Indocyanine Green Angiography Overpredicts Postoperative Necrosis Compared to Multispectral Reflectance Imaging.

BACKGROUND: Sufficient perfusion is foundational to successful reconstructive surgery. Various technologies have been developed to help determine whether tissue is adequately perfused, or whether it will be prone to necrosis postoperatively. Indocyanine green (ICG) angiography is one such method that uses fluorescence and analyzes tissue perfusion. Multispectral reflectance imaging (MSRI) is an alternative technology that analyzes optical properties of oxygenated and deoxygenated hemoglobin to determine tissue viability. Because tissue in low-perfusion states may still survive because of sufficient oxygenation, the authors hypothesized that compared to MSRI, ICG angiography overpredicts necrosis, potentially resulting in unnecessary resection of viable tissue. This study expands on preliminary work to investigate this hypothesis. METHODS: This was a prospective cohort of patients undergoing prepectoral direct implant reconstruction at a single institution. Each patient was examined intraoperatively with both ICG angiography and MSRI. Decisions to resect tissue were made in conjunction with MSRI and ICG images collected purely for data analysis. Patients were followed postoperatively for at least 2 months for signs of postoperative necrosis. RESULTS: Fifty-three cases were included. ICG angiography accurately predicted viability in 40 of 40 patients (100%) and incorrectly predicted necrosis in 11 of 13 patients (84.6%). Simultaneously, MSRI predicted necrosis in zero patients and accurately predicted viability in 51 of 53 patients (96.2%). There was no statistically significant difference in demographic data among patients predicted to experience necrosis by means of ICG angiography versus those predicted to have entirely viable tissue. CONCLUSION: This study suggests that ICG angiography is prone to overpredicting postoperative necrosis in comparison to MSRI. CLINICAL RELEVANCE STATEMENT: This study suggests that multispectral reflectance imaging may benefit practicing plastic surgeons in determining the likelihood of postoperative necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

A Second Drain Decreases Seroma Formation in Prepectoral Immediate Breast Reconstruction with an Acellular Dermal Matrix.

Seroma formation is the most common complication after mastectomy. While the exact pathophysiology behind seroma development has not been entirely elucidated, seromas are associated with negative outcomes in breast reconstruction. The utilization of drains is one method to combat seroma. However, the current state of plastic surgery is divided as to whether one drain or two drains is optimal in reducing seroma formation. We hypothesized that using two drains instead of one drain would reduce the risk of seroma more so than one drain. Methods: This was a retrospective cohort study of patients who underwent prepectoral direct to implant reconstruction at a single institution by a single surgeon. Each patient underwent reconstruction with either one or two drains. Patients were followed postoperatively for rates of seroma formation. Seroma were classified as either minor or major. Secondary variables including drain duration, infection, and necrosis were also analyzed. Results: A total of 99 breasts and 71 patients experienced breast reconstruction with two drains, and 163 breasts corresponding to 135 patients received reconstruction with one drain. In the two drain cohort, 14 (14.1%) developed a seroma, with 11 (11.1%) being minor seromas and three (3.03%) being major seromas. In comparison, out of the one drain cohort, 41 (25.2%) developed a seroma, with 35 (21.5%) being a minor seroma and six (3.68%) being classified as major. Conclusion: This study suggests that two drains decreases the rate and risk of seroma formation compared to one drain in prepectoral breast reconstruction with an acellular dermal matrix.

Neurosurgical management of a rare congenital supratentorial neurenteric cyst with associated nasal dermal sinus: case report.

The authors describe the case of a patient with the classic clinical presentation and radiographic features of a nasal dermal sinus with an associated intracranial cyst; however, histopathology revealed that the intracranial cyst was neurenteric instead of the typical epidermoid or dermoid cyst. Preoperative assessment included CT and MRI, which revealed a direct communication between the patient's nasal polypoid lesion and the anterior skull base via the foramen cecum. At the hands of a multidisciplinary plastic surgery and neurosurgery team, the patient underwent concurrent gross-total resection of the nasal polypoid lesion, the intracranial intradural cystic lesion, and their interconnecting tract.

Closure of meningomyelocele defects using acellular dermal matrix.

Spina bifida is the most common birth defect of the CNS, with meningomyelocele observed in 1 in 800 to 1000 infants. A single reliable method of providing adequate soft-tissue coverage (skin, but also including subcutaneous fat, fascia, and muscle) of the meningomyelocele defect while preventing dehiscence and infection has yet to be defined. This study reviews a case series of 3 patients with large meningomyeloceles treated by a single neurosurgeon /plastic surgeon team at a single institution. Following repair of the neural elements (both dura and neural placode), soft-tissue coverage (skin, but also subcutaneous tissue and fascia) was achieved using acellular dermal matrix over the neural elements, repaired with sutures, and covered with skin flaps. In this series of 3 patients, stable coverage was achieved in all patients. One patient experienced minor wound dehiscence treated with debridement and primary closure with simple relaxing incisions. This series demonstrates that the usage of acellular dermal matrix provides a stable soft-tissue coverage for large meningomyelocele defects in an easily reproducible operation preserving local soft tissue (muscle, fascia) for potential salvage operations or revisions (such as for scoliosis) as well as providing a less demanding operation on the fragile physiology of the neonate.

Pediatric lower extremity mower injuries.

Lawn mower injuries in children represent an unfortunate common problem to the plastic reconstructive surgeon. There are approximately 68,000 per year reported in the United States. Compounding this problem is the fact that a standard treatment algorithm does not exist. This study follows a series of 7 pediatric patients treated for lower extremity mower injuries by a single plastic surgeon. The extent of soft tissue injury varied. All patients were treated with negative pressure wound therapy as a bridge to definitive closure. Of the 7 patients, 4 required skin grafts, 1 required primary closure, 1 underwent a lower extremity amputation secondary to wounds, and 1 was repaired using a cross-leg flap. Function limitations were minimal for all of our patients after reconstruction. Our basic treatment algorithm is presented with initial debridement followed by the simplest method possible for wound closure using negative pressure wound therapy, if necessary.

An arteriovenous malformation of the external ear in the pediatric population: A case report and review of the literature.

The literature regarding arteriovenous malformations of the external ear is sparse. A case of a patient clinically diagnosed with an arteriovenous malformation of the external ear that was managed empirically with surgical excision, without recurrence, is presented. The pathogenesis, clinical presentation, radiological work up and management options regarding arteriovenous malformations are reviewed.

Decreasing expander breast infection: A new drain care protocol.

BACKGROUND: Risk factors for expander reconstruction infection are well known. However, drain use as a risk factor for the development of infection is unclear. OBJECTIVE: To review a simple method for drain use to help reduce rates of infection in expander breast reconstruction. METHODS: Two hundred consecutive single-surgeon (JDM) immediate first-stage expander breast reconstructions were retrospectively reviewed. The records were reviewed for history and physical examination, intra-operative technique, perioperative management, adjuvant therapy, and outcome with respect to expander infection necessitating premature explantation within the first eight weeks. Infection was defined on clinical basis, with or without culture positivity. All expanders (Mentor, USA) were the same model (textured, port-integrated and biodimensional). Two consecutive series of reconstructions were then created. The first series included 177 reconstructions while the second series included 23 reconstructions. Unlike the first series, the second series introduced a protocol in which all reconstructions received mupirocin 2% cream to the drain sites and all drains were removed at the end of the first week. Additionally, in the second series, all expanders were secluded from direct in vivo contact with the closed suction drain either by the use of an intervening Alloderm sling (LifeCell Corporation, USA, 15 of 23 breasts) or by subdermally tunnelling the drain superficial to an adequate fatty subcutaneous layer (eight of 23 breasts). RESULTS: Patients who developed infection in the first series and all patients in the second series shared statistically the same level of aggregate risk factors (P=0.531). The infection rate (5.65%, 10 infections in 177 breasts) in the first series was statistically greater than in the second series (0%, 0 in 23 breasts, P=0.001). CONCLUSIONS: The present study found that percutaneous closed suction drains do serve as an increased risk for expander infection. However, early results indicate that in vivo protection of the expander with Alloderm or subdermal tunnelling, topical antibiotic ointment use and early drain removal may significantly reduce expander infection.

Predicting breast reduction weight using the mass of breast ptosis.

BACKGROUND: The preoperative prediction of therapeutic breast reduction weights, to achieve both relief of breast weight symptoms and yet achieve excellent breast shape, remains a challenge. OBJECTIVES: To design a simple clinical method to preoperatively predict and quantify therapeutic breast reduction weights. METHODS: In 31 women who underwent therapeutic bilateral reduction mammaplasty, the mass of the hypertrophic breast hanging below the inframammary fold was preoperatively weighed and then compared with the mass of the reduction specimen. Thirty patients underwent breast reduction using a superomedial nipple-areolar pedicle. Postoperative breast weight-related symptoms and breast shape findings were then noted. Statistical analysis relied on mean, SD, sample size, Mann-Whitney test for medians, Levene's test for variances and regression analysis. RESULTS: The average clinical follow-up was 160 days, with all patients achieving satisfactory breast size and shape from both the patient and surgeon's perspectives. All patients reported improvement of back pain, shoulder pain and lower neck pain. Two breasts developed delayed healing of the lateral skin flap, necessitating debridement and reclosure, followed by uneventful ongoing healing. There was no significant difference in preoperative ptotic breast mass and resectional breast mass (all P>0.05). CONCLUSIONS: Simple preoperative weighing of the ptotic portion of the hypertrophic breast can serve as a goal for the reduction weight, while creating pleasing breast proportions and improving breast weight-related symptoms. Preoperative quantification of the ptotic breast mass may guide the reduction technique and assist insurance precertification efforts.

Parental satisfaction with the CranioCap: a new cranial orthosis for deformational plagiocephaly.

OBJECTIVE: This study evaluates the safety and parent satisfaction of a new cranial orthosis designed to treat deformational plagiocephaly. DESIGN: A retrospective phone survey of parental satisfaction of a new cranial orthosis that has Food and Drug Administration (FDA) clearance for treatment of deformational plagiocephaly. SETTING: A tertiary referral center for children with craniofacial anomalies. PATIENTS: The first 232 consecutive infants enrolled in this program were retrospectively reviewed. INTERVENTIONS: Infants were entered in the cranial orthosis program if they had been diagnosed with deformational plagiocephaly and were less than 1 year of age, and if the infant's parents were interested in enrolling in a monitored cranial orthosis program. MAIN OUTCOME MEASURE: After completing therapy, a random sample of 81 parents (half completing treatment) was surveyed. Parents rated the improvement in their infant's head shape from 1 (least) to 5 (most). They were asked if they would repeat the program with a subsequent child. To date, 70% (162/ 232) have completed treatment. RESULTS: The orthosis was worn an average of 89 days. On average, parents rated head shape improvement 4.06 out of 5 (range, 3 to 5). Of parents surveyed, 81 (100%) would repeat the program with a subsequent child. There were three (3/232 or 1.3%) minor complications: one child with a persistent rash that resolved with termination of orthosis use, one child with a skin irritation that resolved with orthosis recontouring, and one child who could not be successfully fit. CONCLUSIONS: The CranioCap, a new cranial orthosis with clearance for treatment of deformational plagiocephaly, appears to be safe, well tolerated, and has excellent parent satisfaction.

Isolated xanthoma of the frontal bone.

Xanthomas of soft tissue are common, well described lesions. Much less common are xanthomas of bone. Rarer still are xanthomas of the bones of the skull or facial skeleton. The case of a woman with an incidentally found isolated xanthoma of the frontal bone in the setting of normal blood lipid levels is reported. Surgical treatment of such lesions is both diagnostic, in excluding other lesions such as eosinophilic granuloma, and therapeutic.

Midface distraction to alleviate upper airway obstruction in achondroplastic dwarfs.

OBJECTIVE: The use of midface distraction in patients with achondroplasia and upper airway obstruction secondary to midface hypoplasia has not been reported. In this report, we review the treatment of two patients with severe midface hypoplasia and obstructive sleep apnea secondary to achondroplasia using midface distraction osteogenesis. DESIGN, SETTING, AND PATIENTS: Two patients with achondroplastic dwarfism and midface hypoplasia with airway obstruction were treated in a tertiary referral center for craniofacial disorders. RESULTS AND CONCLUSIONS: Both patients had their tracheostomies decannulated after midface distraction of 25 mm. Midface distraction osteogenesis is useful to alleviate upper airway obstruction from midface hypoplasia seen in achondroplasia.

The role of reduction mammaplasty in reconstructing partial mastectomy defects.

The management of breast tumors in women with macromastia can be challenging. Reconstructive options are limited and breast conservation therapy is often not indicated or results in poor cosmetic outcomes. The purpose of this report was to present a series of women with macromastia who underwent simultaneous reconstruction of a partial mastectomy defect with bilateral reduction mammaplasty. A retrospective review was performed and included all women who underwent partial mastectomy with simultaneous reduction mammaplasty. Data points included patient demographics, preoperative assessment, operative intervention, adjuvant treatment, and outcomes. Twenty women were included in the series (mean age, 43 years; range, 11 to 72 years) with an average body mass index of 32.6 (range, 24.9 to 44.1). Tissue diagnosis was ductal carcinoma (n = 8), ductal carcinoma in situ (n = 6), fibroadenoma (n = 4), and benign breast tissue (n = 2). The various reduction mammaplasty techniques were documented with regard to tumor size and location. The superior medial and inferior pedicles seemed to be the most versatile techniques. One patient required completion mastectomy with autologous tissue reconstruction given positive margins. All patients were disease-free at follow-up (mean, 23 months) and postoperative cancer surveillance was not impaired by the combined procedures. The versatility of reduction mammaplasty allows this procedure to be performed in conjunction with partial mastectomy for any tumor location. Combining these procedures in patients with macromastia provides numerous therapeutic benefits at low cost, while reducing breast distortion and preserving symmetry.