Capsular contracture is a common adverse outcome following implant breast reconstruction, often associated with radiation treatment. The authors hypothesize that muscle fibrosis is the main ...contributor of breast reconstruction contracture after radiation. Retrospective chart review identified patients that underwent DTI reconstruction with pre-or post-operative breast irradiation. Signs of capsular contracture were assessed using clinic notes and independent graders reviewing two-dimensional images and anatomic landmarks. Capsular contracture rate was greater in the subpectoral vs. prepectoral group (n = 28, 51.8% vs. n = 12, 30.0%, p = 0.02). When compared to prepectoral DTI reconstruction in irradiated patients, subpectoral implant placement was nearly 4 times as likely to result in capsular contracture (p < 0.01). Rates of explantation, infection, tissue necrosis, and hematoma were comparable between groups. We also found that when subpectoral patients present with breast contracture, chemoparalysis of the muscle alone can resolve breast asymmetry, corroborating that muscle is a key contributor to breast contracture. As prepectoral breast reconstruction is gaining popularity, there have been questions regarding outcome following radiation treatment. This study suggest that prepectoral breast reconstruction is safe in an irradiated patient population, and in fact compares favorably with regard to breast contracture.
Preparedness measures for the anticipated surge of coronavirus disease 2019 (COVID-19) cases within eastern Massachusetts included the establishment of alternate care sites (field hospitals). Boston ...Hope hospital was set up within the Boston Convention and Exhibition Center to provide low-acuity care for COVID-19 patients and to support local healthcare systems. However, early recognition of the need to provide higher levels of care, or critical care for the potential deterioration of patients recovering from COVID-19, prompted the development of a hybrid acute care–intensive care unit. We describe our experience of implementing rapid response capabilities of this innovative ad hoc unit. Combining quality improvement tools for hazards detection and testing through in situ simulation successfully identified several operational hurdles. Through rapid continuous analysis and iterative change, we implemented appropriate mitigation strategies and established rapid response and rescue capabilities. This study provides a framework for future planning of high-acuity services within a unique field hospital setting.
The present moment is not the first time that America has found itself at war with a pathogen during a time of international conflict. Between crowded barracks at home and trenches abroad, wartime ...conditions helped enable the spread of influenza in the fall of 1918 during World War I such that an estimated 20-40% of U.S. military members were infected. While the coronavirus disease 2019 (COVID-19) pandemic is unparalleled for most of today's population, it is essential to not view it as unprecedented lest the lessons of past pandemics and their effect on the American military be forgotten. This article provides a historical perspective on the effect of the most notable antecedent pandemic, the Spanish Influenza epidemic, on American forces with the goal of understanding the interrelationship of global pandemics and the military, highlighting the unique challenges of the current pandemic, and examining how the American military has fought back against pandemics both at home and abroad, both 100 years ago and today.
OBJECTIVE:We describe the first successful penis transplant in the United States in a patient with a history of subtotal penectomy for penile cancer.
BACKGROUND:Penis transplantation represents a new ...paradigm in restoring anatomic appearance, urine conduit, and sexual function after genitourinary tissue loss. To date, only 2 penis transplants have been performed worldwide.
METHODS:After institutional review board approval, extensive medical, surgical, and radiological evaluations of the patient were performed. His candidacy was reviewed by a multidisciplinary team of surgeons, physicians, psychiatrists, social workers, and nurse coordinators. After appropriate donor identification and recipient induction with antithymocyte globulin, allograft procurement and recipient preparation took place concurrently. Anastomoses of the urethra, corpora, cavernosal and dorsal arteries, dorsal vein, and dorsal nerves were performed, and also inclusion of a donor skin pedicle as the composite allograft. Maintenance immunosuppression consisted of mycophenolate mofetil, tacrolimus, and methylprednisolone.
RESULTS:Intraoperative, the allograft had excellent capillary refill and strong Doppler signals after revascularization. Operative reinterventions on postoperative days (PODs) 2 and 13 were required for hematoma evacuation and skin eschar debridement. At 3 weeks, no anastomotic leaks were detected on urethrogram, and the catheter was removed. Steroid resistant-rejection developed on POD 28 (Banff I), progressed by POD 32 (Banff III), and required a repeat course of methylprednisolone and antithymocyte globulin. At 7 months, the patient has recovered partial sensation of the penile shaft and has spontaneous penile tumescence. Our patient reports increased overall health satisfaction, dramatic improvement of self-image, and optimism for the future.
CONCLUSIONS:We have shown that it is feasible to perform penile transplantation with excellent results. Furthermore, this experience demonstrates that penile transplantation can be successfully performed with conventional immunosuppression. We propose that our successful penile transplantation pilot experience represents a proof of concept for an evolution in reconstructive transplantation.
Preputial Grafts: The Forgotten Donor Site Ehrlichman, Richard J; Driscoll, Daniel N; Cornejo, Kristine ...
Annals of plastic surgery,
2018-December, 2018-12-00, 20181201, Volume:
81, Issue:
6
Journal Article
Peer reviewed
BACKGROUNDThe prepuce is an excellent donor site for skin grafts with minimal donor site morbidity. Full-thickness grafts are often required for correction of congenital syndactyly and in burn ...contractures.
METHODSPreputial skin was used for grafting in 18 children5 with burn contractures and 13 with congenital syndactyly.
RESULTSExcellent graft take was achieved with appropriate postoperative care. Postoperatively, there were occasional milia (42%) and hyperpigmentation. These grafts were noted to have superior mobility and elasticity. There was no donor site morbidity.
CONCLUSIONSPreputial skin is accessible, easy to harvest, and hairless and has minimal donor site morbidity. It is especially well suited for the hands and fingers when elasticity of the graft is beneficial.
Abstract
Periorbital burns generate contraction and distortion of periorbital soft tissue, causing eyelid malfunction, further contributing to loss of vision from corneal scarring or perforation. We ...present our multidisciplinary algorithm to restore vision in patients with burn-related bilateral corneal blindness with light perception. Chart review was performed for four consecutive burn patients requiring periocular reconstruction and keratoprosthesis. Initial treatment included globe coverage with eyelid releases and grafts. Strategy of corneal replacement was determined by eyelid position and function and sufficiency of tear production. All patients were corneal blind with light perception only and cicatricial ectropion. The eye with better visual prognosis was reconstructed. Eyelid reconstruction procedures consisted of lid releases with full-thickness skin graft (FTSG) or split-thickness skin graft (STSG). Two patients regained adequate lid function and underwent standard keratoprosthesis placement. Two underwent mucous membrane grafts followed by keratoprosthesis. All patients experienced improved postoperative vision in their reconstructed eye. Corneal injury due to periocular burns can lead to blindness. Early involvement of ophthalmology, protective measures, and early ectropion release are critical. For severe burns, a multidisciplinary approach, where adequate globe protection is followed by keratoprosthesis placement, can effectively restore vision in patients with burn-related corneal blindness.
Abstract
Introduction
The ear is one of the most highly visible structures on the face. One or both ears are frequently involved in panfacial burns. Because they are bilateral structures, asymmetries ...are clearly visible. Reconstruction of burned ear deformity often requires replacement or modification of skin and/or cartilage. Even these are successfully replaced, scar contractile forces can cause deformation of the ear. One of these deformities is lop or cup ear, in which the helical rim is either folded over, wrinkled or tight. We describe the necessity of applying otoplasty techniques to address this problem.
Methods
A retrospective chart review analysis was performed to assess demographic variables, procedural indications and procedural outcomes in pediatric patients treated at our hospital for complex ear reconstruction for ear deformities after her surgery. Inclusion criteria were pediatric patients aged 0 to 21 years admitted to Shriners Hospital for Children-Boston from January 1, 2010 to January 1, 2021 for burn injury, who subsequently required follow-up complex ear reconstruction for ear deformities after burn injury. Of these patients, those with lop ear deformities who required construction were examined. Using the Trauma Registry of the American College of Surgeons (TRACS) and Shriners Hospital for Children Information Source (SHCIS) databases, we identified 12 eligible patients. Surgical procedure data was obtained from the SHCIS electronic medical records. Surgical photographs were obtained with patient informed consent. Those patients who required Medpor or cartilage frame reconstructions were excluded.
Results
12 patients required an otoplasty-type procedure to obtain desired results or symmetry with the contralateral ear. This technique involved a posterior incision in the auriculomastoidmastoid sulcus, are you a year and cartilage modification with sutures to to re-create the antihelical fold an superior crus as well as conchal setback sutures.
Conclusions
Because ears are bilateral structures, symmetry is extremely poor. Because of multiple contractile forces on the external ear from secondary healing or contraction of skin grafts, the ear is often displaced anteriorly and the upper portions become folded. Treatment requires reconstruction of the natural folds of the ear and shortening of the helical rim to mastoid distance. this requires an otoplasty approach with a posterior incision,, exposure of the cartilaginous framework and modification of the cartilage with incisions and sutures. This technique however requires adequate soft tissue coverage of the ear.
Abstract
Introduction
The breast and anterior chest are the most commonly burned part of the trunk. Burn injuries to the breast can be associated with pain, asymmetries, and significant social ...stigma. Burns to the breast bud in the young female may inhibit normal breast development, and result in either significant asymmetries or amastia, making the treatment of breast burn injuries challenging.
Methods
A retrospective chart review was conducted on all female patients under the age of 21 years admitted to our institution for breast burn injuries from January 1st 2008 – December 30th 2018.This project was undertaken at our institution as an exempt project under 45 CFR 46.101 and, as such, it was not formally supervised by an Institutional Review Board. Patients were included if they had follow-up reconstructive procedures for breast burn injuries many days after their acute phase treatment.
Results
Ninety-six patients aged 1 to 20 years have been admitted to our institution with burned breast injuries. The mean age of this cohort (n=96) was 6.4 ±4.8 years with a mean percent TBSA of 36.3 ±21.4 and a mean time since injury from admission of 2279.1 ±2284.1 days. Flame burns (66.8%) were the most common etiology for breast burn injuries, followed by scald burns (22.8%), in this cohort. The mean body mass index was 22.7 ±6.3 kg/m2. Follow up for reconstructive procedures was 7.2 ±5.6 years after injury date.
Conclusions
Our institution’s ten-year experience of 96 female patients with severe burn injuries has enhanced our understanding of reconstructive techniques. The location, size, anatomic extent, type of deformity, and symmetry must all be assessed before any treatment plans, which may need to include a combination of modalities.
Applicability of Research to Practice
Most importantly, surgeons must preserve viable breast bud tissue during debridement. Scar contractures should be released once there are signs of breast development, and the scar contracture significantly impairs normal breast development. Treatment of these contractures with a combination of release and grafting, local flaps or tissue expansion can reduce breast asymmetry. Reduction mammoplasty may be used safely in burned female patients with minimal risks, if key principles are followed.
Ketamine Modulates Theta and Gamma Oscillations Lazarewicz, Maciej T.; Ehrlichman, Richard S.; Maxwell, Christina R. ...
Journal of cognitive neuroscience,
07/2010, Volume:
22, Issue:
7
Journal Article
Peer reviewed
Open access
Ketamine, an
-methyl-
-aspartate (NMDA) receptor glutamatergic antagonist, has been studied as a model of schizophrenia when applied in subanesthetic doses. In EEG studies, ketamine affects sensory ...gating and alters the oscillatory characteristics of neuronal signals in a complex manner. We investigated the effects of ketamine on in vivo recordings from the CA3 region of mouse hippocampus referenced to the ipsilateral frontal sinus using a paired-click auditory gating paradigm. One issue of particular interest was elucidating the effect of ketamine on background network activity, poststimulus evoked and induced activity. We find that ketamine attenuates the theta frequency band in both background activity and in poststimulus evoked activity. Ketamine also disrupts a late, poststimulus theta power reduction seen in control recordings. In the gamma frequency range, ketamine enhances both background and evoked power, but decreases relative induced power. These findings support a role for NMDA receptors in mediating the balance between theta and gamma responses to sensory stimuli, with possible implications for dysfunction in schizophrenia.
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