Surgical Management of Deep Brain Stimulator Scalp Erosion without Hardware Removal.

BACKGROUND: Scalp erosion in patients with deep brain stimulation (DBS) hardware is an uncommon complication that lacks a clearly defined management strategy. Previous studies have described various therapies including conservative treatment with antibiotics and surgical debridement with or without hardware removal. OBJECTIVES: The aim of this study was to review the efficacy of a hardware-sparing management strategy for the treatment of scalp erosion. METHODS: Five patients with previous DBS implantation presented with scalp erosion and visible hardware exposure at the calvarial burr hole site, and underwent tension-free, vascularized, rotational scalp flap, with preservation of the leads under the pericranium. Two of the procedures were performed after an unsuccessful attempt at primary closure and 3 as a primary procedure. Each patient was followed clinically for at least 14 months postoperatively to evaluate for wound-healing and adverse effects. RESULTS: The median duration from initial DBS hardware implantation to erosion and revision surgery was 12 months (range 1.5-62 months). Three patients were documented to have positive intraoperative cultures in spite of the absence of purulence. At the last follow-up, all patients were noted to have complete wound-healing and no evidence of infection or erosion. CONCLUSIONS: DBS scalp erosion can be managed by rotational scalp flap without hardware removal, even in cases where infection is identified.

Cleft and Craniofacial Clinic Formats in the United States: National and Institutional Survey.

BACKGROUND: Craniofacial teams employ multidisciplinary clinics to optimize patient care. Different clinic formats exist among teams. Formats include providers rotating from room to room as separate specialties, patients rotating from room to room to either separate specialties or as 1 group, as well as providers rotating together as 1 group. Surveys were used to study family preferences between the different formats and to compare them with trends of national practices. METHODS: Families of the authors' team clinic patients were surveyed from November 2012 to February 2013, after a clinic format change from patients moving between rooms to see providers, to providers moving between rooms to see patients. This survey focused on patient satisfaction, clinic format preference, and their perception of efficiency. A second, national survey was distributed to 161 American craniofacial teams approved by the American Cleft Palate-Craniofacial Association to survey clinic formats, provider satisfaction, and experience with other formats. Institutional survey data were tabulated as percentages and further analyzed using the Mann-Whitney Test. The national survey data was then tabulated and compared with authors' institutional results. RESULTS: Thirty-nine of 54 (72.2%) families responded to the institutional survey. Providers moving between rooms were associated with greater patient satisfaction (mean 4.8 of 5, 5 being most satisfied) (0<0.0001), shorter perceived clinic time (76.9%), and an increased sense of comfort (84.6%). The difference in satisfaction rates was statistically significant (P <0.0001) between the primary clinic formats of providers rotating (mean of 4.8) and patients rotating (mean of 2.4).The national survey had 93 responses of 161 (57.7%). 54.9% of respondents have providers rotating between examination rooms, and 32.3% have patients moving between rooms. Other formats included the entire team moving as a group between rooms (10.8%) and specialties sitting together in 1 room while patients rotate (9.7%). Respondents were satisfied with current formats (mean 4.24 of 5, 5 being most satisfied). 22.2% had tried a different format previously. CONCLUSION: The most common American cleft and craniofacial clinic format is providers moving between rooms; however, all formats have high provider satisfaction. At our institution, patients prefer when providers move between rooms. Our study suggests that clinic formats do not need to be standardized, and the clinic format utilized should be tailored to the individual needs of the institution.

Determinants of breast appearance and aging in identical twins.

BACKGROUND: Appearance, aging, and disorders of the breast are multifactorial. There are intrinsic, patient-specific characteristics, such as breast growth during puberty and propensity for breast cancer, which are primarily inherited. There are also environmental factors, which can be potentially controlled. Monozygotic twins provide an excellent research opportunity to examine the role of extrinsic factors in subjects with identical genetic predispositions. OBJECTIVES: The authors investigate the role and significance of various environmental and acquired factors on breast aesthetics. METHODS: Identical female twins were recruited during the Twins Days Festival in Twinsburg, Ohio, in 2009 and 2010. After consent was obtained, enrolled subjects completed a comprehensive survey on their medical and personal history. Standardized digital photographs were taken by medical photographers. Sixteen aesthetic breast features were subjectively rated by 6 plastic surgery residents blinded to the survey results. These ratings were then analyzed against survey data to determine the significance of different exogenous factors on breast appearance. RESULTS: A total of 161 pairs of identical female twins (n = 322) with a mean (SD) age of 47.6 (14.5) years were recruited. Twins who moisturized their skin daily had significantly fewer rhytids (P = .002). Twins who received hormone replacement therapy after menopause had more attractive breast shape, size, projection, areolar shape, and areolar size (P < .03). However, twins who had a higher body mass index, greater number of pregnancies, and larger cup sizes had significantly less attractive breasts (P < .05). Twins who smoked cigarettes and consumed alcohol also had significantly less attractive breasts (P < .05). Twins who breastfed had less attractive areolar size and shape but better skin quality than their counterparts who never breastfed (P < .03). Finally, there was a significantly higher incidence of breast pain in twins who primarily slept on their sides compared with twins who primarily slept on their backs (P < .008). CONCLUSIONS: This study implicates several environmental factors that significantly affect the aesthetic quality of breasts.

Successful use of an autologous homologous skin construct for the management of acute surgical and traumatic wounds: a clinical experience in two patients.

INTRODUCTION: Autologous homologous skin construct promises to regenerate appendage-bearing skin using a small ellipse of full-thickness tissue that is harvested from the patient and sent to the manufacturer for processing. With so many surgical treatments available for wound management, data on the value and efficacy of this product will play a particularly important role in determining its indications for use. OBJECTIVE: It was hypothesized that the AHSC would be most beneficial in patients who are unable to undergo conventional reconstruction with skin grafts or flaps. The experience of successfully using the product in 2 patients with a relative contraindication to skin grafting is described. CASE REPORTS: The first patient had a history of a collagen genetic mutation and presented after traumatic degloving of the lower extremity, which was initially treated with a dermal regeneration template. The second patient had a previous history of failed skin grafting of a surgical wound following excision of a recurrent nonmelanoma skin cancer of the back. The patients were followed to the end point of complete wound healing at 4 months (case 1) and 5 weeks (case 2). CONCLUSIONS: Although more rigorous medical and financial analysis of this treatment will be necessary, these early data suggest a potential role for the AHSC in the management of wounds for patients who cannot receive conventional techniques for wound coverage.

Evidence-Based Performance Measures: Quality Metrics for the Care of Patients Undergoing Breast Reconstruction.

The American Society of Plastic Surgeons commissioned the Breast Reconstruction Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing breast reconstruction surgery. Two outcome measures were identified. The first desired outcome was to reduce the number of returns to the operating room following reconstruction within 60 days of the initial reconstructive procedure. The second desired outcome was to reduce flap loss within 30 days of the initial reconstructive procedure. All measures in this report were approved by the American Society of Plastic Surgeons Breast Reconstruction Performance Measures Work Group and the American Society of Plastic Surgeons Executive Committee. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, American Society of Plastic Surgeons' Qualified Clinical Data Registry reporting, and national quality reporting programs.

Mapping the superficial inferior epigastric system and its connection to the deep system: An MRA analysis.

The superficial inferior epigastric vasculature plays a critical role in free abdominal tissue transfer. However, its anatomic variations are incompletely characterized. An investigation was conducted on the preoperative imaging of patients undergoing free-flap breast reconstruction by a single surgeon between 2008 and 2013. This study included patients who underwent abdominal magnetic resonance angiogram (MRA). A coordinate system was used to draw the main trunk and primary branches from each patient's superficial inferior epigastric system. Each hemiabdomen's branching pattern was categorized as simple, complex, or absent. The number of superficial-to-deep inferior epigastric connections and the presence or absence of a superficial system crossing the midline were recorded. Interrater reliability was assessed for two raters. This analysis included 53 patients (106 hemiabdomens). A total of 80 (75%) hemiabdomens were categorized as having simple and 10 (9%) as complex branching patterns. A total of 16 (15%) hemiabdomens had no identifiable vessels. At least one superficial-to-deep connection was found among 89 hemiabdomens (84%). Superficial systems crossing the midline were found in 14 patients (26%). Our findings support the high degree of anatomic variation in the superficial inferior epigastric system, including a significant number of patients lacking superficial-to-deep connections and bilaterally communicating systems. These variations may be identified on preoperative MRA.

Breast fibroadenomas in adolescents: current perspectives.

Fibroadenomas are one of the most common benign tumors of the breast in the adolescent population. They account for 68% of all breast masses and 44%-94% of all biopsied breast lesions. Fibroadenomas can range from asymptomatic masses to painful and rapidly growing tumors that can cause significant esthetic distortions of the breast. Given the prevalence of fibroadenomas in the adolescent population and the psychosocial morbidity of finding a mass in the adolescent breast, it is imperative for physicians treating adolescent patients to be familiar and up to date with this disease process. The goal of this article is to provide a brief review of the classification, etiology, symptoms, initial work-up, and update on the management of breast fibroadenomas in the adolescent population.

Timing of radiation and outcomes in implant-based breast reconstruction.

OBJECTIVE: Limited data exist regarding the effect of radiation timing on complications of tissue expander/implant-based breast reconstruction. This study seeks to compare outcomes of tissue expander/implant reconstruction in patients undergoing postmastectomy radiotherapy, those with previous radiation therapy following breast conservation therapy, and those who did not receive radiation therapy. METHODS: The records of the patients of a single surgeon were reviewed from January 2007 to July 2013. All patients undergoing tissue expander/implant breast reconstruction were placed into one of three groups based on the timing of radiation therapy: postmastectomy (Current), previously following breast conservation therapy (Prior), and no radiotherapy (No XRT). Medical records were reviewed for any reported complications, and statistical analysis was performed. RESULTS: A total of 210 patients (265 breasts) were included in the analysis. Current patients were more likely than No XRT patients to experience expander infection (20% vs. 2.6%, p = 0.001) and expander removal (26% vs. 8.3%, p = 0.007). Prior patients were more likely than No XRT patients to undergo conversion to tissue flap reconstruction (10.5% vs. 0.6%, p = 0.031). No significant differences were found between groups with respect to cellulitis, abscess formation, hematoma, seroma, skin flap necrosis, expander exposure, implant exposure, or implant infection. CONCLUSIONS: This study supports the relative safety of tissue expander/implant breast reconstruction in selected groups of patients who have received radiation therapy. Differences in rates of expander infection, expander removal, and conversion to tissue flap reconstruction represent potential areas for further research.

Lack of identifiable biologic behavior in a series of porcine mesh explants.

INTRODUCTION: Biologic matrices used in abdominal wall reconstruction are purported to undergo remodeling into connective tissue resembling native collagen. Key steps in that process include inflammatory response at the mesh/tissue interface, cellular penetration, and neovascularization of the matrix, followed by fibroblast proliferation and collagen deposition. We aimed to examine the concept of biologic mesh remodeling/regeneration in a series of explanted porcine biologic meshes. MATERIALS AND METHODS: A cohort of patients who underwent removal of porcine biologic mesh was identified in a prospective database. Mesh/tissue samples were analyzed using standard hematoxylin/eosin and Masson's trichrome staining. Main outcome measures included: inflammatory response at the mesh/tissue interface, foreign body reaction (FBR), cellular penetration, neovascularization, and new collagen deposition. All evaluations were performed by a blinded senior pathologist using established grading scales. RESULTS: A total of 14 cases with implant time ranging from 4 to 33 months were identified and analyzed. All meshes were placed as intraperitoneal underlay. There were 7 non-cross-linked and 7 cross-linked grafts. Cross-linked grafts were associated with mild FBR and moderate fibrous capsule formation. Similarly, non-cross-linked grafts had mild-to-moderate FBR and encapsulation. Furthermore, non-cross-linked grafts were associated with no neovascularization and minimal peripheral mesh neocellularization. Cross-linked grafts demonstrated neither neovascularization nor neocellularization. Although no grafts were associated with any quantifiable new collagen deposition within the porcine biologic matrix, minimal biodegradation/remodeling was observed at the periphery of the non-cross-linked grafts only. CONCLUSION: The biologic behavior of porcine meshes is predicated on their ability to undergo mesh remodeling with resorption and new collagen deposition. In the largest series of human biologic explants, we detected no evidence of xenograft remodeling, especially in the cross-linked group. Although underlay mesh placement and other patient factors may have contributed to our findings, the concept of porcine biologic mesh regeneration does not seem to be prevalent in the clinical setting.

The effects of neoadjuvant and adjuvant chemotherapy on the surgical outcomes of breast reconstruction.

Breast reconstruction following mastectomy has become, in many centers the standard of care. An increasingly encountered trend is the use of neoadjuvant chemotherapy to downstage high stage tumors and to decrease tumor burden prior to definitive oncologic surgery. These agents clearly provide a survival benefit, but also have the potential to adversely affect the surgical course of immediate and delayed breast reconstruction. The use of new biologic and hormonal agents may also have effects on surgery and reconstruction. Furthermore, chemotherapeutic agents as a whole may impair cellular functions necessary for normal recovery from surgery. In this paper we present a concise review for the reconstructive surgeon on adverse effects of chemotherapeutic, hormonal and biologic agents used for treatment of breast cancer, important perioperative issues, and also discuss their potential effect on breast reconstruction.

The partial AlloDerm sling: reducing allograft costs associated with breast reconstruction.

BACKGROUND: Many surgeons now incorporate Acellular Dermal Matrix (ADM) into expander-based breast reconstruction. ADM is safe, provides full expander coverage, eliminates the need for additional muscular dissection and has improved aesthetic outcomes. However, its use increases surgical costs. Whether this cost is offset by decreased operative times or a reduced number of revision procedures is unknown. METHODS: We have developed a new technique that minimises the amount of ADM required in many patients. The 'partial sling' approach has been used for 145 consecutive patients (197 breasts) by a single surgeon from 2007 to 2010. After mastectomy, any portion of the pectoralis major insertion at, or <1 cm from, the planned inframmary fold is left intact and becomes the inferior margin of the expander pocket. The minimal size of ADM required is then determined by measuring from the pectoralis to the lateral breast margin. In this study, we exclusively used AlloDerm. Preoperative breast measurements, intra-operative fill volume, time to exchange procedure, number of expansion procedures and complications were recorded for all patients. RESULTS: Patients were grouped according to the surface area (cm(2)) of ADM required. Good aesthetic outcomes were obtained in all groups. Two groups had a significant difference in intra-operative fill volumes but this did not correlate to an increase in the number of expansion procedures required. Of 197 reconstructed breasts less than 64 cm(2) of ADM was used for 40 breasts (20%). CONCLUSIONS: The partial AlloDerm sling can minimise the costs associated with ADM use in breast reconstruction for many patients without increasing complications or altering aesthetic outcomes.

The first muscular branch of the deep inferior epigastric artery: an anatomical study and clinical applications.

BACKGROUND: Reconstruction of distal lower extremity defects often necessitates free tissue transfer. Because of its reliable vascular anatomy, pedicle length, and vessel size, the free rectus abdominis flap is widely used for this purpose. To minimize donor-site morbidity, several authors have described a segmental, or "partial," free rectus abdominis flap. METHODS: After an initial study in cadavers, measurements of the vascular anatomy of the first muscular branch of the deep inferior epigastric artery were recorded during abdominal wall dissections in 18 patients undergoing free rectus abdominis reconstruction. The partial rectus muscle free flap or "rectus plug" was then used in seven patients to reconstruct lower extremity defects. RESULTS: The first muscular branch was seen in all 20 dissections. The mean distance to the branch point from the origin of the deep inferior epigastric artery was 53.60 ± 9.63 mm. The branch point occurred before the deep inferior epigastric artery passed under the lateral border of the rectus in five dissections and deep to the muscle in 15. The mean length of the muscular branch was 20.85 ± 4.04 mm, and the mean total pedicle length was 77.0 ± 8.46 mm. The supplied portion of muscle was used successfully to reconstruct lower extremity defects in seven patients; at 1-year follow-up, all had healed with good contour and without donor- or recipient-site complications. CONCLUSION: The free rectus plug has minimal donor-site morbidity and a reliable anatomy, and should be considered for coverage of lower extremity defects smaller than 25 cm2. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.