Why do patients seek revisionary breast surgery?

BACKGROUND: Patient motivations for revisionary breast surgery following breast augmentation, mastopexy-augmentation, and breast reduction are often overlooked. Most patients presenting for a revision do so because they desire a subsequent improvement in their appearance or wish to correct a problem resulting from the primary operation. OBJECTIVE: We present and analyze the clinical indications for revisionary breast surgery in a series of 134 consecutive cases. METHODS: We retrospectively reviewed the charts of 134 patients who underwent revisionary breast surgery in a single clinic from 1994 to 2009. Patients were grouped based on operative procedure: augmentation (n = 110), mastopexy-augmentation (n = 10), bilateral breast reduction (n = 15), breast malformation correction (n = 1). Three categories were also specified according to the cause for secondary surgery: (1) the surgeon's operative plan was flawed and/or involved a technical error, (2) an independent factor occurred such as ptosis or capsular contracture, or (3) there was a combination of both factors. RESULTS: The most frequent reasons for revisionary surgery among aesthetic implant patients were the development of ptosis (42%), capsular contracture (29%), and lower-pole deformities (19%). Twenty-six percent of patients had a combination of problems. Revision among breast reduction patients was due to volume loss from overresection (40%), nipple-areola loss (27%), and breast asymmetry (27%). The average time between the first surgery and reoperation was 8.9 years for augmentation, 4.3 years for mastopexy-augmentation, and 2.9 years for reduction. In implant patients, the biggest problem leading to revisionary surgery was natural progression (66% augmentation, 90% mastopexy-augmentation). However, among breast reduction patients, 73% of revision requests were a result of problems with surgeon judgment or technique. CONCLUSIONS: Our study demonstrates that although the rate of surgeon-specific problems was high in reduction patients, overall, independent factors were the primary reason patients sought revisionary breast surgery. This may be contrary to commonly held beliefs that attribute poor results and revision requests to incorrect surgical technique and erroneous surgical decision making.

Marjolin ulcer in hidradenitis suppurativa: case reports.

Hidradenitis suppurativa is a chronic, recurrent, inflammatory disease of apocrine gland-bearing skin areas. Long-standing low-grade infection and chronic abscess formation result in ulcers, fistulas, and progressive scars. A rare complication is the development of squamous cell carcinoma, known as Marjolin ulcer. We report 3 cases in which squamous cell carcinoma developed despite medical treatments and local excisions. Because of the poor prognosis associated with squamous cell carcinoma, we advocate wide excision of hidradenitis suppurativa lesions when other treatments have failed.

Freezing adipose tissue grafts may damage their ability to integrate into the host.

In this study, the effect of freezing on the morphology, viability, and VEGF synthesis of human adipose tissue grafts is examined. Currently, storage of adipose grafts involves freezing in simple saline solutions. However, the effect of freezing on the morphology and function of adipose tissue remains unclear. As a result, this study attempts to determine whether freezing adipose grafts should be considered prior to soft-tissue augmentation. In this study, the freezing of adipose grafts in saline for only 24 hr resulted in morphological changes in vivo and affected their ability to synthesize VEGF. The use of a simple cryopreservation medium containing sucrose appeared to maintain VEGF synthetic levels by the grafts and improved both their morphology and retention in vivo. However, the benefits of this cryopreservation medium were directly linked to storage time as long-term storage did not result in any noticeable benefit to graft retention. Finally, as an alternative to freezing, adipose grafts were combined with human adipose-derived stem cells (ASCs) to determine if their presence could enhance in vivo graft structure. The presence of ASCs did appear to improve graft structure in vivo over the short term and was also capable of improving tissue morphology when combined with grafts frozen in PBS. In conclusion, the successful use of adipose grafts may require a closer examination of the graft's storage conditions and time. Specifically, it now appears that the practice of freezing in saline may not be advisable if graft viability, activity, and structure are to be maintained in vivo.

Lessons from the modern battlefield: successful upper extremity injury reconstruction in the subacute period.

BACKGROUND: Reconstructive techniques and protocols for limb salvage of upper extremity battlefield injuries remains poorly defined. Our study describes the types of flaps, the timing of reconstruction, and success rates of war upper extremity reconstruction during a 30-month period using the Bethesda limb salvage protocol. METHODS: Soldiers with significant upper extremity injuries with complex open fractures from Operation Iraqi Freedom and Operation Enduring Freedom-Afghanistan who underwent tissue transfer flaps were reviewed (n = 26, free flaps n = 6). Data analysis included mechanism of injury, associated injuries, types of flap, postoperative complications, wound infection rates, and outcome data. RESULTS: The cause of injury consisted of improvised explosive device (61%), rocket-propelled grenades (15%), motor vehicle crash (8%), land mine (8%), and gunshot wound (4%). Mean age was 25 years. Mean number of prereconstructive washouts was six (range, 3-22). Forty-six percent of wounds were culture positive at admission (75% were Acinetobacter species). All patients had other coexisting extremity, trunk or facial injuries. Average time to flap reconstruction was 31 days (range, 9-161). In 66% of the cases, a fasciocutaneous flap was used, and in the remaining cases, muscle (19%) and adipofascial (15%) flaps were performed. Flap success rate was 96%, with one flap loss because of venous congestion (managed with limb shortening). Infection rate was 8%. Complete coverage was achieved in all upper extremity wounds and early occupational therapy resulted in improved return to function. CONCLUSIONS: Despite massive bone and soft tissue defects, high preoperative wound colonization, and delays in definitive reconstruction, devastating war wounds can be successfully reconstructed in the subacute period with low flap failure, infection, and amputation rates.

Simultaneous revascularization and coverage of a complex volar hand blast injury: case report using a contralateral radial forearm flow-through flap.

War wounds have created a unique reconstructive challenge for successful functional limb salvage. Various injury patterns related to improvised explosive devices (IEDs) occur and proper reconstruction goes a long way in reducing subsequent disfigurement and morbidity. One case in which a contralateral radial forearm flow-through flap is used for simultaneous revascularization and coverage of an IED hand blast injury is described. The advantages of this flap was its consistent arterial anatomy and long vascular pedicle. The thin skin paddle was used for soft tissue coverage of flexor tendon repair, median and ulnar nerve reconstruction, and metacarpal bone open reduction and internal fixation (ORIF). Recovery of motor function was satisfactory.

Completely laparoscopic nonanatomic hepatic resection using saline-cooled cautery and hydrodissection.

The technical aspects of laparoscopic hepatic resection have evolved rapidly. The key to any approach is establishing a reliable method to prevent or control hemorrhage during parenchymal transection. Although combining a hand-assist technique with laparoscopy allows improved control of bleeding risk, this requires the addition of a hand-port incision. The development of novel devices that can be used to safely divide liver parenchyma laparoscopically may lessen the need for hand-assist. Here, we report a series of laparoscopic hepatic resections that were attempted without the use of hand-assistance (completely laparoscopic). Resections were performed using saline-cooled cautery (Tissue-Link Endohook) and/or hydrodissection (Erbe Helix Hydrojet). Fifteen laparoscopic hepatic resections were attempted by a single surgeon from 2002 to 2006. In each case, a nonanatomic, completely laparoscopic approach was attempted. Patients with lesions at the hepatic dome or those requiring lobectomy or hilar dissection were excluded. Fourteen of 15 cases (93%) were accomplished completely laparoscopically, while one patient required placement of a hand port. Resected tumors averaged 3.9 cm diameter. There were no bile leaks and no patient required transfusion. Average length of stay was 4.1 days (range 1-5). Complications included ileus (1) and atrial fibrillation (1). In six patients with malignancies, margins were negative and there have been no local or port recurrences. This report demonstrates the feasibility of completely laparoscopic hepatic resection using novel devices for parenchymal transaction. Hand-assist techniques remain useful as a salvage strategy or for larger resections.

Fibromatosis presenting as a sacrococcygeal mass.

Most children older than a year who present with a sacrococcygeal mass have a malignant tumor. We describe an 8-year-old child with of a sacrococcygeal soft tissue mass that was completely resected with histologic findings consistent with fibromatosis. Fibromatosis is a deep-seated, musculoaponeurotic, borderline tumor that is rare in childhood and has a high incidence of local recurrence even after margin-free resection. We review and discuss management strategies for treatment of fibromatosis in children. This case represents the first report of fibromatosis presenting as a sacrococcygeal mass.

Lessons from operation Iraqi freedom: successful subacute reconstruction of complex lower extremity battle injuries.

BACKGROUND: War wounds associated with Operation Iraqi Freedom have created a unique reconstructive challenge. The objective of this study was to report and analyze the timing and success rates of lower extremity reconstruction associated with devastating war wounds. METHODS: A retrospective review was conducted of injured personnel requiring extremity flap reconstruction at the National Naval Medical Center over a 30-month period. Collected data included mechanism of injury, time from initial injury to closure, number of prereconstruction wound washouts, types of flap, flap failures, associated injuries, and wound culture characteristics. RESULTS: From September of 2004 to February of 2007, 46 (36 pedicled and 10 free flaps) lower extremity flap reconstructions (10 fasciocutaneous, 34 musculocutaneous, and two adipofascial) were performed on 43 patients. Patient age ranged from 19 to 37 years. Time to reconstruction ranged from 7 to 82 days (average, 21 days). Seventy-six percent of all injuries were associated with an improvised explosive device blast. Mean number of prereconstructive washouts was five (range, two to 13). Fifty percent of all wounds cultured at admission revealed positive results, of which 57 percent were associated with Acinetobacter species. Total flap loss occurred in one flap and partial flap loss occurred in two flaps. CONCLUSION: Despite reconstruction in the subacute period, the high rate of antimicrobial colonization before wound closure, and the devastating nature of improvised explosive device blast injuries, early analysis of the National Naval Medical Center war extremity reconstruction cohort demonstrates low total and partial flap loss rates and acceptable infection rates.

BMP-2 does not influence the osteogenic fate of human adipose-derived stem cells.

BACKGROUND: Recent studies have shown that bone morphogenetic protein (BMP)-2, a potent osteogenic growth factor, in combination with human adipose-derived stem cells can heal critical-sized bony defects. However, whether BMP-2 induces an osteogenic response in the adipose-derived stem cells remains unknown. METHODS: : In vitro calcium production, osteogenic gene expression, and BMP-2 receptor expression on the adipose-derived stem cell surface were analyzed in BMP-2-stimulated adipose-derived stem cells. The cells (2 x 10(7) cells) maintained in osteogenic medium were treated with an initial pulse of BMP-2 for 48 hours or 7 days or were given continuous BMP-2. To assess the response of these cells to BMP-2 in vivo, they (250,000 cells) were seeded into polylactic-co-glycolic acid (PLGA) collagraft scaffolds treated with 5 microg of BMP-2 and implanted into critical-sized femoral rat defects (n = 40). Healing was assessed histologically and quantitated by micro-computed tomography. RESULTS: In vitro treatment of adipose-derived stem cells with BMP-2 revealed decreased ability of the cells to undergo matrix calcification, demonstrated by decreased calcium production and decreased osteogenic gene expression of transcription factor Cbfa-1 and key extracellular proteins. Flow cytometry demonstrated decreased expression of BMP-2 receptors 1a and 1b in osteogenically differentiated adipose-derived stem cells stimulated with BMP-2. In vivo implantation of adipose-derived stem cell-seeded PLGA did not result in healing of critical-sized femoral defects in rodents, whereas implantation of BMP-2-absorbed PLGA, with or without adipose-derived stem cells, consistently healed these defects. CONCLUSIONS: The data suggests that osteogenic differentiation of adipose-derived stem cells is marginally affected by the addition of BMP-2. Consequently, stem cells in combination with BMP-2 may not be a viable strategy for the bony healing.

Correction of secondary cleft lip deformity: the whistle flap procedure.

BACKGROUND: The Kapetansky flap was described to repair a whistle deformity or central vermilion defect following a primary bilateral cleft lip repair. The authors studied a modification of this technique, called the Whistle (wide-hinged island swing transposition labial enhancement) flap, to correct a wide array of secondary cleft lip deformities. METHODS: Patients with secondary cleft lip deformity who underwent the Whistle flap correction were studied (n = 21). Vertical lip height, lateral lip projections, and three-dimensional volumetric measurements were recorded along with physician and parent-patient satisfaction surveys. RESULTS: From 1994 to 2006, 23 Whistle flap procedures were performed on 21 cleft lip patients (bilateral, n = 13; unilateral, n = 8). The average age at surgery was 15.4 years (range, 13 to 21 years). The average follow-up was 27.6 months. The vertical height of the cleft side Cupid's bow to vermilion bottom had a mean increase of 164 percent. Lateral projection of the upper lip showed a mean increase of 117 percent. Preoperatively, patients exhibited mean volumetric asymmetry of 29.4 percent, and this was reduced following treatment to approximately 3.1 percent. Physician satisfaction using a modified Whitaker classification (categories I through IV) demonstrated that 56 percent of patients were category I (no refinements necessary) and 44 percent were category II (minor revisions are advisable). Parent-patient satisfaction in the follow-up period was a mean of 3.5 as measured using a five-point scale ranging from 0 to 4. There were minimal perioperative complications. CONCLUSION: The Whistle flap procedure provided a versatile and reliable option for the correction of vermilion defects from secondary cleft lip deformities.

Predictive factors in identifying subspecialty fellowship applicants who will have academic practices.

BACKGROUND: The challenge of subspecialty fellowship directors is to recruit surgeons who are motivated to continue the tradition of teaching by entering academic medicine. The authors looked for predictive factors to help with more accurate selection of applicants. METHODS: Application and follow-up data from plastic surgery subspecialty fellows in craniofacial surgery, hand surgery, and microsurgery from the University of California, Los Angeles were reviewed for the years 1987 through 2002 (n = 62). Fellows were divided into three groups as follows: group 1, full-time academic; group 2, part-time clinical faculty; and group 3, private practice at 1 year and 5 years after fellowship. Common factors of fellows within the three groups were listed. RESULTS: Although a majority of applicants (95 percent) indicated an aspiration to practice academic medicine, only one-third remained in full-time academics 5 years after their subspecialty training. There was a trend toward leaving academic practice: the rates at 1 year were 74 percent for group 1 (academic) and 5 percent for group 3 (private practice), but by 5 years this had equalized (group 1, 34 percent; group 3, 32 percent). Group 1 (academic) showed more academic productivity publications per year, academic titles, editorial boards, and active participation in medical societies compared with group 3 (private practice). The factors that were more common to group 1 were married or married with children, five or more publications, one or more years of research, and 7 or more years of training. CONCLUSION: Plastic surgery fellowship directors may look at the following predictive factors of applicants if they would like their graduates to carry on the tradition of teaching future plastic surgeons: (1) previous dedicated research training, (2) more years of clinical training, and (3) more scientific publications.