Surgical Site Infections in Breast Surgery - A Primer for Plastic Surgeons.

Surgical site infection (SSI) is defined as an infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted at surgery. Substantial research has been performed to identify the etiological agents, risk factors, and potential treatment options for SSIs. As breast surgery becomes increasingly popular, plastic surgeons are likely to encounter more patients presenting with SSIs. This article summarizes current evidence on pathogens, risk factors, and management strategies for SSIs and highlights further areas of study.

Autologous Fat Grafting in Plastic and Reconstructive Surgery: An Historical Perspective.

Autologous fat grafting (AFG or lipofilling) is a common technique used in plastic and reconstructive surgery that involves the transfer of autologous fat tissue from one region of the body to another. The indications and techniques of AFG have changed dramatically over the years. We recount the historic milestones to the current state.

Midterm follow-up of the reimplantation technique in patients with relatively normal annulus: is David I still a clinically valid option?

OBJECTIVE: The aim of this study was to evaluate the midterm results of the reimplantation technique with a straight tubular graft in patients with aortic root aneurysms with or without aortic insufficiency. METHODS: From February 2002 to November 2012, 51 consecutive patients underwent the David I valve-sparing aortic procedure for aortic root aneurysm; the mean age was 59.9±12.3 years. Nine patients (17.6%) had a bicuspid aortic valve. Patients were followed prospectively for 4.78±3.60 years (median, 5 years). Operative results, survival, freedom from redo aortic surgery and from recurrent aortic insufficiency greater than 2+ were assessed. RESULTS: No in-hospital mortality was recorded. In 5 cases, adjunctive procedures on the aortic valve were needed to achieve good leaflet coaptation. Aortic regurgitation was significantly lower at discharge (2.3±1.0 vs 0.3±0.5; P<.001). There were 5 postoperative deaths, all noncardiac related. Survival was 91.0%±4.4% at 5 years; freedom from redo aortic surgery was 96.8%±3.2% and freedom from recurrent aortic insufficiency greater than 2+ was 96.8%±3.2%. The outcomes in patients with repaired bicuspid aortic valves showed no significant differences compared to the outcomes in patients with repaired tricuspid valves. CONCLUSIONS: The reimplantation procedure using a straight tube is a safe and reproducible valve-sparing technique that can achieve no in-hospital mortality and durable midterm results, either in bicuspid or tricuspid valves. Further studies are needed to assess the behavior of repaired valves under physical stress at long-term follow-up.

Chordal cutting in ischemic mitral regurgitation: a propensity-matched study.

OBJECTIVE: The optimal surgical treatment of ischemic mitral regurgitation (MR) has not been well defined. Second-order chordal cutting (CC), in selected patients, can improve surgical outcomes. METHODS: From 2007 to 2011, 31 patients underwent CC for ischemic MR. The indication was the presence of increased tethering of the anterior leaflet, with a bending angle (BA) <145°. Patients with same echocardiographic characteristics were identified and propensity matched for age, ejection fraction (EF), MR grade, diameters, and BA. Only patients with preoperative and follow-up echocardiograms were included and divided into 2 groups of 26 patients each, CC and no-CC. RESULTS: Preoperatively, in the CC and no-CC groups, the age was 61 ± 9 and 62 ± 10 years, EF was 31% ± 5% and 29% ± 8%, MR grade (0-4) was 3.6 ± 0.6 and 3.3 ± 0.8, and diastolic and systolic dimension was 56 ± 7 and 43 ± 8 mm and 57 ± 11 and 44 ± 11 mm, respectively. The New York Heart Association class and BA was 2.7 ± 0.6 and 2.6 ± 0.7 and 137° ± 4° and 137° ± 6°, respectively. All patients underwent overreductive annuloplasty. In the CC group, second-order chords were cut using aortotomy. After a mean of 33 ± 15 months, the MR grade was 0.6 ± 0.6 and 1.1 ± 0.8 (P = .014) and the EF was 40% ± 5% and 35% ± 7% (P = .005) in the CC and no-CC groups, respectively. The corresponding diastolic and systolic diameters were 52 ± 5 and 38 ± 8 mm and 53 ± 11 and 41 ± 12 mm (P = NS). The modifications were significant only in the CC group (P = .022 and P = .029 for the diastolic and systolic dimensions, respectively). The corresponding New York Heart Association class decreased to 1.1 ± 0.3 and 1.5 ± 0.6 (P = .004). The BA increased to 182° ± 4° in the CC (P < .001) and remained unchanged (137° ± 6°) in the no-CC group. CONCLUSIONS: In selected patients with a BA <145° and coaptation depth ≤10 mm, CC is related to less MR return or persistence, improved EF, and lower New York Heart Association class.

Resecting and nonresecting techniques for posterior mitral leaflet prolapse.

BACKGROUND: Posterior leaflet (PL) prolapse is commonly treated with quadrangular resection, but nonresecting techniques were proposed as an alternative. We evaluated our experience to identify specific indications to nonresecting techniques. METHODS: From March 2006 to February 2009, 60 patients were treated for PL prolapse, 21 using resecting (group R), and 39 nonresecting (group NR) techniques. Patients in group R had fibroelastic deficiency with isolated P2 prolapse and P1 or P3 (or both) thin or short (n = 15); need of excessive P2 resection (more than 1/3 of the posterior annulus) (n = 10); dominant or codominant circumflex artery (n = 10). Some of them were young and were operated on without preoperative coronary angiography (n = 4). RESULTS: One patient (1.7%) in group R died during the first 30 days after surgery. Three-year survival was 89.6 ± 4.5, similar in both groups. A postoperative echocardiogram was obtained 20 ± 6 months after surgery in every survivor. Mitral regurgitation decreased significantly soon after surgery without any significant modification at follow-up in both groups. CONCLUSIONS: nonresecting techniques provide good midterm results, similar to resecting ones. To resect or not resect part of the PL has, in our personal practice, its own indications and contraindications. Extensive use of artificial chords and reduction of PL height, when indicated, is able to provide other tools to safely expand mitral repair for PL prolapse.

Echocardiographic-based treatment of functional tricuspid regurgitation.

OBJECTIVES: Functional tricuspid regurgitation (FTR) worsens over time, and its natural history is unfavorable. An aggressive surgical strategy, using the echocardiographic systolic dimensions of the tricuspid annulus (sysTA), can be helpful to reduce the detrimental late effects of FTR. METHODS: From March 2006 to February 2008, 298 patients, with at least FTR grade 1+, underwent mitral valve surgery. Of these 298 patients, 167 underwent tricuspid repair (treated group [T], moderate-or-greater FTR in 108 and mild in 59, with sysTA > 24 mm) and 137 did not (untreated group [UT], moderate-or-greater FTR in 16 and mild in 115; 81 with sysTA > 24 mm and 34 with sysTA of ≤ 24 mm). The 256 survivors underwent echocardiographic examination at a mean follow-up of 13 ± 8 months. RESULTS: Preoperatively, at discharge, and at the follow-up examination, the mean FTR grade was 1.11 ± 0.32, 0.87 ± 0.49, and 1.03 ± 0.57 (P = NS) in the UT group and 2.11 ± 0.92, 0.45 ± 0.36, and 0.48 ± 0.32 (P < .001) in the T group. A total of 24 patients had FTR grade 2 or greater, 16 (14.5%) in the UT group and 8 (5.5%) in the T group (P = .026). In the UT group, 10 of 16 patients had sysTA of 25 to 28 mm and 6 of 10 had sysTA greater than 28 mm. No patient with mild FTR and sysTA of 24 mm or less had an increased FTR grade. Globally, 12 patients (10.9%) had an increased FTR grade in the UT group versus none in the T group (P < .001). Patients with postoperative atrial fibrillation had less residual FTR if annuloplasty had been performed (1.6 ± 0.7 vs 0.91 ± 0.63, P = .005). CONCLUSIONS: An aggressive strategy for FTR correction, using the sysTA, was able to reduce the FTR grade 1 year after surgery, but mitral surgery alone could not.

Echocardiographically based treatment of chronic ischemic mitral regurgitation.

OBJECTIVES: We evaluated results of an echocardiographically based strategy combining mitral annuloplasty with other procedures to treat chronic ischemic mitral regurgitation. METHODS: From March 2006 to February 2009, 147 patients underwent mitral valve surgery for chronic ischemic mitral regurgitation. Mean effective regurgitant orifice was 36 ± 11 mm(2), and ejection fraction was 35% ± 9%. On the basis of echocardiographic findings, in 10 cases a prosthesis was inserted and mitral annuloplasty was performed in 137 cases, isolated in 83, associated with chordal cutting in 12 cases (in 5 anterior leaflet was augmented with pericardial patch), and with exclusion of anteroseptal (n = 35) or inferior (n = 7) scars in 42. RESULTS: Thirty-day mortality was 4.8%; 3-year survival was 86% ± 3%. None of the 126 survivors were in New York Heart Association functional class III or IV. Among 117 survivors of mitral valve repair, after 18 ± 6 months mean effective regurgitant orifice reduced from 34.1 ± 10.2 mm(2) to 2.3 ± 0.4 mm(2) (P < .001). Nine patients showed residual effective regurgitant orifice 10 to 19 mm(2). Reverse remodeling was present in 69 patients (59.0%), no remodeling in 40 (34.1%), and continuous remodeling in 8 (6.9%). Ejection fraction changed from 37% ± 10% to 43% ± 10% (P < .001), improving in 47, remaining unchanged in 63, and worsening in 7. CONCLUSIONS: Echocardiographically based strategy contributed to reduced postoperative mitral regurgitation persistence (effective regurgitant orifice ≥ 10 mm(2) in 7.7% of cases, with no patients showing effective regurgitant orifice ≥ 20 mm(2)). All patients remained in New York Heart Association functional class I or II, but more than mitral annuloplasty was performed in close to 40%.

In utero exposure to di-(2-ethylhexyl) phthalate affects liver morphology and metabolism in post-natal CD-1 mice.

The plasticizer di-(2-ethylhexyl)phthalate (DEHP) affects reproductive development, glycogen and lipid metabolism. Whereas liver is a main DEHP target in adult rodents, the potential impact on metabolic programming is unknown. Effects of in utero DEHP exposure on liver development were investigated upon treatment of pregnant CD-1 mice on gestational days (GD)11-19. F1 mice were examined at post-natal days 21 (weaning) and 35 (start of puberty): parameters included liver histopathological, immunocytochemical and alpha-fetoprotein (AFP) gene expression analyses. In utero DEHP exposure altered post-natal liver development in weanling mice causing significant, dose-related (i) increased hepatosteatosis, (ii) decreased glycogen storage, (iii) increased beta-catenin intracytoplasmic localization (females only). At puberty, significantly decreased glycogen storage was still present in males. A treatment-induced phenotype was identified with lack of glycogen accumulation and intracytoplasmic localization of beta-catenin which was associated with increased AFP gene expression. Our findings suggested that DEHP alters post-natal liver development delaying the programming of glycogen metabolism.

Lonidamine affects testicular steroid hormones in immature mice.

The effects on the hypothalamus-pituitary-testicular axis of the well-known antispermatogenic drug lonidamine (LND) has not been elucidated so far. In the present study, the possible changes of the testicular steroid hormones were evaluated in immature mice for a better characterization of the LND adverse effects both in its use as antitumoral agent and male contraceptive. Male CD1 mice were orally treated on postnatal day 28 (PND28) with LND single doses (0 or 100 mg/kg b.w.) and euthanized every 24 h from PND29 to PND32, on PND35 and on PND42 (1 and 2 weeks after the administration, respectively). Severe testicular effects were evidenced in the LND treated groups, including: a) significant testis weight increase, 24 h and 48 h after dosing; b) sperm head counts decrease (more than 50% of the control) on PND29-32; c) damage of the tubule morphology primarily on the Sertoli cell structure and germ cell exfoliation. All these reproductive endpoints were recovered on PND42. At the same time, a significant impairment of the testicular steroid balance was observed in the treated mice, as evidenced by the decrease of testosterone (T) and androstenedione (ADIONE) and the increase of 17OH-progesterone (17OH-P4) on the first days after dosing, while the testicular content of 17beta-estradiol (E2) was unchanged. The hormonal balance was not completely restored afterwards, as levels of T, ADIONE and 17OH-P4 tended to be higher in the treated mice than in the controls, on PND35 and PND42. These data showed for the first time that LND affects intratesticular steroids in experimental animals. However further data are needed both to elucidate the mechanism responsible for the impairment of these metabolic pathways and to understand if the androgens decrease observed after LND administration could be partially involved in the testicular damage.

Long-term effects of lonidamine on mouse testes.

Lonidamine (LND) [1-(2,4-dichlorobenzyl)-1H-indazole-3-carboxylic acid] is a well-known antispermatogenic drug. The aim of this study was to identify its possible long-term sequelae on the reproductive system of mice as compared with rats, where most data have been obtained until now. Sexually mature CD1 male mice were administered a single dose of LND (200 mg/kg bw by gavage) and killed 24 and 48 h, 6 days and 2, 4 and 8 weeks after the treatment. Testes were collected, weighed and (1) fixed in Bouin's solution for histological analysis or (2) reduced to monocellular suspensions and ethanol fixed to undergo flow cytometry (FCM) DNA content analysis. No effect on body weight and/or food consumption was observed in the treated group in comparison with the control group. Testicular weight was significantly reduced 24 h after the treatment. Reduced seminiferous epithelium with a progressive lack of intercellular cohesion and marked depletion of spermatids, infiltration of granulocytes, desquamation into the tubular lumen and increased intertubular spaces were present by 24 h after the treatment and persisted to a marked degree at 48 h, 6 days and 2 and 4 weeks up to a marked degeneration of tubular structures with absence of spermatogenesis. The same effects, albeit with a moderate severity, were still present 8 weeks after the treatment. As also detected by FCM, primary spermatocytes appeared to be the main cellular target. Sertoli and Leydig cells were remarkably spared. The histological findings are consistent with those previously observed in rats and point out that testicular damage may persist for several weeks after a single-dose administration. Findings are discussed in comparison with testicular toxicity elicited by other xenobiotics.