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ABSTRACT: Background: Women undergo breast reconstruction at different time-points in their cancer care; knowing patients' preoperative quality of life (QoL) is critical in the overall care of the patient with breast cancer. Our objective was to describe presurgical QoL among women undergoing immediate, delayed, or major revision breast reconstructive surgery at our institution. Methods: From March 2008 to February 2009, we administered preoperative BREAST-Q questionnaires to women who presented to our institution for breast reconstruction. Univariate and multivariate analyses were performed to compare patient cohorts across multiple QoL domains including body image, physical well-being, psychosocial well-being, and sexual well-being. Results: Of the 231 patients who presented for preoperative consultation, 176 returned the questionnaire (response rate 76%; 117 from the immediate, 21 from the delayed, and 32 from the major revision reconstruction groups, plus 6 mixed or unknown). The three groups differed significantly (P < 0.05) across four of the six domains: body image (satisfaction with breasts), psychosocial well-being, sexual well-being, and physical well-being of the chest and upper body. The immediate reconstruction group had higher (better) scores than the delayed reconstruction group, which had higher (better) scores than the major revision group. Conclusion: These data suggest that women presenting for breast reconstruction at different stages of reconstruction have different baseline QoL. Such data may help us better understand patient selection, education, and expectations, and may lead to improved patient-surgeon communication. © 2013 Wiley Periodicals, Inc. Microsurgery, 2013.
Microsurgery 02/2013; · 1.61 Impact Factor
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Plastic and reconstructive surgery 05/2012; 129(5):849e. · 2.74 Impact Factor
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ABSTRACT: BackgroundUsing the 2006 Surveillance, Epidemiology, and End Results (SEER) database and the 2004 Area Resource File (ARF), the likelihood
of mastectomy for stages I–III breast cancer patients in urban versus rural populations are examined. County and patient level
data are evaluated for impact on receipt of mastectomy. Patient variables included age, stage, race, and marital status, and
community variables are income, employment, and radiation facility staff density. The likelihood of mastectomy in urban and
rural patients, and the impact of the different variables on that procedure, is reported.
MethodsThis retrospective analysis of a combined dataset from the 2006 SEER database and the 2004 ARF linked using the federal information
processing standard (FIPS) state county variable evaluates patient and county variables with multivariate regression.
ResultsFrom 1992 to 2003, 137,303 patients were identified in the SEER database. The rural population (county population of <20,000)
comprised 9.58% of the overall population. On bivariate analysis, the likelihood of mastectomy was significantly higher among
rural patients (59.90% versus 44.92%, P < 0.001). Multivariate analysis demonstrated that rural residency is an independent factor affecting receipt of mastectomy
(odds ratio [OR] 1.58, 95% confidence interval [CI] 1.26–1.97). The likelihood that a patient received a mastectomy was impacted
by the significant patient factors of stage at diagnosis, race, and marital status, and significant community factors were
employment, education level, and density of radiation technologists.
ConclusionAn increased likelihood of mastectomy for rural patients with stages I–III breast cancer is shown with analysis of patient
and community factors that may play a role.
Annals of Surgical Oncology 04/2012; 15(10):2644-2652. · 4.17 Impact Factor
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ABSTRACT: The sympathetic innervation of the hand was demonstrated using formaldehyde staining techniques in the 1990s and provides a basis for both medical (botulinum toxin type A) and surgical (sympathectomy) therapeutic approaches. This research investigates the sympathetic innervation of the human foot using tyrosine hydroxylase immunohistochemistry.
With institutional review board approval, six freshly amputated lower extremities had arterial, venous, and peripheral nerve biopsies obtained at the distal leg, ankle, and forefoot levels. Tibial, peroneal, sural, and saphenous nerves were processed immediately for immunohistochemical staining using an anti-tyrosine hydroxylase antibody, for light and electron microscopy evaluation. Qualitative assessments noted the presence or absence of tyrosine hydroxylase-positive fibers in artery, vein, and peripheral nerve. Within the nerve, location of the tyrosine hydroxylase staining was noted.
The presence of tyrosine hydroxylase-positive material was identified in each artery, vein, and nerve examined at each level of the foot and ankle. For the artery, the staining was in the adventitia, and rarely in the media of the vessel wall. There were clear entry points into the artery from the connective tissue. For the vein, the staining was more evenly distributed but to a lesser intensity than in the artery. Within each nerve at the proximal levels, the staining was diffusely throughout the fascicles, with clear sites of fibers leaving the periphery.
It is concluded that (1) sympathetic innervation of the foot arrives along each peripheral nerve, (2) the vessels already contain sympathetic innervation at the level of the ankle, and (3) the sympathetic innervation of the foot is extensive.
Plastic and reconstructive surgery 04/2012; 129(4):905-9. · 2.74 Impact Factor
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ABSTRACT: Two work-horse approaches to postmastectomy breast reconstruction are the deep inferior epigastric perforator flap and the superior gluteal artery perforator (SGAP) flap [and its variation, the lateral septocutaneous superior gluteal artery perforator flap]. Our purpose was fourfold: 1) to analyze our experience with the SGAP flaps for simultaneous bilateral breast reconstruction; 2) to analyze our experience with lateral septocutaneous superior gluteal artery perforator flaps for that procedure; 3) to compare our results with those in the literature; and 4) to highlight the importance of preoperative three-dimensional computed tomographic angiography.
A retrospective chart review was completed for 23 patients who underwent breast reconstruction between December 2005 and January 2010 via an SGAP flap (46 flaps). We reviewed flap weight, ischemia time, length of stay, overall flap survival, fat necrosis development, and emergency re-exploration.
Mean weights were 571.2 ± 222.0 g (range 186-1,117 g) and 568.0 ± 237.5 g (range 209-1,115 g) for the left and right buttock flap, respectively. Mean ischemia time was 129.1 ± 15.7 and 177.7 ± 24.7 minutes for the first and second flap, respectively. Mean hospital stay was 5.3 ± 2.5 days. All flaps survived. Fat necrosis developed in five flaps (10.8%), and emergency re-exploration was required in three patients (three flaps).
When harvesting abdominal tissue is a poor option, the SGAP flap is an efficacious procedure for patients desiring autologous breast reconstruction, and bilateral procedures can be performed simultaneously.
Microsurgery 03/2012; 32(5):344-50. · 1.61 Impact Factor
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A Lee Dellon,
Vickie L Muse,
D Scott Nickerson,
Thomas Akre,
Sharon R Anderson,
Steve L Barrett,
Kent R Biddinger,
Peter J Bregman,
Bryan P Bullard,
Damien M Dauphinee, [......],
Jerome K Steck,
Raymond G Stolarski,
Patrick Swier,
Tatiana A Wellens-Bruschayt,
Bronwyn Wilke,
Eric H Williams,
Michael A Wood,
William A Wood,
Michael P Younes,
Fuat Yuksel
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ABSTRACT: This is the first multicenter prospective study of outcomes of tibial neurolysis in diabetics with neuropathy and chronic compression of the tibial nerve in the tarsal tunnels. A total of 38 surgeons enrolled 628 patients using the same technique for diagnosis of compression, neurolysis of four medial ankle tunnels, and objective outcomes: ulceration, amputation, and hospitalization for foot infection. Contralateral limb tibial neurolysis occurred in 211 patients for a total of 839 operated limbs. Kaplan-Meier proportional hazards were used for analysis. New ulcerations occurred in 2 (0.2%) of 782 patients with no previous ulceration history, recurrent ulcerations in 2 (3.8%) of 57 patients with a previous ulcer history, and amputations in 1 (0.2%) of 839 at risk limbs. Admission to the hospital for foot infections was 0.6%. In patients with diabetic neuropathy and chronic tibial nerve compression, neurolysis can result in prevention of ulceration and amputation, and decrease in hospitalization for foot infection.
Journal of Reconstructive Microsurgery 03/2012; 28(4):241-6. · 1.43 Impact Factor
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A Lee Dellon,
Vicki L Muse,
Nickerson D Scott,
Thomas Akre,
Sharon R Anderson,
Steve L Barret,
Kent R Biddinger,
Peter J Bregman,
Bryan P Bullard,
Damien M Dauphinee, [......],
Jerome K Steck,
Raymond G Stolarski,
Patrick Swier,
Tatiana A Wellens-Bruschayt,
Bronwyn Wilke,
Eric H Williams,
Michael A Wood,
William A Wood,
Michael P Younes,
Fuat Yuksel
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ABSTRACT: Predictive ability of a positive Tinel sign over the tibial nerve in the tarsal was evaluated as a prognostic sign in determining sensory outcomes after distal tibial neurolysis in diabetics with chronic nerve compression at this location. Outcomes were evaluated with a visual analog score (VAS) for pain and measurements of the cutaneous pressure threshold/two-point discrimination. A multicenter prospective study enrolled 628 patients who had a positive Tinel sign. Of these patients, 465 (74%) had VAS >5. Each patient had a release of the tarsal tunnel and a neurolysis of the medial and lateral plantar and calcaneal tunnels. Subsequent, contralateral, identical surgery was done in 211 of the patients (152 of which had a VAS >5). Mean VAS score decreased from 8.5 to 2.0 (p <0.001) at 6 months, and remained at this level for 3.5 years. Sensibility improved from a loss of protective sensation to recovery of some two-point discrimination during this same time period. It is concluded that a positive Tinel sign over the tibial nerve at the tarsal tunnel in a diabetic patient with chronic nerve compression at this location predicts significant relief of pain and improvement in plantar sensibility.
Journal of Reconstructive Microsurgery 03/2012; 28(4):235-40. · 1.43 Impact Factor
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ABSTRACT: The purpose of this study is to describe the early experience of a single surgeon just out of training, including preoperative conditioning, surgical approach, and outcomes in bilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstruction patients.
We retrospectively reviewed 54 consecutive patients who underwent 108 DIEP flap breast reconstructions performed by a single surgeon over an initial 2.5-year period.
There was 100% overall flap survival. The unplanned reoperation rate was 7.6% (n = 4). Minor complications including nonoperative infection, minor wound dehiscence, and donor site seroma occurred in 26% of patients (n = 14). Significant late complications were abdominal wall bulge (n = 1) and fat necrosis < 10% of volume (n = 1). Tissue expander explantation due to infection occurred in 25% of attempted staged patients (two of eight); this did not seem to compromise their oncologic treatment or final reconstruction outcome.
This study demonstrates the efficacy of the DIEP flap for bilateral autologous breast reconstruction in the immediate, staged, and delayed settings.
Microsurgery 02/2012; 32(4):275-80. · 1.61 Impact Factor
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ABSTRACT: Although distal tibial nerve compression is well recognized, proximal tibial nerve compression remains a rarely recognized clinical condition. This report defines the presentation, diagnosis, surgical decompression technique, and clinical outcome of neurolysis of the tibial nerve at this soleal sling compression site.
Forty-nine patients with 69 proximal tibial nerves (20 bilateral) were stratified retrospectively into three groups: neuropathy (n = 10), failed tarsal tunnel syndrome (n = 25), and trauma (n = 14). Pain level, strength of the flexor hallucis longus muscle, neurosensory testing of the hallux, and subjective sensory improvement were evaluated. Each proximal tibial nerve compression was subjected to neurolysis with division of the soleal sling.
Results were stratified into poor, fair, good, and excellent based on the amount of pain relief and improvement in motor and sensory function. In all groups combined, there were 13 excellent (26.5 percent), 13 good (26.5 percent), 18 fair (36.7 percent), and five poor (10.2 percent) results. Results in the neuropathy group were excellent in two patients, good in three, fair in four, and poor in one (mean follow-up, 18.7 months). Results in the failed tarsal tunnel syndrome group were excellent in two, good in six, fair in 13, and poor in four patients (mean follow-up, 13.9 months). The trauma subgroup had the best outcomes: excellent in nine patients, good in four, fair in one, and poor in zero (mean follow-up, 13.4 months).
Regardless of cause, if a proximal tibial nerve compression beneath the soleal sling is identified, neurolysis may improve pain and sensory and motor function.
Therapeutic, IV.
Plastic and reconstructive surgery 02/2012; 129(2):454-62. · 2.74 Impact Factor
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Plastic and reconstructive surgery 01/2012; 129(1):217e-219e. · 2.74 Impact Factor
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ABSTRACT: The purpose of this study was to determine whether resection of the nerve that innervates the origin of the adductor muscle group in addition to an adductor fasciotomy will decrease pain and improve function in patients with a chronic "groin pull."
The authors conducted a retrospective multicenter chart review of 12 patients presenting with refractory groin pull. In two patients, the problem was bilateral. There were eight female and four male patients. Injuries were related to sports (n=6), gynecologic procedures (n=3), and other injuries (n=3). Surgery included adductor fasciotomy plus resection of a nerve to the periosteal origin of the adductor muscles. Cadaver dissections were performed to identify the nerve's origin.
In 13 of the 14 patient specimens, nerves were identified histologically: each of the five cadaver dissections demonstrated the anterior branch of the obturator nerve to be this nerve's origin. At a mean of 16.7 months after surgery, 11 of the 12 patients (92 percent) and 13 of the 14 limbs (93 percent) responded with relief of pain and improved activities of daily living. Of the 14 patients, eight had an excellent result (67 percent), three had a good result (25 percent), and one experienced a failure (7 percent).
Chronic impairment related to a groin pull injury may be considered caused by a contracture of the adductor muscle group, which can be treated with fasciotomy. A branch of the obturator nerve is shown to innervate the origin of these muscles, and denervation can be performed simultaneously with fasciotomy, improving pain and function.
Plastic and reconstructive surgery 10/2011; 128(4):926-32. · 2.74 Impact Factor
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ABSTRACT: Microvascular breast reconstruction often sacrifices the internal mammary artery by means of an end-to-end anastomosis. However, an end-to-side anastomosis to the internal mammary artery will maintain the option of using the internal mammary artery for future coronary artery bypass. The authors' goal was to show the feasibility and reliability of the end-to-side arterial anastomosis by comparing it with the end-to-end anastomosis in terms of associated ischemia time, flap weight, incidence of thrombosis and fat necrosis, and overall flap survival.
The authors reviewed the medical records of 22 consecutive patients who underwent 30 autologous breast reconstructions performed by one surgeon at The Johns Hopkins Hospital Avon Foundation Breast Center and whose deep inferior epigastric artery perforator or superficial inferior epigastric artery flap pedicles were anastomosed using an arterial end-to-side hand-sewn technique (15 anastomoses) or an arterial end-to-end hand-sewn technique (15 anastomoses). The authors compared the identified parameters and set the level of significance at the 0.05 alpha level.
The only significant difference between the end-to-side and end-to-end groups was mean ischemia time: 85.3±18.1 minutes (range, 55 to 113 minutes) and 64.4±23.6 minutes (range, 30 to 113 minutes), respectively.
Although ischemia times were increased in the end-to-side group, they remained within acceptable limits. Therefore, this technique is a reliable and technically feasible method of preserving the internal mammary artery system for future potential cardiac surgery.
Therapeutic, III.
Plastic and reconstructive surgery 10/2011; 128(4):225e-232e. · 2.74 Impact Factor
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Plastic and reconstructive surgery 08/2011; 128(2):592-3. · 2.74 Impact Factor
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ABSTRACT: Three-dimensional computed tomographic angiography (3D CTA) can be used preoperatively to evaluate the course and caliber of perforating blood vessels for abdominal free-flap breast reconstruction. For postmastectomy breast reconstruction, many women inquire whether the abdominal tissue volume will match that of the breast to be removed. Therefore, our goal was to estimate preoperative volume and weight of the proposed flap and compare them with the actual volume and weight to determine if diagnostic imaging can accurately identify the amount of tissue that could potentially to be harvested.
Preoperative 3D CTA was performed in 15 patients, who underwent breast reconstruction using the deep inferior epigastric artery perforator flap. Before each angiogram, stereotactic fiducials were placed on the planned flap outline. The radiologist reviewed each preoperative angiogram to estimate the volume, and thus, weight of the flap. These estimated weights were compared with the actual intraoperative weights.
The average estimated weight was 99.7% of the actual weight. The interquartile range (25th to 75th percentile), which represents the "middle half" of the patients, was 91-109%, indicating that half of the patients had an estimated weight within 9% of the actual weight; however, there was a large range (70-133%).
3D CTA with stereotactic fiducials allows surgeons to adequately estimate abdominal flap volume before surgery, potentially giving guidance in the amount of tissue that can be harvested from a patient's lower abdomen.
Microsurgery 07/2011; 31(7):510-6. · 1.61 Impact Factor
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ABSTRACT: Plastic Surgeons, by training, are familiar with constriction bands of the fingers and toes. The purpose of this report is to discuss the management of a rare constriction band syndrome that was almost circumferential at the level of the T12 dermatome, and is most appropriately considered a pelvic constriction band as it was below the umbilicus. The patient had constriction bands about the toes at birth, and was also noted to have a band circumferentially below the umbilicus, which did not cause any distress and was not treated. When the patient entered high school and began to lift weights, play football, and have a growth spurt of 2 inches, he began to experience pain below each costal margin and over the iliac crest bilaterally. His physical examination demonstrated pain in the region of the subcostal nerve and the lateral cutaneous branches of L2 as they crossed the iliac crest. By CAT scan, the band appeared to include the rectus fascia. The band was excised to a depth that included the external oblique fascia and preserved the anterior rectus sheath. Small branches of the subcostal nerves and the lateral branches of L2 were killed, and, where appropriate, they were implanted into the external oblique muscle. Closure was obtained by undermining, and a Z-plasty was not included. Healing was without complications and gave an improved appearance to the trunk. At 6 months after surgery, he had resumed college-level rugby and had no further pain related to the constriction band.
Annals of plastic surgery 01/2011; 66(1):80-3. · 1.29 Impact Factor
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ABSTRACT: Free tissue transfer has become a mainstay in breast reconstruction, with the internal mammary system frequently used as the recipient vessels. Sacrificing the internal mammary artery, however, eliminates the potential to use this vessel as a coronary artery bypass conduit in the future and potentially increases recipient-site morbidity. The authors' goal was to evaluate the learning curve and effectiveness of their use of the internal mammary intercostal perforators for microsurgical breast reconstruction.
The authors reviewed one surgeon's consecutive series of 100 abdominal adipocutaneous perforator flap breast reconstructions (72 patients) from July of 2005 through January of 2007. The internal mammary perforators were used as recipient vessels in 23 flaps, the traditional internal mammary vessels were used in 66, and the thoracodorsal vessels were used in 11. To see if there was a learning curve, flaps were analyzed in five consecutive cohorts of 20.
A learning curve was shown: internal mammary perforators were used in 5 percent of the first cohort and 45 percent of flaps in the final cohort. Flap survival was 99 percent; the one failure occurred in a traditional internal mammary flap reconstruction. Small palpable areas of fat necrosis were observed in one internal mammary perforator flap (4.3 percent) and in five traditional internal mammary or thoracodorsal flaps (6.5 percent).
In all the authors' cohorts, internal mammary perforator vessels were used safely without increasing the incidence of flap failure or fat necrosis seen with the traditional approach. The learning curve for this technique resulted in increased use of these internal mammary perforators, indicating that operator experience is critical.
Plastic and reconstructive surgery 01/2011; 127(1):34-40. · 2.74 Impact Factor
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Gedge D Rosson
Annals of Surgical Oncology 12/2010; · 4.17 Impact Factor
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Plastic and reconstructive surgery 12/2010; 126(6):318e-319e. · 2.74 Impact Factor
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ABSTRACT: Acute postoperative pain following craniofacial or esthetic surgery, or trauma is readily treated with medicinal regimens. Facial pain persisting for more than six months is defined as chronic and must be distinguished from nontraumatic atypical facial pain or "tic-douloureaux." Our surgical experience managing chronic facial (trigeminal) pain is reviewed to provide insight into the success of our current algorithm for managing patients with chronic facial pain.
We performed a retrospective review of nine consecutive patients operated for post-traumatic chronic trigeminal nerve pain. Most patients were women (mean age 41 years). Data evaluated included mechanism of nerve injury, physical exam, CT scans, computer-aided neurosensory testing, and diagnostic nerve blocks. Surgical management included hardware removal, neurolysis, and/or neuroma resection with nerve grafting when indicated. Primary outcome measurement included Likert pain scale score (range 0-10). Secondary outcome measurements included sensory exam, medication requirement, and return to work. Based on these outcome measures, results were defined as excellent, good, fair, or poor.
Five of the nine patients had excellent outcomes, one was good, two were fair, and one was poor. The one patient with a poor result had temporary improvements, but later returned to baseline. No patient was made symptomatically worse or had operative complications.
Successful treatment of chronic, post-traumatic trigeminal nerve pain can be expected using an algorithm that measures sensory function of the involved trigeminal nerve branch. Then either preserves that function through neurolysis or reconstruction with a nerve graft, or eliminates that function through neuroma resection.
Microsurgery 11/2010; 30(8):614-21. · 1.61 Impact Factor
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ABSTRACT: Many studies demonstrate direct patient benefits from use of preoperative computed tomography angiograms (CTA) for abdominal tissue-based breast reconstruction. We present a novel classification schema to translate imaging results into further clinical relevance.
Each hemiabdomen CTA was classified into a schema that addressed findings of expected anatomy, anatomy that necessitates a change in operative technique and anatomy that suggests less morbid procedures may be considered.
Eighty-six patients (172 hemiabdomens) were available for study. Of the reconstructions performed in this time period, 40 (47%) were bilateral and 46 (53%) unilateral. Based on perforator size and location, relative perimuscular anatomy, and continuity of vessels, five categories were defined: type I "Traditional" anatomy (n = 150, 87%), type II "Highly Favorable" anatomy (n = 11, 6.4%), type III "Altered-Superiorly Translocated" anatomy (n = 9, 5.2%), type IV "Superficial Dominant" anatomy (n = 26, 15%), and type V "Hostile" anatomy (n = 4, 2.3%). The additive total is greater than 100%, because vessels may fall into more than one category.
In providing the microsurgeon with a preoperative vascular map that has the potential to influence the preoperative, operative, and postoperative course, abdominal CTAs should be considered a worthy adjunct to the diagnostic armamentarium of the reconstructive surgeon. These classifications and their clinical impacts become even more important in centers performing increasing numbers of bilateral reconstructions. We believe that our simple schema can facilitate effective use of this powerful tool, aiding in overall care of the breast reconstruction patient.
Microsurgery 11/2010; 30(8):593-602. · 1.61 Impact Factor
