A Prospective Study of Immediate Breast Reconstruction with Laser-Assisted Indocyanine Green Angiography.

BACKGROUND: Complication rates following immediate breast reconstruction range from 4% to 60%. Mastectomy skin flap necrosis (MSFN) is often the sentinel event leading to secondary complications. METHODS: All patients undergoing immediate reconstruction were enrolled. Upon mastectomy completion, the surgeon visually interpreted the skin flaps, performed laser-assisted indocyanine green angiography (LAIGA), and intervened if needed. Patients were followed for 90 days, documenting skin necrosis, infection, seroma, hematoma, implant loss, and reoperation. RESULTS: There were 126 patients who had 206 immediate breast reconstructions. The complication rate was 22.3%. The incidence of MSFN was 14.1%. The reoperation rate was 8.7%. There was 1 necrosis-related implant loss. Postoperative surveys were completed on 193 breasts: 137 had visual and LAIGA interpretation of well or adequately perfused, resulting in 5.8% rate of necrosis, 2 reoperations, and no implant losses. Twenty breasts had visual and LAIGA interpretation of marginal or poor perfusion. Sixteen of these underwent intervention. The necrosis rate in this group was 35% with no implant losses. A third group with 26 breasts had adequate visual interpretation with marginal or poor perfusion on LAIGA. Ten breasts had no intervention, and 16 received intervention. The overall necrosis rate in this group was 42.3%, with 4 reoperations for necrosis and 1 implant loss. CONCLUSIONS: LAIGA can more accurately predict complications from MSFN than surgeon assessment alone. When surgeon decision making is supplemented with LAIGA, it reduces the incidence of MSFN, infection, implant loss, and overall unexpected reoperation rate. LAIGA is a valuable adjunct for intraoperative decision making.

Electrically induced contraction levels of the quadriceps femoris muscles in healthy men: the effects of three patterns of burst-modulated alternating current and volitional muscle fatigue.

OBJECTIVE: The purpose of this study was to compare electrically induced contraction levels produced by three patterns of alternating current in fatigued and nonfatigued skeletal muscles. DESIGN: Eighteen male volunteers without health conditions, with a mean (SD) age of 24.9 (3.4) yrs were randomly exposed to a fatiguing volitional isometric quadriceps contraction and one of three patterns of 2.5-KHz alternating current; two were modulated at 50 bursts per second (10% burst duty cycle with five cycles per burst and 90% burst duty cycle with 45 cycles per burst), and one pattern was modulated at 100 bursts per second (10% burst duty cycle with 2.5 cycles per burst). The electrically induced contraction levels produced by the three patterns of electrical stimulation were compared before and after the fatiguing contraction. RESULTS: The 10% burst duty cycles produced 42.9% (95% confidence interval, 29.1%-56.7%) and 32.1% (95% confidence interval, 18.2%-45.9%) more muscle force (P < 0.001) than did the 90% burst duty cycle pattern. There was no significant interaction effect (P = 0.392) of electrical stimulation patterns and fatigue on the electrically induced contraction levels. CONCLUSIONS: The lower burst duty cycle (10%) patterns of electrical stimulation produced stronger muscle contractions. Furthermore, the stimulation patterns had no influence on the difference in muscle force before and after the fatiguing quadriceps contraction. Consequently, for clinical applications in which high forces are desired, the patterns using the 10% burst duty cycle may be helpful.

The effects of tone-reducing orthotics on walking of an individual after incomplete spinal cord injury.

PURPOSE: Most literature about the efficacy of tone-reducing orthotics pertains to adults and children with central nervous system (CNS) pathology. There is relatively little mention of using this type of orthotic with adults after spinal cord injury (SCI). Therefore, the purpose of this study was to investigate whether tone-reducing orthotics have an effect on gait including electromyographic (EMG) activity, velocity, step length, time in double-limb support, and SCI-Functional Ambulation Inventory (SCI-FAI) scores for an individual with incomplete SCI and spasticity. METHODS: We used a single case design. The subject was a 25-year-old white male who was 16 months post-injury with a diagnosis of T6 left/T9 right sensory, L3 motor American Spinal Injury Association C incomplete SCI. Five different walking conditions were tested during each of two separate sessions: barefoot, shoes, foot plates, one ankle-foot orthosis (AFO) with a joint, and one with a tone-reducing AFO, and tone-reducing AFOs bilaterally. Surface EMG was used to record electrical activity of four muscle groups bilaterally. Step length, gait velocity, and time in double limb support were calculated for all five walking conditions. Gait parameters were further analyzed with video analysis using the SCI-FAI. RESULTS: Mean EMG was relatively constant in all muscle groups under all walking conditions with the exception of the gastrocnemius. In this muscle group, EMG activity with the use of tone-reducing orthotics was better modulated than the other conditions. Gait velocity and step length both increased with tone-reducing orthotics, whereas double limb support time decreased, thus improving the corresponding SCI-FAI score accordingly. CONCLUSION: The subject showed improvement in the control of his lower extremities while wearing bilateral tone-reducing AFOs as evidenced by an increased step length and gait velocity and a decrease in the amount of time spent in double limb support. Electromyographic data were less conclusive, although activity in the left gastrocnemius muscle group was more erratic under alternative walking conditions when compared to the tone-reducing AFOs.

Outcomes in pharyngoplasty: a 10-year experience.

OBJECTIVE: The outcomes of 61 patients who underwent a pharyngoplasty for velopharyngeal insufficiency were reviewed to determine potential risk factors for reoperation. DESIGN: This was a retrospective chart review of 61 consecutive patients over approximately 10 years (1993 to 2003). Variables analyzed included gender, cleft type, age at the time of pharyngoplasty, length of time between palate repair and pharyngoplasty, and associated syndromes. PARTICIPANTS: Of the 61 patients, 20 (34%) had a unilateral cleft lip and palate, 5 (8%) had a bilateral cleft lip and palate, 13 (21%) had an isolated cleft palate, 7 (11%) had a submucous cleft palate, and 16 (26%) were diagnosed with noncleft velopharyngeal insufficiency. RESULTS: Of the 61 patients, 10 (16%) required surgical revision. No statistically significant difference was found among gender, cleft type, age at the time of pharyngoplasty, the length of time between palate repair and pharyngoplasty, and associated congenital syndromes, with respect to the need for surgical revision (p > .05). Of the surgical revisions, 50% (5) were performed for a pharyngoplasty that was placed too low. CONCLUSIONS: Because 50% of the pharyngoplasty revisions had evidence of poor velopharyngeal closure and associated hypernasality resulting from low placement of the sphincter, the pharyngoplasty needs to be placed at a high level to reduce the risk for revisional surgery. The pharyngoplasty is a good operation for velopharyngeal insufficiency with an overall success rate of 84% (51 of 61) after one operation and greater than 98% (60 of 61) after two operations.

Torque responses in human quadriceps to burst-modulated alternating current at 3 carrier frequencies.

STUDY DESIGN: Independent group design, 1 group per carrier frequency, with subjects stratified by gender and systematically assigned to groups. OBJECTIVE: To determine the effect of the frequency of burst-modulated alternating current (AC) on the electrically induced torque (EIT) response of the quadriceps femoris muscle. BACKGROUND: Many studies have examined the influence of current amplitude and burst modulation on the EIT response. However, research is limited on the effects of carrier frequency on the EIT response of the quadriceps femoris. METHODS AND MEASURES: Twenty-three healthy subjects (mean age +/- SD, 22.7 +/- 1.7 years) volunteered for the study and were systematically assigned to 1 of 3 groups: group 1 (2500-Hz AC), group 2 (3750-Hz AC), and group 3 (5000-Hz AC). For normalization purposes, maximal voluntary isometric contraction (MVIC) force was assessed with a load cell prior to the application of 5 minutes of neuromuscular electrical stimulation (NMES). The EIT and current amplitude were recorded during each of the 5 minutes of NMES. RESULTS: The mean EIT ([EIT/MVIC] x 100) produced at equivalent current amplitudes when using the 2500-Hz carrier frequency was significantly greater than the mean EITs generated at 3750 Hz (P = .004) and 5000 Hz (P<.001), respectively. CONCLUSIONS: Burst-modulated alternating current delivered at 2500 Hz produced greater EITs than those generated at 3750 and 5000 Hz.

Gynecomastia: an outcome analysis.

BACKGROUND: Gynecomastia refers to the presence of femalelike mammary glands in a male. This disorder can lead to significant psychologic stress and self-consciousness. This study consists of a chart review of 174 patients treated surgically between July 1, 1976, and February 27, 2001. RESULTS: Operative procedures were excision, excision with suction-assisted lipectomy (SAL), SAL, skin excision (skin) and skin excision with SAL. Overall complication rate was 20%. No significant difference in complication rates was found between grades or procedures. Revision rates between grades were I = 10.3%, II = 14.5% and III = 34.8% (P < 0.001). In grade III, gynecomastia revision rates for excision +/- SAL was 29% and skin +/- SAL was 38.1% (P = 0.644). Of the 8 revisions in the skin-sparing procedures, 6 were revised with a scar-forming procedure. Therefore, 77% of patients with grade III gynecomastia were adequately treated with a skin-sparing procedure. CONCLUSION: Skin-sparing operations should be the initial procedure chosen for most grade III gynecomastia patients.

Bilateral reduction mammoplasty in an adolescent population: adolescent bilateral reduction mammoplasty.

Bilateral reduction mammoplasty in adolescent patients can be a controversial procedure because of the significance of possible long-term complications and the permanence of the results. There are no current criteria specifically for adolescent candidates for reduction surgery, although many of these young women may have severe physical symptoms. Therefore, the demographics and outcomes of these patients are of particular interest in determining the risks and benefits particular to this surgery for younger patients. Seventy-three patients who had undergone bilateral reduction mammoplasty between 1981 and 2000 were identified in the hospital and office records of four midwestern plastic surgeons. Patient ages ranged between 12.5 and 18.9 years, with a mean age of 16.1 years. A two-pronged investigation involved examination of demographics of the adolescent population and short- and long-term outcomes and satisfaction. Demographic survey included age, weight, height, BMI, breast size, and amount of tissue removed. Indications for surgery and postoperative complications were surveyed in office records and via questionnaire. Seventeen patients (23%) were successfully contacted and returned a detailed questionnaire evaluating indications for surgery, preoperative and postoperative complications, and overall satisfaction. Eighty-two percent of patients reported resolution of their physical symptoms, including back, shoulder, and neck pain. Self-esteem, however, was cited most commonly as a reason to recommend this procedure to other adolescent women. Nearly 65% of respondents would repeat their adolescent surgical experience, and 82.4% would recommend this procedure to a teenaged friend in a similar situation. The authors' data suggest that adolescent patients benefit significantly from reduction mammoplasty and that long-term satisfaction remains high, despite the age of the patients at surgery.

Strength response in human femoris muscle during 2 neuromuscular electrical stimulation programs.

STUDY DESIGN: Experimental mixed repeated-measures design. OBJECTIVE: To determine the effect of 2 versus 3 neuromuscular electrical stimulation (NMES) training sessions per week on the response to strength training of the quadriceps femoris muscle. BACKGROUND: Many studies have examined the influence of training intensity (percent maximal voluntary isometric contraction [MVIC]) during NMES on the strength response of the quadriceps femoris muscle. However, no study has examined the effects of the number of NMES sessions per week on the change in strength of the quadriceps femoris. METHODS AND MEASURES: Twenty-seven healthy subjects (mean age +/- SD, 23.2 +/- 3.2 years) volunteered for the study and were randomly assigned to 1 of 3 groups; control group (no electrical stimulation); group 2 (NMES 2 times per week); and group 3 (NMES 3 times per week). Groups 2 and 3 received NMES (10 minutes per session) over a 4-week period for a total of 8 and 12 NMES training sessions, respectively. The isometric quadriceps femoris muscle force produced during NMES was monitored during each treatment minute. The MVIC force of the quadriceps femoris was assessed prior to the first week and at the start of weeks 2, 3, and 4 of the 4-week training program, with a final measurement after the fourth week (5 total measurements) for all subjects. RESULTS: Only the mean percent change in quadriceps MVIC before and after the 4 weeks of training with NMES between the control group and group 3 was significantly different (P = .021). CONCLUSIONS: Based on the electrical stimulation parameters and healthy subjects used in this study, NMES caused significant increases in the quadriceps femoris muscle strength when used for 3 training sessions per week for 4 weeks. It is possible that the use of a different electrical stimulation paradigm and/or a different patient population may result in strength gains with 1 or 2 sessions per week.