RESUMEN

Mastectomies for both cancer resection and risk reduction are becoming more common. Existing chest wall irregularities are found in these women presenting for breast reconstruction after mastectomy and can pose reconstructive challenges. Women who desired breast reconstruction after mastectomy were evaluated preoperatively for existing chest wall irregularities. Case reports were selected to highlight common irregularities and methods for improving cosmetic outcome concurrently with breast reconstruction procedures. Muscular anomalies, pectus excavatum, scoliosis, polythelia case reports are discussed. Relevant data from the literature are presented. Chest wall irregularities are occasionally encountered in women who request breast reconstruction. Correction of these deformities is possible and safe during breast reconstruction and can lead to improved cosmetic outcome and patient satisfaction.

Asunto(s)

Mamoplastia/métodos , Mastectomía/métodos , Escoliosis/cirugía , Pared Torácica/cirugía , Adulto , Femenino , Humanos , Persona de Mediana Edad , Satisfacción del Paciente , Escoliosis/patología , Pared Torácica/patología , Resultado del Tratamiento

RESUMEN

BACKGROUND: The pedicled transverse rectus abdominis myocutaneous (TRAM) flap is a reliable reconstructive option in breast cancer patients; however, it carries known risk of donor site hernia formation. Some hormonal therapy drugs have been associated with hernia formation in animal models. Minimal data exist concerning impact of hormonal therapy for breast cancer on abdominal donor site complications after breast reconstruction. METHODS: Patients who underwent TRAM flap for breast cancer or high-risk status at a single institution by the senior author from 2003 to 2015 were identified. Charts were reviewed. Patient demographics, comorbidities, treatments, and abdominal complications were recorded. Patients were divided into groups based on use of hormonal therapy as well as exposure to specific drugs. Statistical analyses were performed. RESULTS: A total of 358 patients were included. Overall hernia rate was 5.9%. About 231 (64.5%) patients had hormonal therapy, whereas 127 (35.5%) did not. Difference in hernia formation was not statistically significant between the hormonal therapy group (6.9%) and the no hormonal therapy group (3.9%; P = 0.359). Patients exposed to tamoxifen and those exposed to anastrozole had no significant difference in complication rates compared with the no hormonal therapy group, whereas patients exposed to letrozole had increased rate of hernia (13.5%; P = 0.037) and infection (21.6%; P = 0.013) compared with the no hormonal therapy group (3.9% and 7.1%, respectively). CONCLUSIONS: Hormonal therapy is a useful adjunct for chemoprevention in breast cancer; however, use of letrozole in patients undergoing reconstruction with pedicled TRAM can lead to increase in certain complication rates.

Asunto(s)

Antineoplásicos Hormonales/efectos adversos , Neoplasias de la Mama/tratamiento farmacológico , Hernia Incisional/inducido químicamente , Mamoplastia , Colgajo Miocutáneo/trasplante , Recto del Abdomen/trasplante , Infección de la Herida Quirúrgica/inducido químicamente , Adulto , Anciano , Anastrozol/efectos adversos , Anastrozol/uso terapéutico , Antineoplásicos Hormonales/uso terapéutico , Neoplasias de la Mama/cirugía , Quimioterapia Adyuvante , Femenino , Humanos , Hernia Incisional/epidemiología , Letrozol/efectos adversos , Letrozol/uso terapéutico , Mamoplastia/métodos , Persona de Mediana Edad , Oportunidad Relativa , Estudios Retrospectivos , Factores de Riesgo , Infección de la Herida Quirúrgica/epidemiología , Tamoxifeno/efectos adversos , Tamoxifeno/uso terapéutico , Resultado del Tratamiento

RESUMEN

OBJECTIVE: Considerable attention has been given to patient-reported outcomes in breast reconstruction. The objective of this study is to evaluate the effect of postreconstruction change in breast volume on validated patient satisfaction survey scores. METHODS: Patients undergoing skin-sparing mastectomy followed by tissue expander/implant reconstruction between July 2010 and July 2014 by a single surgeon were given postoperative patient-reported satisfaction surveys (BREAST-Q). Retrospective chart review of patients with completed surveys was undertaken to record patient characteristics and compare preoperative breast volume (extrapolated from mastectomy mass) with postoperative implant volume, and percent change in volume was calculated. Regressions were utilized to correlate percent change with satisfaction in each category. RESULTS: A total of 160 patient surveys were included. Sixty-five percent of breasts analyzed had increased volume after reconstruction, whereas 35% had decreased volume. The increased volume group had significantly lower body mass index (P = 0.0001) and was significantly younger (P = 0.009) than the decreased volume group. Patients who experienced increase in breast volume reported statistically greater satisfaction with breasts (P = 0.019), overall outcome (P = 0.012), sexual well-being (P = 0.002), and information (P = 0.042) compared with the decreased volume group. Moreover, linear regression revealed that as percent change increased, so did satisfaction with outcome (P = 0.02), sexual well-being (P = 0.005), information (P = 0.018), and surgeon (P = 0.036). Notably, there was not a significant difference in complication rate (P = 0.146) or tumor margin (0.914) between the groups. CONCLUSION: Patients who undergo tissue expander/implant breast reconstruction with final implants that are larger in volume than their native breasts have increased patient satisfaction scores in several categories without increase in complication rate or difference in tumor margin. There is a positive linear relationship between percent change and patient satisfaction.

Asunto(s)

Implantación de Mama/métodos , Mama/anatomía & histología , Mastectomía Subcutánea , Satisfacción del Paciente/estadística & datos numéricos , Expansión de Tejido/métodos , Adulto , Anciano , Mama/cirugía , Implantación de Mama/instrumentación , Implantes de Mama , Femenino , Humanos , Persona de Mediana Edad , Tamaño de los Órganos , Medición de Resultados Informados por el Paciente , Estudios Retrospectivos , Expansión de Tejido/instrumentación , Dispositivos de Expansión Tisular

RESUMEN

BACKGROUND: Recent studies have suggested that sentinel lymph node (SLN) biopsy is of limited value in desmoplastic melanoma. This study was performed to compare the rate of positive SLN biopsy in the Surveillance, Epidemiology, and End Results (SEER) database with that of a multi-institutional clinical trial and to investigate relevant prognostic factors in desmoplastic melanoma. STUDY DESIGN: Patients with desmoplastic melanoma ≥1.0 mm Breslow thickness, who underwent SLN biopsy in a multi-institutional prospective clinical trial, were combined with a single institution melanoma database (combined database) and compared with patients from the SEER database (1998 to 2009). Disease-free survival (DFS) and overall survival (OS) were summarized using Kaplan-Meier curves and compared using Cox proportional hazard models. RESULTS: The rate of positive SLN in the combined database was 17.0% (8 of 47). By comparison, the rate of positive SLN in SEER was lower: 2.5% (15 of 594). On multivariable analysis, Breslow thickness ≥2.6 mm (hazard ratio 8.17, 95% CI 1.26 to 160.1; p = 0.0259) and an interaction between SLN status and ulceration (p = 0.0013) were independent risk factors for worse OS in the combined database; patients with ulceration and a positive SLN had significantly worse OS. In the combined database on multivariable analysis, SLN positivity (p = 0.0161) and ulceration (p = 0.0004) were independent risk factors for worse DFS. CONCLUSIONS: The rate of positive SLN in desmoplastic melanoma may be higher than that reported in the SEER database. Sentinel lymph node biopsy may be considered as part of the comprehensive staging of desmoplastic melanoma ≥1.0 mm Breslow thickness.

Asunto(s)

Melanoma/patología , Biopsia del Ganglio Linfático Centinela , Neoplasias Cutáneas/patología , Adulto , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Humanos , Metástasis Linfática , Masculino , Melanoma/mortalidad , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Programa de VERF , Neoplasias Cutáneas/mortalidad , Análisis de Supervivencia , Estados Unidos/epidemiología

RESUMEN

The ruptured hypogastric artery aneurysm (RHAA) is a rare clinical entity with an evolving and dynamic therapeutic armamentarium. The anatomical location and varied clinical presentation can pose a challenge for successful repair. Recently, endovascular and hybrid operative repairs have significantly improved the historically high-operative mortality rate. We present an illustrative case and contemporary review of the literature with respect to RHAA.

Asunto(s)

Aneurisma Roto , Pelvis/irrigación sanguínea , Anciano , Anciano de 80 o más Años , Aneurisma Roto/diagnóstico , Aneurisma Roto/epidemiología , Aneurisma Roto/terapia , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Tomografía Computarizada por Rayos X , Resultado del Tratamiento

RESUMEN

Locking reconstruction plates have led to significant improvement in osteosynthesis and graft anchorage in mandibular reconstruction following the free fibula osteocutaneous flap. Plate extrusion is the most common complication associated with mandibular reconstruction, occurring in approximately 20% to 48% of cases; often necessitating plate removal once the bone flap has united to the mandible. Radiation therapy is a known risk factor to the development of such a complication and it presents further challenges to the successful removal of the reconstruction plate. Several reports have been published regarding plate removal in the setting of orthopedics that describe the management of jammed or stripped locking screws, but few in the setting of mandibular reconstruction. In this case, we report the successful removal of an exposed titanium mandibular reconstruction plate from a 41-year-old woman 12 months after her initial reconstruction with a free fibula osteocutaneous flap and radiation therapy. The approach was selected because the chin and neck skin could not be expected to be raised for full plate exposure secondary to radiation-induced skin changes (thinning and friability). We also discuss the use of previously employed methods of plate removal in various settings as well as their inherent strengths and weaknesses.

RESUMEN

No report to date describes the added risk traumatic, degloving injuries of the oral cavity may pose when treating fractures of the mandible. The authors describe the oral degloving injury, characterized by separation of periosteum and soft tissue of the anterior floor of the mouth from the inner cortex of the anterior segment. Vascular anatomy of the floor of the mouth is reviewed as a prelude to a description of pathomechanics of the injury and a case report. The higher incidence of oral degloving in youth and in young adulthood and parallels in elective, orthognathic surgery are identified. When this unusual clinical presentation occurs, and when open reduction of fractures of the anterior segment is chosen, a vestibular incision is best avoided. Instead, a submental or upper neck incision is chosen for sufficient exposure to allow reduction and the application of appliances. Meticulous closure of the intraoral void is achieved using one of two techniques, depending on the level of degloving.