Arterialization of the Venous System for Acute and Chronic Ischemia of the Hand: A Case Series With Prospective Duplex Ultrasound Assessment.

Background: Ischemia of the hand is a debilitating condition. In many cases, the cause of ischemia is diffuse atherosclerosis with no distal vessels available for bypass. In these situations, options are limited to restore perfusion, and there is a potential role for arterialization of the venous system to relieve ischemic pain and avoid amputation. Methods: This is a retrospective review of all patients at our institution who underwent arterialization of the venous system between 2010 and 2014 by 4 surgeons for acute or chronic ischemia of the upper extremity not amenable to bypass procedures. Indications, preoperative and postoperative findings, and the requirement for future digital amputations were recorded. The patients were then evaluated prospectively for the patency of arteriovenous anastomosis and the pattern of perfusion by duplex ultrasound studies. Results: Eight patients with 10 upper extremities underwent arterialization of the venous system. All patients with chronic ischemia went on to heal their ischemic ulcerations with relief of rest pain and avoided amputation. Eight upper extremities had arterial Doppler and duplex ultrasound signals showing arterialized dorsal veins demonstrating flow from the dorsal veins heading volar via the intrinsic compartments into the digital arteries. Conclusions: This study illustrates the successful use of arterialization of the venous system of the hand in both acute and chronic hand ischemia. It reports on prospective imaging and duplex ultrasound studies confirming patency of the anastomosis and objective evidence of distal arterial flow. Based on our experience, we believe that arterialization of the venous system may provide an effective salvage option in the setting where no distal bypass is available.

Free tissue transfer for necrotizing fasciitis reconstruction: A case series.

BACKGROUND: Necrotizing fasciitis (NF) is a life-threatening infection requiring extensive debridement that may necessitate amputation. Free tissue transfer (FTT) is an option for reconstruction in difficult cases. Currently, only case reports have described FTT in the setting of NF, and comprehensive evidence on flap outcomes is lacking. The present study characterizes outcomes in patients with FTT following NF. METHODS: All patients admitted with NF between January 1, 2005 and December 31, 2011 to our level 1 burns/trauma referral center were retrospectively reviewed. RESULTS: No significant difference was found in patient demographics between FTT (n=12) and no FTT (n=212). Both groups had the same number of operations, same length of ICU stay, and length of hospitalization. The flaps used were 10 anterolateral thigh, 1 latissimus dorsi and 1 radial forearm. Recipient sites included: upper extremities (6), lower extremities (4), head/neck (1), and genitalia (1). No flap failures and no take-back operations were required. Upper extremities comprised 58.3% of FTT patients compared to 18.9% (p=0.004) in non-FTT patients. Flap operations occurred a mean of 11.6days post-admission with 1.1 operations prior to FTT. Mean FTT size was 213cm2. Flap complications included seroma (n=1), hematoma (n=1). Donor site complications included hematoma (n=1), exposed tendon (n=1) and necrosis (n=1). CONCLUSIONS: This study demonstrates that FTT provides a promising reconstructive option in the setting of NF without adversely affecting patient outcome.

Timing of Postmastectomy Reconstruction Does Not Impair Breast Cancer-Specific Survival: A Population-Based Study.

BACKGROUND: Debate remains over the optimal timing of breast reconstruction after mastectomy. Immediate reconstruction has demonstrated superior psychosocial and aesthetic outcomes, but might delay adjuvant therapy. Conversely, delayed reconstruction allows for timely initiation of adjuvant therapy, but with potentially inferior aesthetic results. The authors examined whether any significant breast cancer-specific survival difference exists on the basis of the timing of reconstruction after mastectomy. PATIENTS AND METHODS: Using a cancer registry, medical insurance, and vital statistics sources, all Nova Scotia women who underwent unilateral mastectomy for breast cancer between 1989 and 2007 were followed to 2012 or time of death. Breast cancer-specific survival was compared for mastectomy patients who did or did not undergo reconstruction. Cox proportional hazards models were fitted adjusting for known demographic, disease severity variables, comorbidities, and reconstruction timing. RESULTS: Of 6790 subjects included in the study, 331 (4.9%) underwent breast reconstruction. Of those who underwent reconstruction, 209 (63%) and 122 (37%) underwent immediate and delayed reconstruction, respectively. Univariate analysis showed improved breast cancer-specific survival among all breast reconstruction patients compared with patients who underwent mastectomy alone (hazard ratio [HR], 0.64; 95% confidence interval [CI], 0.48-0.86). In a multivariate model fitting a time-varying covariate to adjust for timing of reconstruction from mastectomy, no difference in survival was observed between patients who underwent reconstruction at any time and those who underwent mastectomy only (HR, 0.75; 95% CI, 0.56-1.00). No differences in breast cancer-specific survival were observed on the basis of type of reconstruction. CONCLUSION: Results of the current study suggest that breast reconstruction, regardless of its timing, carries no increased risk of breast cancer-specific mortality compared with mastectomy alone.

Accuracy of medical models made by consumer-grade fused deposition modelling printers.

BACKGROUND: Additive manufacturing using fused deposition modelling (FDM) has become widely available with the development of consumer-grade three-dimensional printers. To be useful in maxillofacial surgery, models created by these printers must accurately reproduce the craniofacial skeleton. OBJECTIVE: To determine the accuracy of consumer-grade FDM printers in the production of medical models compared with industrial selective laser sintering (SLS) printers. METHODS: Computed tomography images of a dry skull were manipulated using OsiriX (OsiriX, Switzerland) and ZBrush (Pixologic, USA) software. Models were fabricated using a consumer-grade FDM printer at 100 µm, 250 µm and 500 µm layer heights and an industrial SLS printer. Seven linear measurements were made on the models and compared with the corresponding dry skull measurements using an electronic caliper. RESULTS: A dimensional error of 0.30% was observed for the SLS models and 0.44%, 0.52% and 1.1% for the 100 µm, 250 µm and 500 µm FDM models, respectively. CONCLUSION: Consumer-grade FDM printers can produce medical models with sufficient dimensional accuracy for use in maxillofacial surgery. With this technology, surgeons can independently produce low-cost maxillofacial models in an office setting.

HISTORIQUE: La fabrication additive faisant appel à la modélisation par dépôt de fil en fusion (FDM) s'est généralisée grâce au développement des imprimantes tridimensionnelles pour consommation courante. Pour être utiles en chirurgie maxillo-faciale, les modèles créés par ces imprimantes doivent reproduire le squelette craniofacial avec précision. OBJECTIF: Déterminer la précision d'imprimantes FDM pour consommation courante dans la production de modèles médicaux par rapport à des imprimantes industrielles faisant appel au frittage sélectif par laser (SLS). MÉTHODOLOGIE: Les chercheurs ont manipulé les images tomodensitométriques d'un crâne séché à l'aide des logiciels OsiriX (OsiriX, Suisse) et ZBrush (Pixologic, États-Unis). Ils ont fabriqué les modèles à l'aide d'une imprimante FDM pour consommation courante, à des épaisseurs de couche de 100 µm, 250 µm et 500 µm, ainsi qu'à l'aide d'une imprimante SLS industrielle. Au moyen d'un pied à coulisse électronique, ils ont effectué sept mesures linéaires sur les modèles, qu'ils ont comparées aux mesures du crâne séché. RÉSULTATS: Les chercheurs ont observé une erreur dimensionnelle de 0,30 % dans les modèles SLS et de 0,44 %, 0,52 % et 1,1 % dans les modèles FDM à 100 µm, 250 µm et 500 µm, respectivement. CONCLUSION: Les imprimantes FDM pour consommation courante produisent des modèles médicaux de précision dimensionnelle suffisante pour être utilisés en chirurgie maxillo-faciale. Grâce à cette technologie, les chirurgiens peuvent produire eux-mêmes des modèles maxillo-faciaux à faible coût en cabinet.

Amyotrophic lateral sclerosis presenting as upper limb weakness in a 35 year old female: a case report.

Chiropractors regularly assess and provide treatment for a variety of neuromuscular complaints. Many of these respond well to conservative care however some represent conditions that must be referred for further evaluation. This article chronicles the management of a patient who presented with upper limb weakness and was subsequently diagnosed with amyotrophic lateral sclerosis (ALS). Chiropractors should be informed of the nature and presentation of this disease to facilitate early diagnosis and treatment.

Immediate postmastectomy reconstruction is associated with improved breast cancer-specific survival: evidence and new challenges from the Surveillance, Epidemiology, and End Results database.

BACKGROUND: Although immediate breast reconstruction is increasingly offered as part of postmastectomy psychosocial rehabilitation, concerns remain that it may delay adjuvant therapy or impair detection of local recurrence. No single population-based study has examined the relationship between immediate breast reconstruction and breast cancer-specific survival. METHODS: By using data from the US National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registries, breast cancer-specific survival was compared for female unilateral mastectomy patients who did or did not undergo immediate breast reconstruction. Cox proportional hazards models were fitted, adjusting for known demographic and disease severity variables and stratifying on reconstruction type (implant or autologous) and age. RESULTS: Improved breast cancer-specific survival was observed among all immediate breast reconstruction patients compared with patients who underwent mastectomy alone (hazard ratio [HR]=0.74; 95% confidence interval [CI], 0.68 to 0.80). Implant reconstruction patients below 50 years of age demonstrated the greatest apparent survival benefit (HR=0.47; 95% CI 0.28 to 0.80). Similarly, autologous reconstruction was associated with improved cancer-specific survival among patients below the age of 50 (HR=0.58; 95% CI, 0.42 to 0.80) and between ages 50 to 69 (HR=0.61; 95% CI, 0.43 to 0.85). CONCLUSIONS: Immediate breast reconstruction is associated with decreased breast cancer-specific mortality, particularly among younger women. We believe this association is more likely attributable to imbalances in socioeconomic factors and access to care than to inadequate adjustment for tumor characteristics and disease severity. Further research is needed to identify additional prognostic factors responsible for the improved cancer survival among women undergoing immediate postmastectomy reconstruction.

Barriers to breast reconstruction after mastectomy in Nova Scotia.

BACKGROUND: Breast reconstruction after mastectomy is associated with social, psychological and physical benefits. Barriers to breast reconstruction in the United States include age, stage of disease, socioeconomic status and geographic location; however, little is known about the effects of these factors in the Canadian context of a universal health care system. We sought to determine the rate of breast reconstruction in Nova Scotia, identify characteristics influencing access to the procedure and describe the rates of different reconstructive options. METHODS: We conducted a retrospective cohort study involving all women in Nova Scotia who received diagnoses of breast cancer and had mastectomies between 1991 and 2001. We linked data from 2 administrative databases and performed analyses for each year in the study period. We followed the women until the end of the study period (2001). We used logistic regression to evaluate potential barriers to reconstruction. RESULTS: A total of 3717 women had mastectomies during the 10-year study period; of these women, 142 (3.8%) had breast reconstruction. The reconstruction rate increased to more than 5% in 3 of the last 4 years. Factors affecting the rate of breast reconstruction included patient age, stage of disease and year of mastectomy. Household income did not significantly affect the likelihood of women seeking breast reconstruction. CONCLUSION: The rate of breast reconstruction in Nova Scotia (3.8%) is considerably lower than rates reported in the United States (8%-45%). The fact that household income did not influence the breast reconstruction rate may reflect the universal nature of Canada's public health care system.

MOC-PSSM CME article: Breast reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the various techniques available to reconstructive breast surgeons. 2. Perform a comprehensive assessment of the breast reconstruction candidate. 3. Gain knowledge about the indications and contraindications for different breast reconstructive procedures. 4. Understand the complications inherent to different reconstructive breast procedures. SUMMARY: This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Practice profiles in breast reduction: a survey among Canadian plastic surgeons.

BACKGROUND: Breast reduction is an increasingly common procedure performed by Canadian plastic surgeons. Recent studies in the United States show that use of the inferior/central pedicle inverted T scar method is predominant. However, it is unknown what the practice preferences are among Canadian plastic surgeons. OBJECTIVE: The goal of the present study was to assess trends in breast reduction surgery among Canadian surgeons, including patient selection criteria, surgical techniques and outcomes. METHOD: Surveys were distributed to plastic surgeons at the Canadian Society for Plastic Surgery meetings in 2005 and 2006. Completed surveys were obtained from 140 respondents, and results were analyzed with Excel and SAS software. RESULTS: There was a 40% response rate. The majority of surgeons (66%) used more than one technique for breast reduction. Most commonly, surgeons use the inverted T scar technique (66%) followed by vertical scar techniques (26%). The most popular vertical scar techniques included the Hall-Findlay (14%) and Lejour (13%) methods. Most surgeons (55%) reported complication rates of less than 5% and the most common complication reported was wound dehiscence. There was no difference in overall complication rates between inverted T scar and vertical scar surgeries. The majority of surgeons (98%) carried out breast reduction either exclusively as day surgery or in combination with same-day admission. Breast reduction performed as day surgery resulted in cost savings of $873 per patient. CONCLUSIONS: Canadian plastic surgeons are performing more vertical scar breast reductions than American surgeons. However, both groups rely predominantly on inverted T scar techniques.

Validation of a questionnaire for measuring morbidity in breast hypertrophy.

BACKGROUND: There is a growing body of evidence suggesting that body mass index and predicted breast resection weight may not be appropriate criteria for determining insurance eligibility for breast reduction surgery. Eligibility should ideally be based on need. However, no method for determining need in patients seeking reduction surgery currently exists. The purpose of this investigation was to develop a validated questionnaire for measuring the burden of breast hypertrophy. METHODS: Forty-five symptoms specific to breast hypertrophy were incorporated into a questionnaire that was subsequently administered to a sample of 101 women. Reliability and validity testing was performed according to established psychometric criteria. RESULTS: Three items were omitted based on low item remainder coefficients (Cronbach's alpha) and three were eliminated because of excessive skew. Intraclass correlation coefficients of 0.85 indicated favorable test-retest reliability. Content validity was achieved through the study design and then confirmed by a group of 11 plastic surgeons. The questionnaire showed reasonable criterion validity when compared with corresponding domains in the Short Form-36. Construct validity was excellent. Exploratory factor analysis revealed five questionnaire subdomains: (1) physical implications, (2) poor self-concept, (3) body pain, (4) negative social interactions, and (5) physical appearance. CONCLUSIONS: The authors have developed an evaluative tool termed the Breast Reduction Assessed Severity Scale Questionnaire for measuring the burden of breast hypertrophy. The questionnaire produces subdomain scores and an overall measurement of the burden of breast hypertrophy that may be useful in the assessment of patients.

Symptoms and related severity experienced by women with breast hypertrophy.

BACKGROUND: Breast hypertrophy is a common condition that can be associated with significant morbidity. Symptoms emphasized in the literature include physical problems such as pain, intertrigo, and exercise restrictions. The purpose of this study was to explore the suffering experienced by women with breast hypertrophy and to evaluate the importance of different symptoms. METHODS: Twenty-one women with breast hypertrophy were divided into five focus groups guided by a facilitator. Open discussion was encouraged to generate a comprehensive list of symptoms experienced by women with breast hypertrophy. Subjects then completed an iterative process to determine the relative importance of each symptom. Conversations were recorded, transcribed, and analyzed using Nvivo software. RESULTS: A weighted list of 45 dominant symptoms was created from an initial pool of 128. Physical pain symptoms predominated in the older age group, whereas younger women expressed more psychological symptoms. Difficulties experienced by these women transcended all aspects of their lives. Back, neck, and shoulder pain were considered most troublesome, followed by exercise difficulties, poor posture, and low self-esteem. CONCLUSIONS: This study provides insight into the burden of breast hypertrophy and has implications for the objective assessment of this condition in the clinical setting.

Breast volume determination in breast hypertrophy: an accurate method using two anthropomorphic measurements.

BACKGROUND: Precise determination of breast volume facilitates reconstructive procedures and helps in the planning of tissue removal for breast reduction surgery. Various methods currently used to measure breast size are limited by technical drawbacks and unreliable volume determinations. The purpose of this study was to develop a formula to predict breast volume based on straightforward anthropomorphic measurements. METHODS: One hundred one women participated in this study. Eleven anthropomorphic measurements were obtained on 202 breasts. Breast volumes were determined using a water displacement technique. Multiple stepwise linear regression was used to determine predictive variables and a unifying formula. RESULTS: Mean patient age was 37.7 years, with a mean body mass index of 31.8. Mean breast volumes on the right and left sides were 1328 and 1305 cc, respectively (range, 330 to 2600 cc). The final regression model incorporated the variables of breast base circumference in a standing position and a vertical measurement from the inframammary fold to a point representing the projection of the fold onto the anterior surface of the breast. The derived formula showed an adjusted R of 0.89, indicating that almost 90 percent of the variation in breast size was explained by the model. CONCLUSION: Surgeons may find this formula a practical and relatively accurate method of determining breast volume.

Textured surface breast implants in the prevention of capsular contracture among breast augmentation patients: a meta-analysis of randomized controlled trials.

BACKGROUND: Capsular contracture is a common complication associated with the use of breast implants. Numerous randomized controlled trials addressing the efficacy of textured surface breast implants in reducing capsular contracture have yielded nonuniform results. This meta-analysis addresses the use of textured breast implants in the prevention of capsular contracture. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases were searched to identify all randomized controlled trials involving the use of textured versus smooth breast implants. The results of these trials were meta-analyzed to obtain a pooled odds ratio of the effect of textured surfacing on capsular contracture rates. In addition, subgroup analyses were performed based on implant type (saline or silicone gel), type of surface texturing (Siltex or Biocell), placement (subglandular or submuscular), and length of follow-up. RESULTS: Eleven trials were reviewed. Four were excluded because they failed to meet a priori inclusion criteria. The remaining seven trials were meta-analyzed. Only three of these studies found significantly lower rates of capsular contracture with the use of textured implants. However, when all seven studies were pooled, the odds ratio was found to be 0.19 (95 percent confidence interval, 0.07 to 0.52), indicating a protective effect for surface texturing on the rate of capsular contracture. Submuscular placement was the only subgroup in which significance was not achieved. However, this subgroup consisted of a single study, which was dramatically underpowered. CONCLUSION: The results of this meta-analysis demonstrate the superiority of textured over smooth breast implants in decreasing the rate of capsular contracture.

Prospective study of outcomes after reduction mammaplasty.

BACKGROUND: The purpose of this study was to prospectively assess changes in overall health-related quality of life and breast-related symptoms in women undergoing reduction mammaplasty, and to compare preoperative and postoperative health-related quality of life with that of the normal population. METHODS: Fifty-six patients were evaluated preoperatively and 6 months postoperatively with three questionnaires: the Short Form-36 Health Survey, the Symptom Inventory Questionnaire, and the Rosenberg Self-Esteem Scale. Surgeons completed preoperative patient assessment forms, operative note forms, and postoperative patient assessment forms. RESULTS: Comparison of preoperative and postoperative health-related quality of life showed significant improvements in Short Form-36 Health Survey scores (p < 0.005), the Rosenberg Self-Esteem Scale (p < 0.001), and all symptoms on the Symptom Inventory Questionnaire (p < 0.003). Preoperative mean Short Form-36 Health Survey scores were lower than in the normal population in several areas (p < 0.005). Postoperatively, none of the mean Short Form-36 Health Survey scores were significantly lower than population norms. CONCLUSIONS: This study determined that there is a significant improvement of physical symptoms and health-related quality of life in women undergoing reduction mammaplasty at 6 months after surgery. Before surgery, these patients have a significantly worse health-related quality of life than the normal population, but they normalize postoperatively.

Endoscopic harvest of four muscle flaps: safe and effective techniques.

The recent explosion of endoscopic techniques in plastic surgery has led to the successful harvest of a number of useful muscle flaps. The gracilis, rectus femoris, external oblique, and gastrocnemius muscles can all be harvested safely and reproducibly using endoscopic techniques. The aim of this study was to identify a safe and effective technique for endoscopic muscle flap harvest. Harvesting the gracilis muscle as a free flap and the gastrocnemius as a pedicle flap lends themselves best to the use of endoscopic techniques.