Outcomes of a same day discharge protocol in patients undergoing mastectomy and implant reconstruction.

BACKGROUND: Finite hospital resources has required a closer look at resource allocation. This has prompted a shift toward same day surgeries and a focus on reducing hospital readmissions. Following the institution of a same day discharge protocol for mastectomy and mastectomy with immediate reconstruction, we sought to assess differences in the length of stay and readmission rates. METHODS: This retrospective review evaluates all cases of mastectomy with or without immediate reconstruction performed at a single high-volume center between June 2019 and March 2021. Average length of stay, 30-day readmission rates, Anesthesia Society Assessment class, and type of immediate reconstruction were assessed. Autologous reconstructions were excluded. RESULTS: A total of 413 patients underwent mastectomy with or without reconstruction (n = 148 pre protocol and n = 265 during protocol) between June 2019 and March 2021. Of those 413 patients, 180 underwent reconstruction (n = 62 pre protocol and n = 118 during protocol). The average length of stay after mastectomy following the implementation of the same day discharge protocol was decreased at 0.6 days (n = 265) compared to preimplementation at 1.02 days (n = 148), p < 0.001. The 30-day readmission rate was not significant between the groups, p = 0.13. A total of 180 patients underwent immediate reconstruction after mastectomy. The average length of stay after mastectomy with immediate reconstruction following implementation of the same day discharge protocol was shorter than preimplementation at 1.05 days preimplementation (n = 62) versus 0.58 days following implementation (n = 118), p < 0.001; this finding was significant for both prepectoral and subpectoral implants, p < 0.001. There was no significant difference in 30-day readmission rates between the groups with immediate reconstruction, p = 0.34. CONCLUSION: Same day discharge for mastectomy with reconstruction is as safe as the more widely recognized same day discharge practice for patients with mastectomy alone.

Is head and neck melanoma different from trunk and extremity melanomas with respect to sentinel lymph node status and clinical outcome?

BACKGROUND: Previous studies showed conflicting and inconsistent results regarding the effect of anatomic location of the melanoma on sentinel lymph node (SLN) positivity and/or survival. This study was conducted to evaluate and compare the effect of the anatomic locations of primary melanoma on long-term clinical outcomes. METHODS: All consecutive cutaneous melanoma patients (n=2,079) who underwent selective SLN dissection (SLND) from 1993 to 2009 in a single academic tertiary-care medical center were included. SLN positive rate, disease-free survival (DFS), and overall survival (OS) were determined. Kaplan-Meier survival, univariate, and multivariate analyses were performed to determine predictive factors for SLN status, DFS, and OS. RESULTS: Head and neck melanoma (HNM) had the lowest SLN-positive rate at 10.8% (16.8% for extremity and 19.3% for trunk; P=0.002) but had the worst 5-year DFS (P<0.0001) and 5-year OS (P<0.0001) compared with other sites. Tumor thickness (P<0.001), ulceration (P<0.001), HNM location (P=0.001), mitotic rate (P<0.001), and decreasing age (P<0.001) were independent predictive factors for SLN-positivity. HNM with T3 or T4 thickness had significantly lower SLN positive rate compared with other locations (P≤0.05). Also, on multivariate analysis, HNM location versus other anatomic sites was independently predictive of decreased DFS and OS (P<0.001). By Kaplan-Meier analysis, HNM was associated significantly with the worst DFS and OS. CONCLUSIONS: Primary melanoma anatomic location is an independent predictor of SLN status and survival. Although HNM has a decreased SLN-positivity rate, it shows a significantly increased risk of recurrence and death as compared with other sites.

Mentoplasty with Cancellous Bone Chip Scaffolding: An Innovative Technique for Chin Aesthetics.

SUMMARY: The facial skeleton is foundational for facial aesthetics. The authors describe an alternative technique for cosmetic chin augmentation that does not require alloplastic implants, osseous genioplasty, or autologous bone harvesting. In this new and innovative technique for chin augmentation, tissue bank allograft cancellous bone chips serve as a scaffold for bony ingrowth. The use of bone chips allows for aesthetic contouring with small adjustments in the facial skeleton. The objective of this article is to provide further information on this novel technique and demonstrate the efficacy and safety of tissue bank allograft cancellous bone chips as an alternative graft material for cosmetic chin augmentation. Retrospective review of patients who underwent chin augmentation with cancellous bone chips from July of 2015 to March of 2019 was performed. Photographic results from several patients are included. No patients developed infections, required reoperation, or went on to have explantation of the graft material. Initial results suggest cancellous bone chips are a safe, efficacious alternative graft material for cosmetic chin augmentation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

DOOR syndrome: clinical report, literature review and discussion of natural history.

DOOR syndrome (deafness, onychodystrophy, osteodystrophy, and mental retardation) is a rarely described disorder with less than 35 reports in the literature. The hallmarks of the syndrome, represented in the DOOR acronym, include sensorineural hearing loss, hypoplastic or absent nails on the hands and feet, small or absent distal phalanges of the hands and feet, and mental retardation. The purpose of our communication is to report on an additional patient with DOOR syndrome, delineate common as well as less frequent manifestations of DOOR syndrome, bring attention to the under appreciated facial features in DOOR syndrome, document the natural history of this disorder, and propose a suggested workup of those suspected of DOOR syndrome. DOOR syndrome is associated with characteristic, coarse facial features with large nose with wide nasal bridge, bulbous tip and anteverted nares, a long prominent philtrum and downturned corners of the mouth. The natural history is one of a deteriorative course, with progressive neurological manifestations including sensorineural deafness, seizures from infancy, optic atrophy, and a peripheral polyneuropathy. The majority of patients with DOOR syndrome have elevated levels of 2-oxoglutarate in the urine and plasma. In this report, we present a newborn with manifestations consistent with DOOR syndrome and a progressive clinical course. A comprehensive literature review reveals 32 patients with DOOR syndrome. In conclusion, DOOR syndrome is a neurometabolic disorder with recognizable facial features and a progressive natural history.

Technique for Placement of Peri-Implant Antibiotics Using Antibiotic Putty.

Surgical site infections lead to increased morbidity and health care costs. The use of local antibiotics in the form of powder applied to the surgical wound has significantly increased in orthopaedics. We have developed a technique to introduce local antibiotics in the form of a "putty," to be directly applied to surgical implants. This technique can potentially concentrate the antibiotics around the implant, where it is most needed to prevent bacterial colonization.

Micro Free Orbital Fat Grafts to the Tear Trough Deformity during Lower Blepharoplasty.

BACKGROUND: The tear trough deformity is challenging in lower eyelid rejuvenation. Surgical treatment has evolved, with more modern techniques preserving orbital fat and using autologous fat transposition. The senior author (M.A.C.) reviewed his own experience in targeting the tear trough in lower lid blepharoplasty and presents a new technique that incorporates the addition of micro free fat grafts that adds direct volume to the underlying anatomical depression using a transcutaneous skin-muscle approach. METHODS: Medical records of lower lid blepharoplasty patients performed from February of 2011 to February of 2016 were reviewed. Patients who had tear trough deformities with the addition of micro free fat grafts were included. Standard patient characteristics were collected, complications were identified, and assessment of postoperative results was performed. RESULTS: There were 32 patients included in the study, with a median follow-up of 392 days (range, 45 to 1709 days). Scleral show requiring operative correction occurred in one patient (3 percent). Additional complications included chemosis in four patients (13 percent), which resolved in all patients. No patients had infections, ectropion, lid retraction, or palpable or visible grafts. CONCLUSION: The use of micro free orbital fat grafts is an effective and safe technique to treat the tear trough deformity without increased complication rates and good patient and surgeon satisfaction and should be considered a surgical adjunct during an open blepharoplasty technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Selective Sentinel Lymph Node Dissection in Lower Extremity Melanoma.

BACKGROUND: There is debate as to whether deep inguinal lymph nodes should be removed with the superficial or femoral lymph nodes during sentinel lymph node biopsy for lower extremity melanoma, when both superficial and deep inguinal lymph nodes are identified by preoperative lymphoscintigraphy. This study evaluated the lymphatic drainage patterns in lower extremity melanoma to determine whether certain patterns could be used to limit the level of node removal and define the extent of dissection. METHODS: A retrospective outcomes review was performed of lower extremity melanoma patients with excision and sentinel lymph node biopsy from 1995 to 2010. Outcomes included location of sentinel lymph node drainage basins, sentinel lymph node-positivity, and disease-free and overall survival, with drainage patterns compared between above- and below-knee melanomas. RESULTS: Of 499 patients with lower extremity melanoma having sentinel lymph node biopsy, 356 had below-the-knee and 143 had above-the-knee melanoma. For below-knee melanoma, the node-positivity rate was 23 percent (63 of 271) for superficial inguinal, 0 percent (zero of three) for deep inguinal, and 50 percent (one of two) for popliteal basins. For above-knee melanoma, the positivity rate was 21 percent (24 of 113) for superficial inguinal, 33 percent (one of three) for deep inguinal basins, and 0 percent (zero of zero) for popliteal basins. Importantly, no patients with a negative superficial inguinal sentinel lymph node had a positive deep inguinal sentinel lymph node on final pathologic evaluation [corrected]. CONCLUSIONS: A difference was noted in patterns of sentinel lymph node drainage from lower extremity melanoma below and above the knee. Biopsy for deep inguinal basins may be deferred if there is simultaneous drainage to the superficial inguinal basin by preoperative lymphoscintigraphy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Erratum: Cutaneous Spitzoid melanoma in a very young girl of Asian descent.

[This corrects the article DOI: 10.1136/bcr.09.2010.3343.].

Cutaneous Spitzoid melanoma in a very young girl of Asian descent.

Cutaneous melanoma is extremely uncommon in children. Further, Asian-Americans appear to be at decreased risk for cutaneous melanoma. The authors present the case of a prepubescent Asian girl who presents with the rare spitzoid variant of cutaneous melanoma. The patient is a 4-year-old girl of Chinese descent who presented with a red, raised nodule, which increased in size over a 3-month period. She underwent wide local excision with sentinel lymph node dissection. On histopathologic analysis, she was found to have Spitzoid melanoma of childhood/adolescence. Spitzoid melanoma in children is rare and incompletely understood. A recent systematic review was only able to identify 82 such cases published over a 57-year period. To our knowledge, this is the first report of Spitzoid melanoma in a paediatric age patient of Asian descent. While this clearly is an uncommon demographic, it seeks to highlight important differences in racial predilection for Spitzoid melanoma.