Failed pneumoperitoneum for laparoscopic surgery following autologous Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction: a case report.

BACKGROUND: Laparoscopic abdominal surgery may prove difficult in patients who have undergone previous abdominal procedures. No reports in the medical literature have presented an aborted laparoscopic procedure for failed pneumoperitoneum following autologous flap-based breast reconstruction. CASE PRESENTATION: A 55-year-old woman presented with recurrent invasive lobular carcinoma of the right breast as well as a history of ductal carcinoma in situ of the left breast. The patient desired to proceed with bilateral skin- and nipple-sparing mastectomies with right axillary lymph node biopsy, followed by immediate bilateral autologous deep inferior epigastric perforator (DIEP) flap-based breast reconstruction. Preoperatively, a computerized tomography angiogram was obtained for reconstructive preparation, which revealed a left adrenal mass. Ensuing work-up diagnosed a pheochromocytoma. Given the concern for breast cancer progression, the patient elected to proceed first with breast cancer surgery and reconstruction prior to addressing the adrenal tumor. Subsequently, 3 months later the patient was brought to the operating room for a laparoscopic left adrenalectomy for the pheochromocytoma. With complete pharmacologic abdominal relaxation, the abdomen proved too tight to accommodate sufficient pneumoperitoneum and the laparoscopy was aborted. The patient was evaluated in the outpatient setting for assessment of abdominal wall compliance at regular intervals. Five months later, the patient was taken back to the operating room where pneumoperitoneum was established without difficulty and the laparoscopic left adrenalectomy was performed without complications. CONCLUSION: Pneumoperitoneum for laparoscopic surgery subsequent to autologous DIEP flap-based breast reconstruction may prove difficult as a result of loss of abdominal wall compliance. Prior to performing laparoscopy in such patients, surgeons should consider the details of the patient's previous reconstructive procedure and assess potential risk factors for difficulty with insufflation. Lastly, careful abdominal examination should be performed to indicate whether laparoscopy for elective procedures should be delayed until abdominal wall compliance normalizes.

Microsurgical Fenestration and Paraspinal Muscle Pedicle Flaps for the Treatment of Symptomatic Sacral Tarlov Cysts.

OBJECTIVE: Sacral Tarlov cysts are rare causes of sciatic and sacrococcygeal pain and neurologic deficits. Although several microsurgical treatments have been described, the optimal treatment has yet to be determined. We describe our initial experience with symptomatic lesions combining 1) cyst fenestration and imbrication and 2) filling the epidural space using vascularized paraspinous muscle flaps rotated into the cystic cavity. METHODS: We retrospectively reviewed all consecutive cases of symptomatic giant sacral Tarlov cysts treated with microsurgery at our institution between 2003 and 2011. The main outcome measure was self-reported symptom relief. Postoperative imaging, surgical complications, and subsequent treatments were also recorded. RESULTS: Thirty-five patients were treated. Mean age was 52 years. All patients presented with a chief complaint of sacral-perineal pain. The mean cyst size was 3.6 cm (largest diameter). Follow-up beyond the initial hospital stay was available in 86% (median 8 months). Ninety-three percent reported improvement in pain at some point during the postoperative course but 50% of those developed recurrent pain symptoms. Postoperative imaging was available in 69% of the patients in whom 92% showed complete obliteration (25%) or reduction in cyst size (67%). CONCLUSIONS: The combination of microsurgical cyst fenestration and the use of vascularized muscle pedicle flaps to fill the cystic cavity and the epidural space results in obliteration or reduction in size of the majority of cysts and is associated with initial improvement in pain in most patients. However, delayed recurrence of pain was common with this technique.

Social problems in plastic surgery residents: a management perspective.

BACKGROUND: It is presumed that plastic surgery residents experience various social problems, just as do their peers in other specialty training programs and in the general public. These issues can occasionally disrupt the resident's personal training experience and sometimes the program as a whole. A survey was performed to assess the magnitude of the problem, and the issues revealed were assessed to assist the program director and the resident in reaching successful completion of the residency. METHODS: A survey was designed by the executive committee and staff of the American Council of Academic Plastic Surgeons and sent to all plastic surgery training programs in the United States. A response rate of 66 percent was achieved. The programs reported on the social issues occurring in their residents over the preceding 5 years. The results were presented at a business meeting of the Council. RESULTS: Thirty-seven percent of programs reported that at least one resident had left their program during the study period. Twenty percent reported that a resident had been asked to leave the program. The frequency of social problems resulting in disruption of the training program was tabulated in the following areas: divorce; pregnancy/parturition; financial, legal, or family issues; drug or alcohol abuse; illness/injury; and interpersonal conflicts. CONCLUSIONS: Plastic surgery residents experience social problems that can affect the timely completion of their training. Attention to these issues requires patience, creativity, sensitivity, and a commitment to the residents' ultimate success, and adherence to institutional, legal, and accreditation body mandates.

Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an evidence-based consensus conference statement from the American Association of Plastic Surgeons.

BACKGROUND: There is a growing concern for microbial resistance as a result of overuse of antibiotics. Although guidelines have focused on the use of antibiotics for surgery in general, few have addressed plastic surgery specifically. The objective of this expert consensus conference was to evaluate the evidence for efficacy and safety of antibiotic prophylaxis in plastic surgical procedures. METHODS: THE AUTHORS: searched for existing high-quality systematic reviews for antibiotic prophylaxis in the literature from the MEDLINE, Cochrane Library, and Embase databases. All synonyms for antibiotics were combined with terms for relevant plastic surgery procedures. The searches were not limited by language, and included all study designs. In addition, supplemental hand searches were performed of bibliographies of relevant articles, and extensive "related articles." Meta-analyses were performed and reviewed by experts selected by the American Association of Plastic Surgeons to reach consensus recommendations. RESULTS: Database searches identified 4300 articles, from which 2042 full-text articles were identified for eligibility. De novo meta-analyses were performed for each plastic surgical category. In total, 67 studies met the inclusion criteria, including nine for breast surgery, 17 for head and neck surgery, 10 for orthognathic surgery, seven for rhinoplasty/septoplasty, 19 for hand surgery, five for skin surgery, and two for abdominoplasty. CONCLUSIONS: Systemic antibiotic prophylaxis is recommended for clean breast surgery and for contaminated surgery of the hand or the head and neck. It is not recommended to reduce infection in clean surgical cases of the hand, skin, head and neck, or abdominoplasty.

Multidisciplinary management of advanced basal cell carcinoma: report of four cases.

BACKGROUND: Advanced basal cell carcinomas (BCC) are neoplasms with high-risk clinical characteristics that can develop as locally advanced disease or metastasis. Treatment of advanced BCC may result in significant morbidity due to the technical challenges of size and/or location or in which surgery and radiation therapy may be contraindicated. No standard of care exists for the management of advanced BCC. As such, the difficulty in managing these tumors necessitates a multidisciplinary approach to patient care. METHODS: We report four cases of advanced BCC that benefited from a multidisciplinary approach, as well as highlight treatment considerations and factors in the development of advanced BCC. RESULTS: All four complex cases of advanced BCC presented to a multidisciplinary non-melanoma skin cancer tumor board with extensive tumor involvement. Treatment of disease was effective in preventing recurrence while optimizing aesthetic outcomes. CONCLUSIONS: The multidisciplinary tumor board has a central and important role in the evaluation and management of advanced BCC.

Memory regulatory T cells reside in human skin.

Regulatory T cells (Tregs), which are characterized by expression of the transcription factor Foxp3, are a dynamic and heterogeneous population of cells that control immune responses and prevent autoimmunity. We recently identified a subset of Tregs in murine skin with properties typical of memory cells and defined this population as memory Tregs (mTregs). Due to the importance of these cells in regulating tissue inflammation in mice, we analyzed this cell population in humans and found that almost all Tregs in normal skin had an activated memory phenotype. Compared with mTregs in peripheral blood, cutaneous mTregs had unique cell surface marker expression and cytokine production. In normal human skin, mTregs preferentially localized to hair follicles and were more abundant in skin with high hair density. Sequence comparison of TCRs from conventional memory T helper cells and mTregs isolated from skin revealed little homology between the two cell populations, suggesting that they recognize different antigens. Under steady-state conditions, mTregs were nonmigratory and relatively unresponsive; however, in inflamed skin from psoriasis patients, mTregs expanded, were highly proliferative, and produced low levels of IL-17. Taken together, these results identify a subset of Tregs that stably resides in human skin and suggest that these cells are qualitatively defective in inflammatory skin disease.

Long-term reconstructive outcomes after expander-implant breast reconstruction with serious infectious or wound-healing complications.

INTRODUCTION: Immediate expander-implant breast reconstruction has been associated with postoperative complications, including infection and wound-healing problems. In extreme cases, these issues can lead to expander-implant loss. Little is known about the long-term reconstructive outcomes for patients who develop major complications threatening their expander-implant reconstructions. METHODS: A review of all patients who underwent mastectomy and immediate expander-implant reconstruction at University of California, San Francisco (UCSF) from 2005 to 2007 was performed. A prospective database was queried for patients who developed a major postoperative complication related to infection or wound-healing problems requiring unplanned operative intervention. Only patients who had a minimum of 3 years' follow-up were included in the study. RESULTS: Twenty-nine patients were identified who met study criteria. Mean follow-up time was 52.5 months (range, 41-71 months). Six of the 29 (20.7%) patients had received prior breast irradiation, and 9 patients (31%) underwent postoperative radiation therapy. Reasons for unplanned return to the operating room included infection (n = 11, 37.9%), expander-implant exposure (n = 5, 17.2%), nonhealing wounds without underlying exposure (n = 3, 1.3%), or >1 of these indications (n = 10, 34.5%). Unplanned operative intervention (such as wound debridement or expander-implant exchange or removal) was required once in 10 patients (34.5%), twice in 10 patients (34.5%), 3 times in 4 patients (13.8%), 4 times in 1 patient (3.4%), and 5 or greater times in 4 patients (13.8%). At the conclusion of all operative interventions, 15 patients (51.7%) had successful breast reconstruction using an expander-implant technique. Five additional patients (17.3%) ultimately achieved successful salvage reconstruction with either a transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flap. Nine patients (31%) did not have successful breast reconstruction. Of these 9 patients, 5 elected to abandon reconstructive efforts after 1 unplanned return to the operating room for expander-implant removal, whereas the rest underwent at least 1 attempt at expander-implant salvage, with the overall rate of final successful reconstruction after attempt at salvage 83.3% (20 of 24 patients). CONCLUSIONS: Even when unplanned operative intervention is required to address postoperative wound-healing or infectious complications after expander-implant reconstruction, the majority of patients can achieve successful reconstructive outcomes at long-term follow-up, including those patients requiring multiple operative interventions to treat their complication.

Cavernous nerve repair with allogenic adipose matrix and autologous adipose-derived stem cells.

OBJECTIVES: To investigate whether adipose-derived matrix seeded with adipose-derived stem cells (ADSC) can facilitate the repair of injured cavernous nerves (CNs). METHODS: Human and rat adipose tissues were decellularized and fabricated into various forms, including adipose tissue-derived acellular matrix thread (ADMT). ADMT seeded with ADSC were transplanted into subcutaneous space and examined for signs of inflammation. ADSC-seeded ADMTs were then used to repair CN injury in rats, followed by assessment of histology and erectile function. RESULTS: Adipose tissue can be fabricated into acellular matrices of various shapes and sizes, including threads and sheets. Seeding of ADMT occurred rapidly: within 24 hours, 55% of the surface was covered with ADSC and within 1 week, 90% was covered. Transplantation of the seeded ADMT into the subcutaneous space of an allogenic host showed no signs of inflammatory reaction. At 3 months after grafting into CN injury rats, approximately twice as many cells were found on seeded ADMT as on unseeded ADMT. The seeded ADMT also had various degrees of S100 and neuronal nitric oxide synthase expression, suggesting CN axonal ingrowth. Rats grafted with seeded ADMT overall had the best erectile function recovery when compared with those grafted with unseeded ADMT and those ungrafted. However, as a result of large variations, the differences did not reach statistic significance (P = .07). CONCLUSIONS: Grafting of ADSC-seeded matrix resulted in a substantial recovery of erectile function and improvement of histology. However, further refinement of the matrix architecture is needed to improve the success rate.

Emerging trends in the outsourcing of medical and surgical care.

As total health care expenditures are expected to constitute an increasing portion of the US gross domestic product during the coming years, the US health care system is anticipating a historic spike in the need for care. Outsourcing medical and surgical care to other nations has expanded rapidly, and several ethical, legal, and financial considerations require careful evaluation. Ultimately, the balance between cost savings, quality, and patient satisfaction will be the key determinant in the future of medical outsourcing.

Plastic surgeons' satisfaction with work-life balance: results from a national survey.

BACKGROUND: Plastic surgery demographics are transforming, with a greater proportion of women and younger physicians who desire balance between their career and personal lives compared with previous generations. The authors' purpose was to describe the patterns and correlates of satisfaction with work-life balance among U.S. plastic surgeons. METHODS: A self-administered survey was mailed to a random sample of American Society of Plastic Surgeons members (n = 708; 71 percent response rate). The primary outcome was satisfaction with work-life balance. Independent variables consisted of surgeon sociodemographic and professional characteristics. Logistic regression was used to evaluate correlates of satisfaction with work-life balance. RESULTS: Overall, over three-fourths of respondents were satisfied with their career; however, only half were satisfied with their time management between career and personal responsibilities. Factors independently associated with diminished satisfaction with work-life balance were being female (odds ratio = 0.63; 95 percent CI, 0.42 to 0.95), working more than 60 hours per week (versus < 60 hours per week; odds ratio = 0.44; 95 percent CI, 0.28 to 0.72), having emergency room call responsibilities (versus no emergency room call, odds ratio = 0.42; 95 percent CI, 0.27 to 0.67), and having a primarily reconstructive practice (versus primarily aesthetic practice; odds ratio = 0.53; 95 percent CI, 0.30 to 0.93). CONCLUSIONS: While generational differences were minimal, surgeons who were female, worked longer hours, and had emergency room call responsibilities and primarily reconstructive practices were significantly less satisfied with their work-life balance.

Assessing the plastic surgery workforce: a template for the future of plastic surgery.

BACKGROUND: The American Society of Plastic Surgeons (ASPS) formed the Plastic Surgery Workforce Task Force to study the size of the plastic surgery workforce and make recommendations about future workforce needs. The ASPS member workforce survey and two supplementary surveys of plastic surgery academic chairs and senior residents were developed to gain insights on current and projected demand for plastic surgery procedures and to find out more about plastic surgeons' current daily practice patterns and plans for the future. METHODS: The ASPS member workforce survey was mailed to 2500 randomly selected ASPS active members practicing in the United States, and a second mailing was sent to 388 unique members who practice in an academic setting; a total of 1256 surgeons responded (43.5 percent response rate). The survey of academic chairs was distributed to 103 attendees at the annual meeting of the Association of Academic Chairmen of Plastic Surgery, and 74 returned the survey (71.8 percent response rate). The survey of senior residents was e-mailed to 183 graduating residents, of whom 65 responded (35.5 percent response rate). RESULTS: Useful demographic information regarding the current plastic surgery workforce was obtained from these surveys. In addition, insight into current trends in practice composition and procedural demand was gained. CONCLUSIONS: The rapid growth of the U.S. population, combined with a significant number of plastic surgeons approaching retirement and an unchanged number of plastic surgery residency training positions, will lead to a discrepancy between the demand for plastic surgery procedures and the supply of appropriately trained physicians. Without an increase in the number of plastic surgeons trained each year, there will be a significant shortage in the next 10 to 15 years.