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Metastatic salivary gland tumors are rare clinical entities of the head and neck. Parotid gland carcinoma with distant metastases heralds a poor prognosis with a median survival of 4.3-7.3 months. The lungs, long bones, liver and brain are the most common sites of metastasis for parotid gland cancer, along with a few reported cases describing metastasis to the ileum, spleen and iliac crest. We present the first case to our knowledge of parotid adenocarcinoma metastasis to the breast.

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BACKGROUND: The cause of maxillary growth restriction in patients with cleft lip and palate remains controversial. While studies have investigated the effects surgical technique and timing have on maxillary growth, few focus on patients with isolated cleft palate (ICP). The purpose of this study was to determine the impact palate repair and its associated complications may have on maxillary growth. METHODS: A retrospective chart review of ICP patients who underwent palatoplasty from 1962 to 1999 at Akron Children's Hospital was performed. Patient demographics, Veau type, age at primary repair, closure technique, presence of fistula or velopharyngeal insufficiency (VPI), number of palatal operations, maxillary hypoplasia (MH) frequency, and follow-up were recorded. Exclusion criteria included patients with cleft lip, submucous cleft, or syndromes. RESULTS: Twenty-nine non-syndromic ICP patients were identified; 62% (n = 18) had Veau type 1 and 38% (n = 11) had Veau type 2. All patients underwent 2-flap or Furlow palatoplasty with mobilization of mucoperiosteal flaps. Vomerine flaps were used in all Veau 2 cleft palate closures. Palatoplasty was performed at a mean age of 19.9 ± 8.2 months. Average follow-up was 209 ± 66.5 months. The rate of VPI was 59% (n = 17) and the rate of oronasal fistula was 14% (n = 4). CONCLUSIONS: There was a low incidence of MH despite complications after initial palate closure. Our results seem to suggest that age at palate closure, type of cleft palate, and type of surgical technique may not be associated with MH. Additionally, subsequent procedures and complications after primary palatoplasty such as VPI and palatal fistula may not restrict maxillary growth.

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BACKGROUND: Implant-based reconstruction is currently the most common postmastectomy breast reconstruction modality with over 86,000 procedures performed in 2017. Although various methods for reconstruction techniques have been described, partial subpectoral implant placement with or without acellular dermal matrix coverage remains the most popular approach. Recently, prepectoral implant placement has gained increased recognition as a method that avoids some of the potential morbidities of submuscular implant placement. Currently, few studies have examined the outcomes of performing this approach. The purpose of this study was to evaluate and compare the outcomes of prepectoral and subpectoral direct to implant (DTI) immediate breast reconstruction. METHODS: Data from a prospective cohort of consecutive patients undergoing prepectoral DTI immediate breast reconstructions at our institution from February 2016 to November 2017 were collected. The incidence of complications such as mastectomy skin flap necrosis, seroma, hematoma, infection, implant loss, and unexpected reoperation were recorded and compared with a cohort of consecutive patients who underwent subpectoral DTI immediate breast reconstruction from May 2014 to July 2015. RESULTS: One hundred twelve prepectoral DTI immediate breast reconstructions were performed on 62 patients. Four breasts (4.4%) were diagnosed with infection. There were 8 breasts (7.1%) that suffered from mastectomy skin flap necrosis (5 partial thickness necrosis, 3 full thickness necrosis). There was 1 implant loss related to full thickness necrosis that required salvage with autologous tissue reconstruction. Prepectoral breast reconstruction had less esthetic revisions and comparable complications when compared with the historical subpectoral cohort. CONCLUSIONS: When compared with the subpectoral DTI approach, prepectoral DTI breast reconstruction grants favorable complication rates and improved esthetic outcomes. Prepectoral DTI breast reconstruction is a safe modality that should be considered in any patient who is a candidate for immediate breast reconstruction.

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BACKGROUND: Laser-assisted indocyanine green angiography (LAIGA) has been proven to accurately detect mastectomy skin flap necrosis (MSFN) intraoperatively and prevent postoperative complications in breast reconstruction. The purpose of this study was to examine the cost-effectiveness of the routine use of LAIGA in immediate breast reconstruction and to perform a break-even point analysis. METHODS: This is a retrospective review of prospectively gathered data from all patients who underwent immediate breast reconstruction from January 2014 to January 2015. LAIGA was routinely used in all cases. Patients were followed for at least 90 days to capture postoperative complications. Costs were calculated by reviewing itemized bills and Medicare Reimbursement Current Procedural Terminology codes to assess surgeon fees. Outcomes and costs were compared with a historical cohort of patients who underwent breast reconstruction before the implementation of LAIGA. RESULTS: Two-hundred-and-six immediate breast reconstructions (126 patients) were performed using LAIGA for a total cost of $210,700. The average cost of MSFN in our LAIGA cohort was $30,496. The routine use of LAIGA decreased the MSFN rate from 12.4% to 6.3% and prevented MSFN on 13 breasts resulting in a gross cost savings of $396,453, and net savings of $185,753. Break-even point analysis demonstrated that number of cases needed to break even decreases as the average MSFN cost and MSFN reduction rate increase. CONCLUSION: The routine use of LAIGA in immediate breast reconstruction is cost-effective in reducing the incidence of MSFN, implant loss, and overall unexpected reoperation rate.

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Pseudoaneurysms and patch infections are known complications of carotid endarterectomy with patch angioplasty. Although they are rare occurrences, they carry high morbidity and almost uniformly require surgical intervention. Infectious pathogens are often gram-positive bacteria, most commonly Staphylococcus species, whereas gram-negative infections are less frequently observed. We present a case of recurrent pseudoaneurysm in a patient who had a carotid endarterectomy with bovine pericardial patch angioplasty complicated by Pasteurella multocida infection. This case demonstrates the need for recognition and consideration of a broad differential of pathogens in evaluating and treating vascular infections.

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BACKGROUND: Accurate breast cancer staging is essential for optimal management of adjuvant therapies. While breast lymphatic drainage involves both axillary and internal mammary (IM) lymph node (LN) basins, IM LN sampling is not routinely advocated. The current study analyzes the incidence of IM LN metastases sampled during free flap breast reconstruction and subsequent changes in adjuvant treatment. METHODS: A retrospective analysis of patients with positive IM LN biopsies during free flap breast reconstruction was performed. Pre-reconstruction surgical and adjuvant therapies as well as staging and prognostic data were recorded. Change in adjuvant therapies based solely on IM LN positivity was determined. RESULTS: IM LN metastases were found on 28 (1.3%) out of 2057 patients and comprised the study population. Mean age was 49 years with pre-reconstruction chemotherapy or radiation administered in 50 or 54% of cases, respectively. Five (18%) patients had previously undergone lumpectomy with axillary sampling. Mean tumor size was 3.1 cm with tumor location evenly distributed among all four quadrants. Ten (36%) patients had isolated IM LN metastases Patients with both axillary and IM disease had larger lesions, increased prevalence of pre-reconstruction chemotherapy and radiation. Based exclusively on positive IM LN disease, 17 (63%) patients had a change in adjuvant therapy. CONCLUSION: Despite the low incidence of IM LN metastases, IM LN biopsy during free flap breast reconstruction is recommended. In 36% of cases, nodal metastases were isolated to the IM nodes. Identification of IM metastases influenced adjuvant therapies in a majority of cases.

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PURPOSE: Postoperative infection is the most common complications after implant-based immediate breast reconstruction (IBR), with reported rates ranging from less than 1% to 43%. This heterogeneity among the literature may be explained by a lack of consensus on the definition of postoperative infection. The purpose of this study was to review the prevalence of infection and how it is defined in studies involving prosthetic-based IBR. It is necessary to establish a clear definition of infection to standardize the reporting of complications. METHODS: A comprehensive literature review was performed to identify infection rates among implant/tissue expander-based IBR performed between 1996 and 2017. A PubMed search using the keywords "immediate breast reconstruction" matched with "infection" and "tissue expanders" or "implant" was performed. Reconstructive modality, infection rates, and definitions were recorded and reviewed. RESULTS: An initial search provided 196 articles; 138 articles met inclusion criteria and were reviewed. Eighty-five (61%) articles failed to define infection and reported an infection rate ranging from 0% to 22%. The studies that characterized infection had highly variable definitions. Whereas some authors chose to define infection based on Centers for Disease Control guidelines, others used more subjective findings such as clinical signs of infection. CONCLUSIONS: Currently, there is no consensus on the definition of infection after implant-based IBR. We propose that the definition should include the administration of antibiotics beyond the surgeon's standard perioperative period with or without the presence of localized clinical signs of infection (erythema, pain, increased temperature, etc). A universal definition of postoperative infection after implant-based IBR that accurately captures the incidence of infection will allow better comparisons between future studies.

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The use of extracorporeal membrane oxygenation (ECMO) in the treatment of acute respiratory distress syndrome (ARDS) has been described as early as 1972 [Hill 1972]. Though a subsequent randomized trial showed no survival benefit over conventional mechanical ventilation [Zapol 1979], protective ventilation strategies and evolving extracorporeal technology improvements have led to a resurgence in the use of ECMO for patients with ARDS. The most recent randomized clinical trial, Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR), showed a significant mortality reduction in ARDS patients who were treated with ECMO [Peek 2009]. The results of the trial have led some to believe that the widespread adoption of ECMO as a feasible treatment for severe respiratory failure is forthcoming [MacLaren 2012; Del Sorbo 2014]. As the use of ECMO continues to increase, clinicians must be aware of the extremes in patient characteristics for which therapy might be considered reasonable. For example, many studies focus on the limited benefit of advanced therapies, such as ECMO, in the elderly [Salna 2014]. However, there is a paucity of literature on using veno-venous extracorporeal membrane oxygenation (VV ECMO) to treat ARDS in patients with extremity obesity [Ull 2015; Belliato 2016; Kadakia 2017]-a population that is often inherently discriminated against with regards to advanced medical and surgical therapies because of the practical challenges of treating someone of great size as well as the inherent social (and professional) biases against such patients. This case demonstrates application of ECMO in a patient with an extreme body mass index (BMI) and confirms the successful use of ECMO in this BMI patient population.

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BACKGROUND: Current literature comparing outcomes of immediate breast reconstruction using direct-to-implant (DTI) single-stage and 2-stage tissue expanders (TEs) is conflicting. This study compared overall outcomes and determined predictive patient factors associated with higher complication rates. METHODS: After institutional review board approval, a retrospective cohort study of consecutive patients who underwent immediate breast reconstruction from 2010 to 2014 at a single hospital was performed. Demographic data and complications were recorded and compared using univariate analysis. Infection was defined as any patient receiving antibiotics beyond the expected postoperative course or restarting antibiotics for a suspected infection. RESULTS: Seventy-nine breasts (50 patients) underwent immediate breast reconstruction using tissue expansion, and 117 breasts (69 patients) underwent immediate breast reconstruction using the DTI technique. Overall complications, infection rate, and rate of aesthetic revisions were higher in the TE group compared with the DTI group. There was no difference in rates of seroma, hematoma, and mastectomy skin flap necrosis between the 2 groups. Infectious complications were significantly higher in patients with body mass index of greater than 30 who underwent TE-based reconstruction than those who underwent DTI-based reconstruction. CONCLUSIONS: Single-stage DTI immediate breast reconstruction has less overall complications than 2-stage TE-based immediate reconstruction. Direct-to-implant immediate breast reconstruction may provide favorable outcomes in patients with body mass index of greater than 30.

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Parastomal evisceration is a very rare complication occurring after stoma formation. We report the case of this complication which occurred within 3 days status post end sigmoid colostomy in a 69-year-old male who initially presented with perianal infection-severe necrotizing fasciitis. This case highlights the significance of the size of a stomatal aperture and should remind general surgeons of the one of dangerous complications indicated by a stomatal aperture that is just a centimeter larger than the accepted ideal size.