Vertical Inset of the Latissimus Dorsi Flap Improves Reconstruction Aesthetics by Reducing Scar Burden in the "Social Breast".

PURPOSE: The skin paddle of the latissimus dorsi flap is typically inset horizontally (HILD) in breast reconstruction. We describe our experience with the vertical inset of the latissimus dorsi (VILD) and its aesthetic benefit. METHODS: We performed a case-control study comparing the most recent cases of both VILD and HILD. Scar, as seen on anterior-posterior photographs, was digitally measured and compared from 3 clinically relevant areas: (1) all visible scarring ("mirror view"), (2) scarring above the nipple ("self-view"), and (3) scarring above or medial to the nipple ("social view"). Demographics and outcomes were statistically compared. EXPERIENCE/RESULTS: Fifty of the most recent patients receiving HILD or VILD were selected for each group. Average patient age was 55.6 and 51.6 years (P = 0.32), and average follow-up was 531.6 and 606.7 days (P = 0.20), respectively. The VILD scar-length ratios were decreased by 17% in the mirror view (P ≤ 0.01), 37% in the self-view (P ≤ 0.01), and 37% in the social view (P ≤ 0.01). There were no statistically significant differences between groups regarding smoking (P = 0.75), diabetes (P = 0.70), body mass index (P = 0.74), seroma (P = 0.46), infection (P = 1.0), or flap necrosis (P = 0.70). CONCLUSIONS: The VILD is safe and reliable. Measurements from anterior-posterior photographs illustrate statistically significant decreases in overall scar burden (mirror view) and statistically significant reductions in the highly visible self-view and social view. Our study is the first to quantify a reduction in scar burden by using VILD technique.

Body mass index and etiology of intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Extremes of body mass index (BMI) are associated with increased incidence of intracerebral hemorrhage (ICH). Because ICH can result from different vessel pathologies, we investigated whether the effect of BMI depends on ICH etiology. METHODS: We analyzed 384 consecutive ICH cases (188 lobar ICH and 196 deep ICH) and 388 control subjects enrolled between 2004 and 2009 in an ongoing single-center prospective study of primary ICH. ICH was categorized as lobar or deep based on CT imaging at admission. BMI was calculated based on subjects' height and weight at enrollment. We constructed multivariate logistic regression models including BMI and known predictors of ICH occurrence. Analyses were performed separately for lobar and deep ICH subjects versus control subjects. RESULTS: Low BMI (<18.5 kg/m(2)) and very high BMI (>30.0 kg/m(2)) were associated with deep ICH risk (OR, 1.76; P=0.011 and OR, 1.75; P=0.013, respectively), whereas no effect was found for lobar ICH. Furthermore, sex-stratified analyses uncovered that among low BMI individuals, males were at higher ICH risk (OR, 2.85; P=0.041) but females were not (OR, 0.89; P=0.54, respectively). CONCLUSIONS: Extremes of BMI are associated with increased risk of deep ICH, but not lobar ICH, suggesting a role for BMI in the vascular pathologies underlying deep ICH, but not in pathologies such as cerebral amyloid angiopathy that cause ICH in the lobar brain regions.

Packed red blood cell transfusion and decreased mortality in intracerebral hemorrhage.

BACKGROUND: Accumulating data suggest that anemia worsens outcomes in critically ill patients, including those with subarachnoid and intracerebral hemorrhage (ICH). Although packed red blood cell (PRBC) transfusion appears to increase brain tissue oxygen, it is unknown whether such transfusions, which are commonly administered in patients with intracranial hemorrhage, alter outcome. OBJECTIVE: Following up on our observation that anemia is associated with poor outcome in patients with ICH, we investigated whether PRBC transfusion was associated with any benefit. METHODS: Five hundred forty-six consecutive subjects were identified from an ongoing single-center, prospective cohort study of nontraumatic ICH over a 6-year period. Clinical and radiographic characteristics, laboratory values including admission and daily mean hemoglobin values, and all instances of PRBC transfusion were recorded. Aggressiveness of care was assessed by whether the patient had a "do not resuscitate" order activated during hospitalization. The primary endpoint was 30-day survival. RESULTS: Anemia was present in 144 of 546 patients (26%) on admission and developed subsequently in an additional 250, leaving just 152 of 546 patients (28%) who never developed anemia. PRBC transfusion was administered to 100 patients (18%) during their hospital stay, 98% of whom were anemic. In multivariable analysis, PRBC transfusion was associated with improved survival at 30 days (odds ratio: 2.76; 95% confidence interval: 1.45-5.26; P = .002). CONCLUSION: Anemia develops in the majority of patients with ICH at some point during their hospitalization. PRBC transfusion was associated with improved outcome in these patients.

Critical care management of acute intracerebral hemorrhage.

OPINION STATEMENT: Intracerebral hemorrhage is a medical emergency. It is the most deadly and disabling form of stroke, and no individual therapy has been demonstrated to improve outcome. However, it appears that aggressive medical care in general, and management by neuroscience specialists in particular, offers substantial benefit. Therefore, providing the best supportive care based on currently available evidence may well improve outcomes. Airway management and management of blood pressure aimed at maximizing cerebral perfusion while minimizing ongoing bleeding, as well as rapid reversal of anticoagulation, are likely to be important in the early phase. Additionally, efforts should be undertaken to provide careful glucose management and temperature management and to maximize cerebral perfusion pressure. Selected patients are likely to benefit from external ventricular drainage or even hematoma evacuation. Except in rare circumstances, most patients should be managed in a neuroscience intensive care unit during the acute phase. Some patients appear to have no reasonable likelihood of recovery and can be considered for limitations of care such as Do Not Resuscitate orders or Comfort Measures Only orders. However, it can be difficult to accurately predict long-term outcome in the acute phase; formal prognostic tools should be used to offer information to patients and their families. After the hemorrhage has stabilized, efforts to minimize complications include thromboembolism prophylaxis, physical therapy, and acute rehabilitation.