Faculty Bibliography

OBJECTIVE: The purpose of the study was to assess the results and morbidity associated with simultaneous bilateral TRAM free flap breast reconstruction and describe refinements in its surgical technique. SUMMARY BACKGROUND DATA: Bilateral prophylactic total mastectomies might be an agreeable option for those patients at highest risk for breast cancer if autogenous tissue breast reconstruction could be performed with reasonable technical ease and acceptable morbidity. However, some surgeons harbor reservations regarding the extensiveness of the surgery, the associated morbidity, and the aesthetic quality of the resulting outcome. METHODS: A multicenter retrospective review of clinical experience with 120 consecutive patients who underwent 240 simultaneous bilateral TRAM free flap breast reconstructions was developed. RESULTS: The average operating time, including the time required for the breast ablative portion of the procedures, was 8.6 hours. The average length of hospitalization was 7.6 days. However, for the last 40 patients, these figures were reduced to 7.1 hours and 6.1 days, respectively. Nonautologous blood transfusions were needed in 33 cases (28%), but only 1 was required in the last 40 patients. Thromboses developed in six of 240 flaps (2.5%): 4 were arterial and 2 were venous. Re-exploration allowed us to restore circulation in five flaps, whereas one flap was unsalvageable and was replaced successfully with an alternate flap. An uncomplicated deep vein thromboses developed in one patient with a history of recurrent deep vein thromboses that had no adverse effect on her outcome. Minor complications developed in 18 patients (15%) (e.g., hematoma, partial wound necrosis, wound infection, or prolonged postoperative ileus) that did not affect the long-term outcome. Fourteen patients (11.6%) had abdominal wall weakness or hernias. Follow-up time averaged 37.2 months (range, 14-62 months). On last follow-up, patients' self-reported overall satisfaction with the procedure was 56% excellent, 40% good, and 4% fair.CONCLUSIONS: Simultaneous bilateral free flap reconstruction is technically feasible with a high rate of success and an acceptable morbidity. When performed by experienced surgeons, bilateral prophylactic total mastectomies combined with simultaneous bilateral TRAM free flap reconstruction may provide an adequate surgical option with aesthetically acceptable results for patients at high risk for breast cancer

Of 114 patients who had TRAM flap breast reconstruction, 46 (40 percent) had preexisting abdominal surgical scars. Sixty-six free TRAM flaps and 9 pedicled TRAM flaps were performed in the 46 patients. The records were analyzed to determine what impact, if any, abdominal scars had on postoperative complications. There were no reconstructive failures or significant (>25 percent) flap losses. Eight minor complications occurred in 7 patients (15 percent). The incidences of abdominal-wall weakness (4.3 percent), partial flap loss (4.3 percent), minor fat necrosis (4.3 percent), and donor-site wound problems (4.3 percent) were acceptable. Subcostal scars and multiple abdominal scars were found to predispose to skin complications. Right lower paramedian scars precluded free TRAM flaps because of damage to the inferior epigastric vessels in three of three patients. Both obesity (p = 0.003) and smoking (p = 0.05) were associated with a greater risk of wound-healing complications. We conclude that with certain technical modifications, TRAM flap reconstruction is a safe and effective procedure in patients with abdominal scars

This study was undertaken to analyze the effects of significant hyperthermia (> 100 degrees C) associated with the polymerization of polymethlymethacrylate (PMM) on the permeability of the cerebral vasculature in rats. The method used to visualize the pial vasculature included the open pial window technique and epifluorescence microscopy. Results indicated that there is a significant increase in cerebral vascular permeability following in situ polymerization of PMM over the craniectomy site

STUDY OBJECTIVE: To determine the efficacy of lumbar intrathecal (i.t.) morphine in a dose of 0.02 mg/kg in providing analgesia following repair of frontal encephaloceles. DESIGN: Prospective, open-label investigation of i.t. morphine with secondary comparison to a retrospective cohort. SETTING: Metropolitan hospital in the Philippines. PATIENTS: 24 ASA physical status I and II children undergoing frontal encephalocele repair. INTERVENTIONS: Following induction of general anesthesia. I.t. morphine (Group 1) was administered via single-shot technique or through a lumbar i.t. drain placed for cerebrospinal fluid drainage during the surgical procedure. Postoperative analgesia was assessed by visual analog score in patients greater than 5 years of age or a behavioral score in patients less than 5 years of age. The retrospective cohort received postoperative analgesia with intermittent doses of intravenous nalbuphine (Group 2). MEASUREMENTS AND MAIN RESULTS: Group 1 had decreased postoperative analgesic requirements, decreased intraoperative inhalational anesthetic requirements, and a longer time to the first request for postoperative analgesia than Group 2. The time to the first request for postoperative analgesia was 16.0 +/- 9.1 hours in Group 1 and 1.6 +/- 1.2 hours in Group 2 (p < 0.0001). Six of 12 patients in Group 1 required no analgesic drugs during the first 24 postoperative hours while all 12 patients in Group 2 (p = 0.02) did require analgesic drugs during this period. The patients in Group 1 who did not require supplemental analgesic drugs maintained pain scores of 2 or less throughout the first 24 postoperative hours. CONCLUSION: Lumbar IT morphine provides effective analgesia following repair of frontal encephaloceles in children and adolescents

Lengthening of the canine mandible using an intraoral distraction device was performed in order to study the effects of distraction on the associated muscles of mastication. Biopsies of the masseter and digastric muscles were taken after lengthening at four different time intervals to assess the temporal changes in the masticatory muscles of 10 dogs. Biopsies of the muscles on the contralateral side also were taken from 6 of these dogs before lengthening to establish a control group. Each biopsy was analyzed histologically and spectophotomerically for RNA, DNA and protein content. The digastric muscle underwent transient atrophy with initiation of distraction but regenerated completely after 48 days of fixation. The masseter muscle was unchanged initially but showed evidence of atrophy only after 20 mm of distraction it continued to exhibit evidence of atrophy during fixation. Protein synthesis was decreased significantly during periods of atrophy in the masseter; no such change was noted in the digastric. Unlike the masseter, the digastric fibers lie in a plane parallel to the vector of distraction. These findings suggest that any muscle affected by skeletal distraction in the same plane or vector (e.g., digastric) adapts with compensatory regeneration and hypertrophy. Moreover, those muscles lying in a different plane (e.g., masseter) show persistent evidence of atrophy with decreased protein synthesis

The purpose of this study was to evaluate the application of bioabsorbable fixation devices in reconstructive craniofacial procedures in the pediatric population. We reviewed 22 cases in which bioabsorbable plates and screws were used in craniofacial surgery for reconstruction. The procedures were performed in a 7-month period. The patients ranged in age from 5 to 228 months at the time of surgery (mean, 76.7 months). The postoperative clinical follow-up ranged from 2 to 16 weeks. The fixation devices were evaluated with regards to satisfactory fixation at the time of procedure. The postoperative follow-up evaluated clinical wound healing, signs of infection or local inflammation, and visibility or palpability of plates through the skin. All patients except one showed satisfactory wound healing with no sign of infection or local inflammation. The plates provided satisfactory fixation and were not visible through the skin. Two patients had plates that were palpable at the 4-month follow-up period. One patient with repair of a blow-out fracture of the orbit with resorbable mesh had redness and swelling over the wound site 2 weeks postoperatively with resolution 4 weeks postoperatively. Our early experience suggests reabsorbable fixation is an attractive option in pediatric plastic and craniofacial surgery. With further experience, this technology may represent the standard of care in reconstruction of the infant calvarium