basis of preliminary results and reports in the literature, and these fractures were started to be treated surgically by open reduction and internal fixation with miniplates and screws, which led to good results and a shorter rehabilitation period. The goal of this study was to determine the safety and efficiency of surgical treatment, as well as to compare long-term results of surgical and conservative treatment, as objectively as possible. PATIENTS AND METHODS: Two groups of patients, which had all sustained a unilateral, extra-articular mandibular condyle fracture, were compared. In the test group, there were 42 surgically treated patients, and in the control group, 20 conservatively treated patients. Clinical parameters and X-ray images were assessed in both groups and compared by the two tailed Student t test, and in case of attributive variables by the χ(2) test. Within the surgically treated group, postoperative and intraoperative complications were noted: temporary facial nerve palsy, development of a parotid salivary fistula, disturbance of auricle sensibility due to injury of the greater auricular nerve, miniplate fracture, as well as intraoperative bleeding, postoperative haematoma formation, infection, reoperation due to fragment malposition and other complications. Postoperative scars were also assessed. RESULTS: Statistically significant differences between the surgically and conservatively treated patients were found when comparing clinical parameters as well as X-ray images, the results being better in the surgically treated group. Complications of surgical treatment were also noted, the most important among them temporary paresis of facial nerve branches, which occurred in 10 patients (24%). Plate fractures occurred in five patients (12%), in four of them miniplates of sizes less than 2.0mm were used. There were no cases of significant intraoperative bleeding, two cases (5%) required drainage of postoperative haematomas, and one patient (2%) experienced a mild postoperative infection, which was easily controlled with amoxicillin with clavulanic acid. The scar was hidden best if a facelift incision was used, and a hypertrophic scar developed in only one patient (2%). CONCLUSION: Results of surgical treatment of condylar process fractures are superior to the results of conservative treatment, and the procedure is safe with the transparotid surgical approach and adequate surgical technique.

Endoscopic decompression of the ulnar nerve at the elbow.

PURPOSE: The ideal operative treatment for cubital tunnel syndrome, the second most common form of peripheral compression neuropathy, remains controversial. We therefore reviewed our series of endoscopically assisted ulnar nerve decompression at the elbow to determine the effectiveness of the procedure, which was intended to minimize perioperative morbidity and scar discomfort. METHODS: In 36 patients (ages 22-76 years) with clinical McGowan grade I (4 patients), II (21 patients), and III (11 patients) and electrophysiologic signs of cubital tunnel syndrome (35 primary, 1 recurrent), 20 cm of the ulnar nerve was released through a 3.5-cm-long skin incision above the medial epicondyle. A 4-mm, 30 degrees standard endoscope and custom-made guiding-dissecting tool were utilized during the procedure, and the mean postoperative follow-up examination was 14 months (range 6-19). RESULTS: No macroscopically visible nerves and vessels were injured during the procedure. The only postoperative complication was hematoma in one patient that resolved after conservative management. One case was converted from endoscopic to open because of a ganglion that surrounded the nerve in the forearm. There was no scar discomfort (ie, painful neuroma, impaired sensibility, or burning sensation) or elbow extension deficit after surgery, and surgical wounds all healed within a week. Outcomes were excellent in 21 of 36 cases and good in 12 of 36 cases. All patients improved electrophysiologically after surgery, were satisfied with the procedure, returned to full activities within 3 weeks, and would have the procedure again. CONCLUSIONS: By using a safe and reliable endoscopic technique characterized by a short incision, minimum soft tissue dissection, and early postoperative mobilization, we were able to preserve the benefits of conventional approaches (namely, complete release and good visualization), while avoiding problems such as painful scarring and elbow contracture.

Port wine stain treatment with a dual-wavelength Nd:Yag laser and cryogen spray cooling: a pilot study.

BACKGROUND AND OBJECTIVES: We report on a pilot study of port wine stain (PWS) treatment with a prototype Nd:YAG/KTP laser system, emitting simultaneously at 1,064 and 532 nm, and equipped with a cryogen spray cooling (CSC) device. STUDY DESIGN/PATIENTS AND METHODS: On 10 patients (4-36 years old, mean: 16.2 years) with skin types II-III, therapeutic efficacy of the dual-wavelength laser (KTP+) was compared with a standard KTP laser (532 nm only) at the same pulse duration (25 millisecond), spot diameter (3 mm), and CSC parameters. The fluences were selected in order to obtain the same immediate response with both laser systems. Blanching of each test segment was assessed 8 weeks post treatment by an independent evaluator and by the subjects, and graded on a 1-4 scale. RESULTS: Significant blanching of PWS was noted 8 weeks after a single therapeutic session with the KTP+ laser (mean: 532 nm radiant exposure: 8.2 J/cm(2)), very similar to that observed with KTP at 12.4 J/cm(2). The evaluator noticed a slight brownish coloration in areas treated with the KTP+ laser. Isolated beam-sized atrophic scars were present in two patients where KTP+ (9 and 10 J/cm(2)) and KTP (14 J/cm(2)) lasers were used. CONCLUSIONS: The addition of 1,064 nm radiation allowed a significant reduction of 532 nm radiant exposure with no loss of efficacy in PWS treatment.

Surgical technique to reduce scar discomfort after carpal tunnel surgery.

A total of 379 patients (416 hands) with clinically diagnosed and electromyographically confirmed carpal tunnel syndrome were enrolled in a prospective study to determine the influence of a modified open decompression technique on postoperative scar discomfort. The new technique used in 184 patients (200 hands) is presented. Special attention was focused on identification and preservation of macroscopically detectable subcutaneous nerves. After using this method, which permits complete visualization of the entire transverse carpal ligament, the incidence of postoperative scar discomfort was 2.5%. This was significantly lower compared with the group of 195 patients (216 hands) treated by standard open decompression technique, without preservation of subcutaneous nerves. Primary results regarding relieving symptoms were comparable in both groups. Five anatomic variations of subcutaneous innervation, at the site of the incision in the line with the radial border of the ring finger, are described. The etiology of scar discomfort is discussed.