In Situ Fenestration: A Simple Technique for Fenestration of Acellular Dermal Matrix During Breast Reconstruction.

BACKGROUND AND AIM: Acellular Dermal Matrices (ADMs) were first described for use in breast surgery in 2001, and in 2005 it was first described to be used in breast reconstruction. However, ADMs are also associated with increased postoperative complications. Fenestration of the ADM may reduce the incidence of postoperative complications. METHODS: We fenestrate the ADM in-situ, after attaching it to the lower pole of the planned pocket using absorbable sutures. CONCLUSIONS: using this technique enables to achieve a fan-shaped ADM mesh within less than a minute; Demonstrating a fast, easy and most importantly sterile method to fenestrate the ADM.

Analysis of Popular Social Media Addressing Breast Augmentation, Implants, and Anaplastic Large Cell Lymphoma.

BACKGROUND: Social media is part of modern life, for better or worse. Patients seek counsel on treatments, their side-effects, and the surgeon performing the surgery. Previous study has found several "dos" and "don'ts" regarding social media. The aim of this study was to specifically look for social media posts addressing breast augmentation, breast implants, and breast implant associated anaplastic large cell lymphoma (BIA-ALCL).The aims of this study were to examine social media posting regarding BIA-ALCL and to analyze the ways general public receive information regarding this disease. METHODS: A prospective analysis of 3 popular, global social media networks was performed, using the key phrase in English "anaplastic large cell lymphoma" or "ALCL" or "#ALCL." Three hundred posts related to breast cancer published on Instagram, YouTube, and Facebook in June 2018 were assessed by the following parameters: author identity, subject, "social media currency" (likes, shares, comments), presence of special effects (videos, photographs, research, etc.). RESULTS: Most posts were posted by professional entity (ie, plastic surgeon, company, or general practitioner), with YouTube being the social media least used by patients (P < 0.001). Facebook was the only social network that had more posts authored by non-professional authors (P < 0.001). Social currency did not change between the professional and non-professional authors. The highest return for investment was seen on Instagram (P < 0.001, "likes" only). YouTube, having the most posts published by professionals, was more positive toward breast augmentation and the use of implants (P < 0.001). CONCLUSIONS: Social media is here to stay and not a trend. It is a tool for the patient when searching for treatment and surgeon. It would be wise to invest and understand these communication platforms, since this is where our patients are, and the way they are researching.

Hidden in plain sight: the (other) danger of COVID-19.

The Novel Coronavirus disease (COVID-19) first emerged in Wuhan province, China, in late November 2019 and changed public healthcare perception. It has caused a significant decline in attendance to outpatient clinics. However, other diseases have not stopped, including malignant melanoma. Survey of the number of visits to plastic surgery outpatient clinic during the first lockdown in Israel concerning malignant melanoma was compared to the same months in the previous years. We assessed the number of visits to the oncology department during 2020 compared to the number of visits and treatment protocols for malignant melanoma. During the first lockdown, the attendance at the plastic surgery outpatient clinic and ambulatory surgery decreased significantly (P = 0.002), both in excisions of suspected malignant melanoma and malignant melanoma follow-ups (P = 0.019 and P = 0.035, respectively). The last third of 2020 (from September to December) had shown a significant rise in new protocols commenced (P < 0.001). This rise in the final third of the year was not noted in 2018 or 2019. These data clearly show the rise in advanced and metastatic malignant melanoma cases due to refraining from medical follow-ups and treatments during the COVID-19 pandemic. Diseases other than COVID-19 have not vanished, and continue to treat those diseases. Ignoring malignant melanoma treatment because of COVID-19 and vice-versa will not benefit our patients.

Morel Lavallée Lesion - A case report and review of literature.

INTRODUCTION: Morel-Lavallée lesion (MLL) is an uncommon entity, by which shearing forces result in a closed degloving lesion. This can result in an infected hematoma and lead to a life-threatening situation. PRESENTATION OF CASE: We present a case of a 59-year-old patient who presented to our emergency department. This patient had a crushing injury, and later was found to have an infected MLL. The patient was treated with surgical drainage, and 2 split thickness skin grafts. The patient fully healed. DISCUSSION: We review the current literature regarding MLL and diagnostic tools in order to accurately and rapidly diagnose this often-missed entity. Special emphasis is given to the treatment of MLL, with the current knowledge as reflected in the literature. CONCLUSIONS: It is important for caregivers to know the diagnostic steps and pitfalls of this elusive diagnosis in order to diagnose and treat MLL quickly, before it turns into a life-threatening state for the patient.

[MELANOMA INCIDENCE, IMMIGRATION AND ORIGIN].

BACKGROUND: Melanoma is a malignant tumor of melanocytes, whose prevalence has been increasing in recent decades. Early diagnosis allows removal of the tumor prior to the metastatic stage and may lead to a complete recovery. OBJECTIVES: To compare melanoma incidence among different epidemiological groups in northern Israel, and to assess the impact of migration on the increase in incidence of the disease. METHODS: A retrospective review was conducted of the medical records of all patients diagnosed with melanoma and treated in the Plastic Surgery Department at the Rambam Health Care Campus in 2016. Demographic data of 130 patients and tumor characteristics were collected and analyzed. RESULTS: European and American immigrants were found to carry an increased risk for melanoma compared to African and Asian immigrants. Increased melanoma risk was also found among a large subset of European immigrants from the former Soviet Union. This sub-group accounted for 32% of study group patients, while they only comprise 9% of the population (p <0.05). Most melanoma tumors in this sub-group were found in upper and lower extremities (60%). Disease was diagnosed at a younger age compared to the other European immigrants (p <0.05), with a trend towards a more advanced disease than the rest of the patients. CONCLUSIONS: Study findings imply an increased melanoma risk in immigrants from the former Soviet Union. Raising awareness of this population to preventative measures and the importance of early diagnosis may reduce morbidity and mortality caused by the disease. Further research is needed to determine whether routine screening tests should be applied to this population.

[MERKEL CELL CARCINOMA: A RETROSPECTIVE STUDY].

BACKGROUND: Merkel Cell Carcinoma (MCC) is an aggressive neuroendocrine skin cancer. Though rare, in recent decades its prevalence has increased, and its incidence has tripled. OBJECTIVES: To describe a cohort of MCC patients treated at a referral center in northern Israel, and to compare their characteristics and course of illness to cases reported in the literature. METHODS: A retrospective review of 18 MCC patients treated in the Plastic Surgery Department at the Rambam Health Care Campus between the years 2011-2016. Patient demographics, medical history, histological findings, systemic involvement, adjuvant therapy, recurrence and survival rates parameters were collected and analyzed. RESULTS: Study group patients were predominantly elderly, mostly men, and mainly Caucasian. A few were immunocompromised. Melanoma and MCC are known to be linked, and indeed, about a quarter of the patients suffered previously from melanoma. Diabetes, although not described as an MCC risk factor, has accounted for about 50% of cases, more than 5 times its prevalence in the general population. Tumor and metastases distribution were similar to the literature. Metastases were found in about 20% of cases at diagnosis. In one third of the patients, lymph nodes were already involved during surgery, with recurrence rates of 50%, and 40% mortality in five years. CONCLUSIONS: Study results, for the first time, imply that there might be an association between diabetes and MCC. A link that could explain the rise of MCC incidence in recent decades. In addition, treatment guidelines were defined for metastatic disease which include the novel immunotherapy as a central component in treatment; hopefully, to improve patients' prognosis in this life-threatening disease.

How Common Is Breast Implant-Associated Anaplastic Large Cell Lymphoma? First Four Cases in Israel.

BACKGROUND: Breast implant-associated anaplastic large cell lymphoma (ALCL) is a rare type of non-Hodgkin's lymphoma that is found around breast implants. ALCL was discovered only two decades ago. In Israel we currently have four diagnosed cases (as of 2018). Until recently, the estimated incidence was 1:300,000 women with breast implants, while recent reports range from 1:3817 to 1:30,000. OBJECTIVES: To determine the occurrence of breast implant-ALCL in Israel. METHODS: We conducted a retrospective analysis of the four patients diagnosed with ALCL in Israel. Cytology was confirmed and the clinical data was collected. Based on the estimated number of women with breast implants in Israel, a calculation of the true incidence was completed. RESULTS: The incidence in Israel is significantly higher than the older incidence reports indicate. We estimated that the lifetime prevalence of the disease is 4:60,000 women with a textured breast implant, or 1:15,000 women with a textured breast implant in Israel. CONCLUSIONS: ALCL is not common. We support the claim that the prevalence is significantly higher than what was initially described. This finding has clinical and medicolegal implications that should be addressed accordingly.

[A CASE REPORT OF THROMBOTIC THROMBOCYTOPENIC PURPURA (TTP) IN A BREAST CANCER PATIENT].

INTRODUCTION: A 49-year-old patient with a genetic expression of BRCA1, was admitted for a bilateral mastectomy and immediate reconstruction with tissue expander, following left breast malignancy (post-lumpectomy and radiation in the same breast). After the operation there were signs of infection in the left breast, for which she was treated with antibiotics. A few days later, mild neurological signs appeared, which resulted in an extensive investigation, and the next day a seizure occurred. Concurrent with the onset of clinical signs, thrombocytopenia and anemia appeared, accompanied by cell fractures in peripheral blood surface and decreased ADAMTS13 activity. The combination of the signs and symptoms led to the diagnosis of thrombotic thrombocytopenic purpura (TTP), probably caused by the antibiotic treatment, and the patient began treatment with plasma-parasites and steroids with a resolution of the findings. It is important to be aware of this entity, because of the disastrous consequences of misdiagnosis and therapeutic failure.

Pneumonia Risk in Urgently Intubated Burn Patients.

BACKGROUND: Pneumonia is a major cause of morbidity and mortality in burn patients with inhalation injuries. An increased risk of pneumonia has been demonstrated in trauma and burn patients urgently intubated in the field vs. emergency departments (EDs). OBJECTIVES: To compare intubation setting (field vs. ED) and subsequent development of pneumonia in burn patients and to evaluate the indication for urgent intubation outside the hospital setting. METHODS: A retrospective medical records review was conducted on all intubated patients presenting with thermal (study group, 118 patients) or trauma (control group A, 74 patients) injuries and admitted to the intensive care unit of a level I trauma and burn center at a single institution during a 15 year period. Control group B (50 patients) included non-intubated facial burn patients hospitalized in the plastic surgery department. RESULTS: Field intubation was less frequent (37% field vs. 63% ED), although it was more frequent in larger burns (total body surface area > 50%; 43% field vs. 27% ED). More field intubated patients developed pneumonia during hospitalization (65% field vs. 36% ED [burns]; 81% field vs. 45% ED [multi-trauma]; 2% non-intubated, P < 0.05), with a significantly higher all-cause mortality (49% field vs. 24% ED, P < 0.05) and dramatically lower rates of extubation within 3 days (7% field vs. 27% ED, P < 0.05). CONCLUSIONS: Field intubation is associated with a higher risk of subsequent development of pneumonia in burn and multi-trauma patients and should be applied with caution, only when airway patency is at immediate risk.

Achieving the Recommended Gestational Weight Gain in High-Risk Versus Low-Risk Pregnancies.

BACKGROUND: Abnormal gestational weight gain (GWG) has been associated with adverse outcomes for mothers and their offspring. OBJECTIVES: To compare the achievement of recommended GWG and lifestyle factors in women with high-risk versus normal-risk pregnancies. METHODS: Pregnant women hospitalized in a gynecological and obstetrics department and pregnant women who arrived at a community clinic for a routine checkup were interviewed and completed questionnaires relating to weight gain and lifestyle factors (e.g., smoking, diet, exercise). Recommended GWG was defined by the American Congress of Obstetricians and Gynecologists (ACOG). RESULTS: GWG higher than ACOG recommendations was reported by 52/92 women (57%) with normal pregnancies and by 43/86 (50%) with high-risk pregnancies. On univariate analysis, characteristics associated with greater GWG were: current or past smoking, age > 40 years, pre-gestational body mass index (BMI) > 25 kg/m2, low fruit intake, and high snack intake. High-risk pregnancies were associated with pre-gestational BMI > 25 kg/m2 (48% vs. 27%, P = 0.012), consumption of vitamins (84% vs. 63%, P = 0.001), avoidance of certain foods (54% vs. 21%, P = 0.015), receiving professional nutritionist consultation (65% vs. 11%, P = 0.001), and less physical activity (9% vs. 24%, P = 0.01). CONCLUSIONS: A minority of pregnant women met the recommended GWG. No difference was noted between normal and high-risk pregnancies. High-risk population tended to have a less healthy lifestyle. Counseling to follow a healthy, balanced diet should be recommended, regardless of pregnancy risk, with particular attention to women at high risk of extra weight gain.

Unusual presentation of epidermoid cyst mimicking breast cancer involving the areola-Case report.

INTRODUCTION: Epidermoid cyst is very common benign lesion of the skin. And may appear anywhere on the surface of the body. Diagnosis is made in most cases by clinical examination, but histological evaluation may be needed in unusual cases. PRESENTATION OF CASE: We report a rare case of a 44 year-old woman who presented with a rapidly growing inflamed mass localized to the left areola, which grew to 4 cm in diameter within a few months. The diagnosis of malignancy was ruled out following pathology examination consistent with epidermoid cyst. After a course of antibiotics, she underwent surgery with nipple sparing and reconstruction of the areola. DISCUSSION: Preoperative diagnosis based on biopsy enable limited surgical excision and preservation of the nipple. Reconstruction of the areola by local areolar flap enable good aesthetic result. CONCLUSION: It is important to be aware of this entity of epidermoid cyst mimicking breast cancer, and the treatment options available in these cases.

Would Marjolin see it coming? Two unusual cases of squamous cell carcinoma.

INTRODUCTION: Cutaneous squamous cell carcinoma (SCC) is a common skin cancer, second in incidence only to basal cell carcinoma (BCC). The incidence of SCC increases significantly with age; thus, it is rarely diagnosed in young patients. In this paper, we present two cases of young patients who presented clinically with purulent lesions that were later diagnosed as large primary SCCs. MATERIALS AND METHODS: A review of the medical records of two patients who were admitted to the department of plastic surgery with a final clinical diagnosis of cutaneous SCC was conducted. Information of the review included history, physical examination, laboratory tests, imaging studies and histology. A literature review was also conducted and discussed. RESULTS: Two female patients under the age of 45 presented with large, purulent lesions that were initially clinically suggestive of an infectious etiology. The lesions were surgically treated by incision and drainage without sending tissue samples to pathology. Biopsies of the lesions were performed to obtain a tissue diagnosis due to recurrence approximately one year after the initial treatment. Histological evaluation revealed well differentiated squamous cell carcinomas. Surgical intervention with wide excision with adjuvant chemotherapy was recommended based on biopsy and CT scan results. DISCUSSION: Aggressive behavior of SCC in young patients is uncommon. The patients in this report were diagnosed only one year after the first sign of the lesion. One patient was first diagnosed with an abscess, and the other with necrotizing fasciitis. The delayed diagnosis of SCC in these two patients is a potential contributing factor to the aggressiveness of the tumors. Therefore, it is imperative to perform skin biopsies of chronic or persistent purulent lesions to rule out malignancies including Marjolin's ulcer. CONCLUSION: Aggressive SCC should be suspected in cases of persistent and relapsing purulent lesions in all patients.

Plastic Surgery Faces the Web: Analysis of the Popular Social Media for Plastic Surgeons.

BACKGROUND: The use of social media is growing tremendously along with its impact on the practice of plastic surgery, for better or for worse. Patients are increasingly using social media to obtain information about either the procedure or the surgeon. OBJECTIVES: The aims of this study were to examine social media posting regarding plastic surgery and to analyze successful online communication methods of the plastic surgeons with the public. METHODS: A prospective analysis of 3 popular, global social media networks was performed, using the English language key phrases "plastic surgery" and "#plastic_surgery." Three hundred posts related to plastic surgery published on Instagram, YouTube, and Facebook in November 2017 were assessed by the following parameters: author identity, subject (self-promotion, educational, commercial, and personal posts), "social media currency" (likes, shares, comments, and views), and if special effects (videos, photos, etc.) or viral subjects such as reality stars or shaming were utilized. RESULTS: Sixty-three percentage of the posts on Instagram originated with plastic surgeons, compared with 18% on Facebook and only 13% on YouTube (P < 0.01); together, the plastic surgeons' posts comprise 31% of the total posts, whereas 49% of posts published by commercial companies (P < 0.01). Most of the posts on Instagram were self-promotional (83%), in comparison to Facebook (29%) or YouTube (6%); P < 0.01. YouTube posts are more personal in nature compared with Instagram and Facebook [39%, 7%, 9%, respectively (P < 0.01)]. Educational content in the posts accounts for only 16% of them, P < 0.01. Shaming is seen in 21% of the posts, especially in Facebook (39%), and mainly related to famous public figures (25%); P < 0.05. Celebrity endorsed posts received more attention in every aspect of social media currency (likes, comments, shares, and views). The use of images of women attracts attention and is widely used in social media posts of plastic surgery (68%). Posts that chose to include videos (22%) are generously rewarded. Online shaming also attracts attention, mostly found in Facebook (39%), and mainly of a public figure (25%). The 10 most powerful attention drawing motives were jokes, attractive female plastic surgeons, celebrities, personal stories, provocative surgeries, videos or photos of surgeries, sex, shaming, and patient education. CONCLUSION: Social media have become an important tool for self-promotion and a means to providing better customer service. This trend applies to the plastic surgeon as well. The study's main insights were to use Instagram, personal stories, educational post, videos and other unique inputs, and involve celebrities in the posts. In general, it would be wise to invest and understand these communication platforms, as they have become the path to dominate the field.

What Is the Color of Your Lymph Node?

We describe a case of tattoo ink in an axillary lymph node, which was observed during an axillary dissection and mastectomy surgery. It is important to be aware of this phenomenon and correctly identify it at the time of surgery, as a misdiagnosis can have serious consequences.

Gestational Weight Gain and Its Relationship with Maternal Characteristics.

BACKGROUND: Both high and insufficient weight gain during pregnancy have been associated with adverse outcomes for mothers and their offspring. OBJECTIVES: To describe self-reported weight gain during pregnancy, assess the concurrence of this weight gain with issued recommendations, and investigate associations between lifestyle factors and weight gain. METHODS: In this cross-sectional study, 109 pregnant women hospitalized in one gynecological and obstetrics department completed questionnaires related to weight gain and lifestyle factors such as smoking, diet and exercise. Recommended weight gain was defined by the American Congress of Obstetricians and Gynecologists and was compatible with the Ministry of Health guidelines in Israel. RESULTS: Fifty-three (49%) participants reported weight gain above the recommendation, 31 (28%) met the recommendations and 25 (23%) reported weight gain below the recommendations. Characteristics associated with high weight gain included past smoking and/or age above 36 years and/or body mass index (BMI) above 25 kg/m2. Only 34 women (31%) reported seeking professional nutritional counseling during pregnancy. An increased tendency to consult a nutritionist was reported among diabetic women. CONCLUSIONS: Only a minority of women gained the recommended weight during pregnancy. High BMI and/or a history of smoking and/or older age were associated with weight gain above recommendations. Particular effort should be directed toward counseling women at high risk of weight gain during pregnancy.