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ABSTRACT: INTRODUCTION: Transverse rectus abdominus muscle flaps (TRAM) can result in significant abdominal wall donor-site morbidity. We present our experience with bilateral pedicle TRAM breast reconstruction using a double-layered polypropylene mesh fold over technique to repair the rectus fascia. METHODS: A retrospective study was performed that included patients with bilateral pedicle TRAM breast reconstruction and abdominal reconstruction using a double-layered polypropylene mesh fold over technique. RESULTS: Thirty-five patients met the study criteria with a mean age of 49 years old and mean follow-up of 7.4 years. There were no instances of abdominal hernia and only 2 cases (5.7%) of abdominal bulge. Other abdominal complications included partial umbilical necrosis (14.3%), seroma (11.4%), partial wound dehiscence (8.6%), abdominal weakness (5.7%), abdominal laxity (2.9%), and hematoma (2.9%). CONCLUSIONS: The TRAM flap is a reliable option for bilateral autologous breast reconstruction. Using the double mesh repair of the abdominal wall can reduce instances of an abdominal bulge and hernia.
Annals of plastic surgery 03/2013; · 1.29 Impact Factor
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ABSTRACT: Mastectomy is a surgical choice for breast cancer, yet breast reconstruction is underused in women older than age 60 years. Because of a paucity of information examining breast cancer reconstruction in the elderly, we sought to review our experience. By retrospective chart review, we evaluated 89 women older than 60 years having mastectomy and reconstruction from January 1998 to June 2008. Mean patient age was 65 years (range, 60 to 74 years). The majority (41%) had Stage 1 disease or Stage 2 (30%). Ductal carcinoma in situ comprised 25 per cent and Stage 3 totaled 2 per cent. Mastectomy for ipsilateral breast tumor recurrence after radiation therapy and lumpectomy comprised 11 per cent. Most underwent immediate breast reconstruction (89%). Reconstructive techniques included two-stage implant (58%), transverse rectus abdominus musculocutaneous (TRAM) flap (10%), latissimus dorsi musculocutaneous flap with implant (2%), or deep inferior epigastric perforator flap (1%). Complications included a 12 per cent infection rate, removal of two expanders resulting from exposure, one TRAM failure, and one TRAM required débriding. Four patients undergoing mastectomy with tissue expander had radiation resulting in one expander being removed. One local skin recurrence was treated with removal of implant and skin resection. Two patients have died from metastatic disease. Age should not be a contraindication for breast reconstruction in elderly women.
The American surgeon 12/2011; 77(12):1640-3. · 1.28 Impact Factor
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ABSTRACT: Spring-assisted surgery has been used for the treatment of craniofacial deformities since its 1997 inception in Sweden by Dr Lauritzen (Scand J Plast Reconstr Surg Hand Surg 1998;32:331-338). Initial applications have focused on the treatment of patients with single-suture craniosynostosis. Recently, indications and applications have expanded to include patients with syndromic craniosynostosis, multiple-suture synostosis, and midface hypoplasia. The advancement of spring-assisted surgery in this country has been hindered by the need for patient-specific spring fabrication because few surgeons understand how to make the springs for each application. We will review our spring design and treatment algorithms to facilitate wider use of this innovative treatment modality.
This is a retrospective institutional review board-approved analysis of the spring design for our first 90 cases of spring-assisted surgery used to treat sagittal synostosis at the North Carolina Center for Cleft and Craniofacial Deformities. Outcome analysis was done to generate a treatment algorithm based on diagnosis, patient age, spring design, number of springs, spring force and expansion, and clinical outcome.
Ninety children with sagittal craniosynostosis (64 males, 26 females) were treated during an 8-year period (2001-2009) with spring-assisted surgery. Mean age at treatment was 4.4 months and mean age at spring removal was 8.8 months. Mean number of springs used was 2 (range, 1-3). Mean spring force used in sagittal synostosis was 5.5-9.5 (range) for the anterior spring and 5.5-9.5 (range) for the posterior spring with a mean posttreatment expansion of 6.65 cm. Analysis of the results shows that spring force and expansion required for optimal correction is dependent on the age at surgery, type of the deformity, and severity of the deformity. Specifically, the younger the child, the weaker the spring needed for surgical correction. General principles for spring application for scaphocephaly include (1) the longer the anterior posterior dimension of the skull deformity, the more likely a third spring is necessary; (2) the narrower the posterior occiput, the stronger the posterior spring required; and (3) if a postcoronal band is seen in the calvarium, a stronger anterior spring is needed.
Long-term experience with spring-assisted surgery has facilitated the development of standardized, reproducible techniques allowing spring design modifications to optimize clinical outcome.
The Journal of craniofacial surgery 10/2009; 20(6):1962-8. · 0.81 Impact Factor
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ABSTRACT: In the past decade, deformational plagiocephaly has seen a staggering increase attributed to the Back to Sleep Campaign of April 1992. With this increase, the possible clinical associations need to be fully understood. The anatomic changes seen include ipsilateral occipital flattening, ipsilateral frontal bossing, ipsilateral anterior ear displacement, contralateral occipital bossing, and contralateral frontal flattening [J Craniofac Surg 2004;15:368-372, erratum in J Craniofac Surg 2004;15:705; Fig. l]. Children with deformational plagiocephaly can have malpositioned ears affecting normal drainage of the eustachian tube as it shifts with this deformity. The eustachian tube plays an important role in draining the middle ear. As evidenced by children with cleft palates, structural differences in the anatomy of the middle ear and eustachian tube can result in an increased susceptibility to otitis media. An institutional review board-approved retrospective study was conducted on all patients whose conditions were diagnosed as deformational plagiocephaly from a cleft and craniofacial deformities clinic for a 2-year period. Parents of patients self-reported the number of ear infections on a questionnaire. The questionnaire results were compared to age-matched patient data available from the Center for Disease Control. There were 1259 patients who fit the inclusion criteria for the questionnaire part of the study, and of these, 634 (50.4%) reported at least 1 ear infection by 1 year of age. In addition to the questionnaire, a subset of infants with deformational plagiocephaly up to 1 year of age were administered a tympanogram, to assess the state of the middle ear. There were 124 patients who fit the inclusion criteria for the tympanometry part of the study, and of these 121 had an abnormal tympanogram at 1 or more clinic visits. The questionnaire did not show deformational plagiocephaly to be a significant risk factor for otitis media in our patient population; however, a trend directly correlating otitis media and the severity level of deformational plagiocephaly was observed. Although this trend lacked statistical significance, further studies should explore these differences. Tympanogrametry showed a marked percentage of infants with deformational plagiocephaly to have eustachian tube dysfunction. Future studies will focus on the significance of these findings.
The Journal of craniofacial surgery 09/2009; 20(5):1407-11. · 0.81 Impact Factor
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ABSTRACT: Fasciotomy wounds can be a major contributor to length of stay for patients as well as a difficult reconstructive challenge. Once the compartment pressure has been relieved and stabilized, the wound should be closed as quickly and early as possible to avoid later complications. Skin grafting can lead to morbidity and scarring at both the donor and fasciotomy site. Primary closure results in a more functional and esthetic outcome with less morbidity for the patient, but can often be difficult to achieve secondary to edema, skin retraction, and skin edge necrosis. Our objective was to examine fasciotomy wound outcomes, including time to definitive closure, comparing traditional wet-to-dry dressings, and the vacuum-assisted closure (VAC) device. This retrospective chart review included a consecutive series of patients over a 10-year period. This series included 458 patients who underwent 804 fasciotomies. Of these fasciotomy wounds, 438 received exclusively VAC. dressings, 270 received only normal saline wet-to-dry dressings, and 96 were treated with a combination of both. Of the sample, 408 patients were treated with exclusively VAC therapy or wet-to-dry dressings and 50 patients were treated with a combination of both. In comparing all wounds, there was a statistically significant higher rate of primary closure using the VAC versus traditional wet-to-dry dressings (P < 0.05 for lower extremities and P < 0.03 for upper extremities). The time to primary closure of wounds was shorter in the VAC. group in comparison with the non-VAC group. This study has shown that the use of the VAC for fasciotomy wound closure results in a higher rate of primary closure versus traditional wet-to-dry dressings. In addition, the time to primary closure of wounds or time to skin grafting is shorter when the VAC was employed. The VAC used in the described settings decreases hospitalization time, allows for earlier rehabilitation, and ultimately leads to increased patient satisfaction.
Annals of plastic surgery 05/2009; 62(4):407-9. · 1.29 Impact Factor
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ABSTRACT: Scaphocephaly is an important but incompletely defined entity resulting from premature fusion of the sagittal suture. Our goal was to use the clarity afforded by three-dimensional computed tomographies (CTs) to discern what characteristics of this disease are most representative and singular. Furthermore, we sought to define a classification system wherein the dominant physical trait, as it results from varied sites of premature fusion, determines the type of scaphocephaly in a particular patient. All patients with CT-diagnosed isolated single-suture sagittal craniosynostosis seen by a single craniofacial surgeon and a single pediatric neurosurgeon over a 5-year period are included (N = 76). Patients were stratified into anterior, central, posterior, or complex subtypes dependent upon the presence of a single dominant characteristic as seen on CT scan. Anterior type features a transverse retrocoronal band; central type has a heaped sagittal ridge; posterior type has an especially prominent occiput; and complex type includes those patients in whom a single dominant feature is not present. Forty-eight patients fit into anterior, central, or posterior types. Thirteen percent (N = 7) lack a single dominant feature and are complex. Incidence and prevalence for each type in this population are the following: anterior, 13/24%; central, 16/29%; posterior, 19/35%; and complex, 7/13%. Heterogeneous points of initial fusion may be responsible for the differing representations. Clinical applications using this classification system are ongoing and may allow us to individualize surgical intervention to optimize clinical outcome.
The Journal of craniofacial surgery 04/2009; 20(2):279-82. · 0.81 Impact Factor
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ABSTRACT: Craniosynostosis is the premature fusion of 1 or more of the cranial sutures, with sagittal synostosis being the most common nonsyndromic single suture synostosis. The pathogenesis of craniosynostosis has been extensively studied and is likely multi-factorial. A complex interaction between the dura and overlying suture via multiple growth factors seems to play the most important role. There have been 3 published studies with patients presenting with scaphocephaly and a cephalohematoma, which raises the question of how the 2 conditions may be related. Cephalohematomas can be seen after trauma and a number of other causative factors but usually resorb over time without sequela. In a small percentage of cases, the hematoma persists and calcifies, leading to significant asymmetry and deformity of the skull. Once it reaches this point, surgical intervention may be required to correct the resulting skull deformity. We present a child with scaphocephaly and a cephalohematoma who underwent surgical correction with resection of the cephalohematoma and sagittal suturectomy with spring-assisted surgery.
The Journal of craniofacial surgery 03/2009; 20(2):410-3. · 0.81 Impact Factor
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ABSTRACT: Complex breast wounds are a constant problem for surgeons. Wound vacuum-assisted closure therapy (VAC) has been shown to be effective for a variety of complex wounds. Our goal was to evaluate our experience with the (VAC) device in the treatment of open breast wounds. We retrospectively identified 18 patients with complex breast wounds treated with the VAC. We analyzed the data regarding the nature and management of these wounds using the VAC device. Fifteen of 18 patients were treated effectively using the VAC. Two patients required muscle flap coverage. One patient had the VAC dressing discontinued secondary to a denial by an insurance company for VAC in the home setting. VAC therapy is an effective treatment for complex wounds. Specifically, our experience shows it to be effective in the treatment of complex breast wounds. Utilization of VAC therapy should be considered for the management of these challenging wounds.
The Breast 11/2006; 15(5):610-3. · 2.49 Impact Factor
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ABSTRACT: The gold standard for closing small cranial defects is autogenous bone: iliac crest, rib, or split calvarial grafts. Autogenous grafts result in donor site morbidity, increased operative time, blood loss, and additional cost, and they are limited in quantity. Hydroxyapatite cements are alternative bone substitutes that eliminate these restrictions. Although the use of hydroxyapatite is well accepted in completely developed crania, its use in the growing pediatric skull is limited. The purpose of the current study was to address the safety and long-term efficacy of this bone substitute for the repair of craniofacial bone defects in the growing pediatric skull. Safety is measured dually by resistance of bone substitute to infection and its tolerability by lack of a foreign body reaction. Efficacy is evaluated as structural skull integrity, volume stability with time, aesthetic quality, and most importantly, the ability to integrate adequately into a growing cranium without subsequent deformity or complications. This is a retrospective review of all pediatric patients at the authors' institution who underwent reconstruction of cranial defects using hydroxyapatite cement between May 1997 and March 2001. Eight patients who underwent 11 operations between the ages of 25 and 100 months (mean, 55 months) were followed up between 23 and 72 months (mean, 38 months). No mortalities or significant morbidities were encountered in the study population. It has been the authors' experience that hydroxyapatite cement is both biocompatible and resistant to infection when used in sites not contiguous with sinus mucosa; and that it is a good alternative to autogenous bone in pediatric craniofacial reconstruction.
Journal of Craniofacial Surgery 02/2005; 16(1):129-33. · 0.82 Impact Factor
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ABSTRACT: Positional plagiocephaly deformities have increased dramatically in all craniofacial clinics in the United States. There are multiple methods for evaluating the degree of deformity, all of which are expensive, time consuming, and have poor reproducibility. We present a clinical classification of plagiocephaly deformities that we have employed since 1998. The classification allows us to quantitate the degree of deformity in these children at any given time, to reliably determine quantitative changes from evaluation to evaluation. The technique is highly reproducible, cost effective and readily understandable to the family, as well as referring physicians.
Journal of Craniofacial Surgery 06/2004; 15(3):368-72. · 0.82 Impact Factor
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ABSTRACT: Enlarged parietal foramina are rare congenital skull defects identified on physical examination and confirmed radiographically. They are round or oval defects situated on each parietal bone approximately 1 cm from the midline and 2 to 3 cm superior to the lambdoid suture. Although small parietal foramina are common variants in up to 60% to 70% of normal skulls, large parietal foramina ranging from 5 mm to multiple centimeters are less common, with a prevalence of 1:15,000 to 1:25,000. We present a case series of four patients with large persistent parietal foramina managed surgically for the correction of this deformity. Two infants were treated with autologous calvarial bone grafts, and two were treated with a mesh plating system and hydroxyapatite. No patient developed any perioperative complications. No perioperative or delayed infections occurred in our patient population. The mean postoperative follow-up was 36 months. One patient required a second procedure with methylmethacrylate because of late bone graft failure, whereas the others were successfully treated by the initial procedure. Foramina parietalia permagna, otherwise known as fenestrae parietals symmetricae, enlarged parietal foramina, giant parietal foramina, or Catlin marks, are a rare clinical entity. A spontaneous decrease in the size of these defects with growth of the infant has been reported, but this closure is usually incomplete. Surgical intervention of persistent large foramina protects the child against potential injury to the underlying brain. We advocate cranioplasty for active young children and those at risk for injury (i.e., seizure disorder) to decrease the risk for potential intracranial injury.
Journal of Craniofacial Surgery 08/2003; 14(4):538-44. · 0.82 Impact Factor
