Faculty Bibliography

The lack of adequate recipient vessels often complicates microvascular breast reconstruction in patients who have previously undergone mastectomy and irradiation. In addition, significant size mismatch, particularly in the outflow veins, is an important contributor to vessel thrombosis and flap failure. The purpose of this study was to review the authors' experience with alternative venous outflow vessels for microvascular breast reconstruction. In a retrospective analysis of 1278 microvascular breast reconstructions performed over a 10-year period, the authors identified all patients in whom the external jugular or cephalic veins were used as the outflow vessels. Patient demographics, flap choice, the reasons for the use of alternative venous drainage vessels, and the incidence of microsurgical complications were analyzed. The external jugular was used in 23 flaps performed in procedures with 22 patients. The superior gluteal and transverse rectus abdominis musculocutaneous (TRAM) flaps were used in the majority of the cases in which the external jugular vein was used (72 percent gluteal, 20 percent TRAM flap). The need for alternative venous outflow vessels was usually due to a significant vessel size mismatch between the superior gluteal and internal mammary veins (74 percent). For three of the external jugular vein flaps (13 percent), the vein was used for salvage after the primary draining vein thrombosed, and two of three flaps in these cases were eventually salvaged. In three patients, the external jugular vein thrombosed, resulting in two flap losses, while the third was salvaged using the cephalic vein. A total of two flaps were lost in the external jugular vein group. The cephalic vein was used in 11 flaps (TRAM, 64.3 percent; superior gluteal, 35.7 percent) performed in 11 patients. In five patients (54.5 percent), the cephalic vein was used to salvage a flap after the primary draining vein thrombosed; the procedure was successful in four cases. In three patients, the cephalic vein thrombosed, resulting in two flap losses. One patient suffered a thrombosis after the cephalic vein was used to salvage a flap in which the external jugular vein was initially used, leading to flap loss, while a second patient experienced cephalic vein thrombosis on postoperative day 7 while carrying a heavy package. There was only one minor complication attributable to the harvest of the external jugular or cephalic vein (small neck hematoma that was aspirated), and the resultant scars were excellent. The external jugular and cephalic veins are important ancillary veins available for microvascular breast reconstruction. The dissection of these vessels is straightforward, and their use is well tolerated and highly successful.

Microvascular tissue transfer has become the gold standard for breast reconstruction. The primary drawback to these procedures is the technical expertise required for microsurgical anastomosis. This problem is compounded by the difficulties in the exposure of recipient vessels deep within the axilla. Previous techniques used for exposure of these vessels are difficult to setup, provide less than optimal exposure, and have been associated with brachial plexus injuries. The authors retrospectively review their experience using the pediatric OMNI retractor for exposure of recipient vessels during microvascular breast reconstruction. Patient demographics, flap choice, recipient vessels, the incidence of neuropraxia/brachial plexopathy, and microvascular complications were analyzed. Patients in whom more traditional methods of vessel exposure were used (ie, Gelpi retractors, arm positioning, fish hooks; 517 reconstructions in 392 patients) were compared with patients in whom vessel exposure was performed using the pediatric OMNI retractor (699 reconstructions in 571 patients). No differences were noted in comorbid conditions or the incidence of microvascular complications. However, the use of the pediatric OMNI was associated with a significant reduction in operative time in unilateral reconstructions (6:23 +/- 0.05 h vs 7:48 +/- 0.05 h; P <0.01) and decreased incidence of brachial plexus injury (0.17% vs 3.3%; P <0.01). The authors think the decreased neuropraxia rate is the result of better exposure afforded by the pediatric OMNI retractor, which improves exposure and eliminates the need for excessive arm abduction or awkward positioning during the dissection and anastomosis of axillary recipient vessels.

The incidence of breast cancer is increasing each year. Concomitantly, cosmetic breast augmentation has become the second most often performed cosmetic surgical procedure. As the augmented patient population ages, an increasing number of breast cancer cases among previously augmented women can be anticipated. The surgical treatment of these patients is controversial, with several questions remaining unanswered. Is breast conservation therapy feasible in this patient population and can these patients retain their implants? A retrospective review of all breast cancer patients with a history of previous augmentation mammaplasty who were treated at the Revlon/UCLA Breast Center between 1991 and 2001 was performed. During the study period, 58 patients were treated. Thirty patients (52 percent) were treated with a modified radical mastectomy with implant removal. Twenty-eight patients (48 percent) underwent breast conservation therapy, which consisted of lumpectomy, axillary lymph node dissection, and radiotherapy. Twenty-two of the patients who underwent breast conservation therapy initially retained their implants. Eleven of those 22 patients (50 percent) ultimately required completion mastectomies with implant removal because of implant complications (two patients), local recurrences (five patients), or the inability to obtain negative margins (four patients). Nine additional patients experienced complications resulting from their implants, including contracture, erosion, pain, and rupture. The data illustrate that breast conservation therapy with maintenance of the implant is not ideal for the majority of augmented patients. Breast conservation therapy with explantation and mastopexy might be appropriate for rare patients with large volumes of native breast tissue. Mastectomy with immediate reconstruction might be a more suitable choice for these patients.

We report on the response of medically refractory neuropathic trigeminal pain in three patients to intravenous administration of a combination of the kappa-partial agonist opioid nalbuphine and the opioid antagonist naloxone. Each of the three patients had developed a painful peripheral neuropathy as a complication of chemical or mechanical injury to the trigeminal nerve. Each patient had been tried on a number of analgesics, including mu-opioids, and had not gained relief or was not able to tolerate side effects of the medications. Pain intensity was measured for 3 h following drug administration using a 10 cm visual analog scale. All three patients reported marked decrease in pain following administration of the nalbuphine and naloxone combination. These findings suggest a novel approach to the management for neuropathic pain.

Previous breeding for the diet-induced obese (DIO) trait from outbred Sprague-Dawley rats produced a substrain with selection characteristics suggesting a polygenic mode of inheritance. To assess this issue further, selectively bred DIO male rats were crossed with obesity-resistant inbred Fischer F344 dams. Male offspring were crossed twice more against female F344 dams. The resultant N3 (F.DIO) rats were then inbred three more times. On low-fat chow, 10-wk-old male and female DIO rats weighed 86 and 59% more than respective F344 rats. By the N3 (F.DIO) generation, they were only 12 and 10% heavier, respectively. After three additional inbreeding cycles, chow-fed F.DIO males had an exaggerated insulin response to oral glucose compared with F344 rats. After 3 wk on a 31% fat (high-energy) diet, male N3 F.DIO rats gained 16-20% more carcass and adipose weight with 98% higher plasma leptin levels, whereas F.DIO females gained 36-54% more carcass and adipose weight with 130% higher leptin levels than comparable F344 rats. After three inbreeding cycles, F.DIO males still gained more weight on high-energy diet and developed a threefold greater insulin response to oral glucose than F344 males. Preservation of the DIO and glucose intolerance traits through successive backcrosses and inbreeding cycles to produce the F.DIO strain lends further support to the idea that they inherited in a polygenic fashion.

The overarching goal of this article is to make explicit the multiple pathways through which the built environment may potentially affect health and well-being. The loss of close collaboration between urban planning and public health professionals that characterized the post-World War II era has limited the design and implementation of effective interventions and policies that might translate into improved health for urban populations. First, we present a conceptual model that developed out of previous research called Social Determinants of Health and Environmental Health Promotion. Second, we review empirical research from both the urban planning and public health literature regarding the health effects of housing and housing interventions. And third, we wrestle with key challenges in conducting sound scientific research on connections between the built environment and health, namely: (1) the necessity of dealing with the possible health consequences of myriad public and private sector activities; (2) the lack of valid and reliable indicators of the built environment to monitor the health effects of urban planning and policy decisions, especially with regard to land use mix; and (3) the growth of the "megalopolis" or "super urban region" that requires analysis of health effects across state lines and in circumscribed areas within multiple states. We contend that to plan for healthy cities, we need to reinvigorate the historic link between urban planning and public health, and thereby conduct informed science to better guide effective public policy.

The authors invoke a population health perspective to assess the distribution of environmental hazards according to race/ethnicity, social class, age, gender, and sexuality and the implications of these hazards for health. The unequal burden of environmental hazards borne by African American, Native American, Latino, and Asian American/Pacific Islander communities and their relationship to well-documented racial/ethnic disparities in health have not been critically examined across all population groups, regions of the United States, and ages. The determinants of existing environmental inequities also require critical research attention. To ensure inclusiveness and fill important gaps, scientific evidence is needed on the health effects of the built environment as well as the natural environment, cities and suburbs as well as rural areas, and indoor as well as outdoor pollutants.