Full-Thickness Chemical Burn From Trifluoroacetic Acid: A Case Report and Review of the Literature
ANNALS OF PLASTIC SURGERY
2018; 81 (5): 528–30
Trifluoroacetic acid (TFA) burns are an ill-defined entity due to a lack of reported sizable burns from this chemical. In this case report of the largest reported burn from TFA, we demonstrate that TFA causes extensive, progressive full-thickness tissue injury that may initially appear superficial. Trifluoroacetic acid does not seem to involve the systemic toxicities that result from hydrofluoric acid burns, and there is no role for calcium gluconate in acute management based on this case. Operative intervention should be staged because wound beds may initially seem healthy yet demonstrate continued necrosis.
View details for DOI 10.1097/SAP.0000000000001579
View details for Web of Science ID 000447899600005
View details for PubMedID 30059387
Trends and inpatient outcomes for palliative care services in major burn patients: A 10-year analysis of the nationwide inpatient sample.
Burns : journal of the International Society for Burn Injuries
INTRODUCTION: Despite advances in critical care and the surgical management of major burns, highly moribund patients are unlikely to survive. Little is known regarding the utilization and effects of palliative care services in this population.METHODS: All major burn hospitalizations were identified within the Nationwide Inpatient Sample. Patients were characterized by burn, demographic, facility, and diseases factors. Palliative care services were identified with International Classification Disease 9th edition code V6.67. Temporal trends were assessed with Poisson modeling. Inpatient mortality and death without surgical intervention were assessed with logistic regression. Outcomes were stratified by modified Baux scores.RESULTS: 7424 major burns were included; 1.9% received palliative care services. Patients receiving palliation had a mean age of 63.6 years (SD 19.6), mean total body surface area of 62.2% (SD 24.9%), and mean modified Baux score of 127.1 (SD 26.7). Adjusting for covariates, the incidence rate ratio was 1.42 over the 10-year period (95% CI, 1.31-1.54, p<0.001). Independent predictors of palliative consultations included older age, larger burns, deeper burns, and higher Elixhauser comorbidity score. Among patients with modified Baux scores between 100-153, those receiving palliative care services were significantly more likely to die without surgery, OR 3.24 (95% CI 1.13-10.39, p=0.029), with no significant difference in mortality, OR 11.72 (95% CI 0.87-22.57, p=0.051) CONCLUSION AND RELEVANCE: Palliative care services were increasingly used during the study period. Palliative care services in highly moribund burn patients do not impact survival and may decrease the likelihood of surgical intervention in select patients.
View details for DOI 10.1016/j.burns.2018.07.012
View details for PubMedID 30115531
Deepithelialized Skin Reduction Preserves Skin and Nipple Perfusion in Immediate Reconstruction of Large and Ptotic Breasts.
Annals of plastic surgery
BACKGROUND: Women with large and/or ptotic breasts are often not considered candidates for nipple-sparing mastectomy (NSM) and/or immediate breast reconstruction given difficulties avoiding ischemic complications and achieving a favorable aesthetic result. We report a novel technique involving deepithelialized skin reduction to simultaneously reduce the skin envelope and preserve perfusion to the skin and nipple in immediate breast reconstruction for women that fit this high-risk anatomic profile.METHODS: We reviewed cases of NSM and skin-sparing mastectomy (SSM) with immediate implant-based and free autologous reconstruction by a single plastic surgeon from 2013 to 2017. All patients had at least size C cup breasts (>500 g) and/or grade 3 ptosis. Select patients undergoing NSM had devascularization of the nipple-areolar complex (NAC) 1 to 2 months before surgery to promote adaptive circulatory change. After mastectomy, skin reductions were performed via Wise, periareolar, or circumareolar reduction patterns, with infolding of a deepithelialized inferior and periareolar skin flap over a tissue expander or free flap. In NSM, the nipple was advanced superiorly and redirected through a keyhole of deepithelialized skin flap.RESULTS: Patients had an average age of 43.6 years and body mass index of 27.7. A total of 33 breasts in 19 patients (14 bilateral, 5 unilateral) underwent deepithelialized skin reduction. There were 14 NSM and 19 SSM. Reconstructions consisted of 13 tissue expanders exchanged to implants and 20 abdominally-based free flaps. Four patients underwent devascularization of the NAC before NSM. Six (18%) breasts had partial thickness flap loss that healed by delayed primary (n = 1) or secondary (n = 5) intention. Four nipples, all in patients without prior NAC devascularization, had ischemic complications (2 epidermolysis, 12.5%; 2 partial necrosis, 12.5%), which all healed by secondary intention with the exception of 1 case of NAC removal.CONCLUSIONS: Skin reduction with deepithelialization and tissue infolding preserves dermal plexus perfusion and promotes nipple and skin flap survival in immediate implant-based and autologous breast reconstruction after SSM and NSM. This technique can be combined with NAC devascularization to further promote nipple perfusion. Overall, this method offers an acceptable complication rate and the potential to expand the reconstructive options available to women with large and/or ptotic breasts.
View details for DOI 10.1097/SAP.0000000000001427
View details for PubMedID 29746276
Intensive Care Unit Monitoring After Pharyngeal Flap Surgery: Is It Necessary?
Journal of oral and maxillofacial surgery
To assess the incidence of perioperative complications and the utility of intensive care monitoring in patients undergoing posterior pharyngeal flap surgery for velopharyngeal dysfunction (VPD).This study was a retrospective evaluation of patients who underwent posterior pharyngeal flap surgery for treatment of VPD and an assessment of the incidence of perioperative complications. Descriptive statistics were computed.Over an 18-year period, 145 patients underwent pharyngeal flap surgery for VPD; 133 (91.7%) had complete data and were included as subjects. Mean patient age was 9.4 ± 7.4 years; 50.4% were female. One hundred twenty-six patients (94.7%) had a history of cleft palate. Thirty-four patients (25.5%) had asthma or obstructive sleep apnea. Eighty-three patients (62.4%) were admitted to the intensive care unit (ICU) for postoperative monitoring. The average length of hospital stay was 1.9 ± 0.9 days (range, 1 to 5 days). There were no incidents of serious postoperative complications, including death, bleeding, flap dehiscence or loss, or airway compromise requiring reintubation. Two patients (1.5%) had perioperative complications related to respiratory issues, one of whom required readmission to the ICU (0.8%). There were no differences in complications between those who were routinely admitted to the ICU and those who went directly to the floor (P = 1.00). There was no association between respiratory comorbidities and complications (P = .06).The perioperative complication rate for posterior pharyngeal flap surgery is low (<2%). Routine ICU admission for monitoring is not necessary.
View details for DOI 10.1016/j.joms.2016.11.010
View details for PubMedID 28011323
Protecting Nipple Perfusion by Devascularization and Surgical Delay in Patients at Risk for Ischemic Complications During Nipple-Sparing Mastectomies
ANNALS OF SURGICAL ONCOLOGY
2016; 23 (8): 2665-2672
Indications for nipple-sparing mastectomy (NSM) are expanding; however, high-risk patients have more ischemic complications. Surgical devascularization of the nipple-areolar complex (NAC) prior to NSM can reduce complications. This study reports perfusion patterns and complications in high-risk patients undergoing 2-stage NSM.Surgical devascularization of the NAC was performed 3-6 weeks prior to NSM in 28 women. Risk factors included ptosis, obesity, smoking, prior breast surgery, and radiation. Using indocyanine green (ICG)-based fluorescence and an infrared camera, blood inflow was visualized intraoperatively. NAC perfusion patterns were classified as: V1, underlying breast; V2, surrounding skin; V3 = V1 + V2, or V4, capillary fill following devascularization. Ischemic complications were analyzed.Baseline perfusion for 54 breasts was 35 % V1, 32 % V2, and 33 % V3. Increasing ptosis was associated with V1 pattern: 86 % for grade 3, 31 % for grade 2, and 18 % for grade 1. Postdevascularization epidermolysis was observed in 63 % of V1 baseline, 41 % of V2, and 22 % of V3 (P = .042) and after NSM in 26 % for V1, 7 % for V2, and 6 % for V3 (P = .131). Ptosis was significantly associated with epidermolysis postdevascularization (P = .002) and NSM (P = .002). Smoking and BMI ≥30 were related to increased ischemic complications. Two or more risk factors were associated with postdevascularization ischemic changes (P = .026), but were not significant after NSM. Nipple loss was not observed, but 2 patients underwent partial areolar resection.Adaptive circulatory changes after devascularization allow tissues to tolerate the additional ischemic challenge of mastectomy. Our findings support extending 2-staged operations to high-risk women previously considered unsuitable for NSM.
View details for DOI 10.1245/s10434-016-5201-8
View details for Web of Science ID 000379189900044
View details for PubMedID 27038458
Breast Augmentation and Breast Reconstruction Demonstrate Equivalent Aesthetic Outcomes.
Plastic and reconstructive surgery. Global open
2016; 4 (7)
There is a perception that cosmetic breast surgery has more favorable aesthetic outcomes than reconstructive breast surgery. We tested this hypothesis by comparing aesthetic outcomes after breast augmentation and reconstruction.Postoperative images of 10 patients (cosmetic, n = 4; reconstructive, n = 6; mean follow-up, 27 months) were presented anonymously to participants who were blinded to clinical details. Participants were asked if they believed cosmetic or reconstructive surgery had been performed. Aesthetic outcome measures were quantified: (1) natural appearance, (2) size, (3) contour, (4) symmetry, (5) position of breasts, (6) position of nipples, (7) scars (1 = poor and 4 = excellent). Images were ranked from 1 (most aesthetic) to 10 (least aesthetic). Analyses included two-tailed t tests, Mann-Whitney U tests, and χ(2) tests.One thousand eighty-five images were quantified from 110 surveys (99% response rate). The accuracy of identifying cosmetic or reconstructive surgery was 55% and 59%, respectively (P = 0.18). Significantly more of the top 3 aesthetic cases were reconstructive (51% vs 49%; P = 0.03). Despite this, cases perceived to be reconstructive were ranked significantly lower (5.9 vs 5.0; P < 0.0001). Mean aesthetic outcomes were equivalent regardless of surgery for 5 categories (P > 0.05), with the exception of breast position that improved after reconstruction (2.9 vs 2.7; P = 0.009) and scars that were more favorable after augmentation (2.9 vs 3.1; P < 0.0001). Age and nipple position (R (2) = 0.04; P = 0.03) was the only association between a demographic factor and aesthetic outcome.Aesthetic outcomes after cosmetic and reconstructive breast surgery are broadly equivalent, though preconceptions influence aesthetic opinion. Plastic surgeons' mutually inclusive-reconstructive and aesthetic skill set maximizes aesthetic outcomes.
View details for DOI 10.1097/GOX.0000000000000824
View details for PubMedID 27536490
View details for PubMedCentralID PMC4977139