Grant Carlson - Academia.edu (original) (raw)

Papers by Grant Carlson

Plastic and Reconstructive Surgery, May 1, 2005

Combined defects of the skin, larynx, pharynx, and esophagus after central compartment exenterati... more Combined defects of the skin, larynx, pharynx, and esophagus after central compartment exenteration of the neck can be extremely difficult to reconstruct. The objective of this article is to evaluate reconstruction of the central compartment using a combination of free jejunal transfer for pharyngoesophageal reconstruction, together with regional deltopectoral flaps for tracheostomal reconstruction and cutaneous resurfacing. Myocutaneous flaps, such as pectoralis major and latissimus dorsi flaps, have been used previously for external coverage but can be bulky, causing obstruction of the tracheostoma. From 1995 to 2002, seven patients underwent reconstruction of the central compartment with seven jejunal and nine deltopectoral flaps. Five patients required resection for tracheostomal recurrence of squamous cell carcinoma, and two patients required resection for massive pharyngocutaneous fistulas. Flap survival, complications, and outcomes were evaluated retrospectively. The mean age of the patients was 68.7 years and the mean length of follow-up was 1.9 years. Overall free jejunal and deltopectoral flap survival was 100 percent, with no partial loss. All patients maintained an adequate airway with stomal patency. These complicated defects can be effectively repaired with free jejunal transfers to restore continuity of the alimentary tract and deltopectoral flaps to reconstruct the tracheostoma and surrounding cutaneous defects. The deltopectoral flap provides a large volume of well-vascularized tissue that provides reliable coverage of the newly reconstructed cervical esophagus and exposed major vessels following exenteration of the central compartment. Its thin, pliable nature allows suturing of the tracheal remnants to skin edges without tension and avoids intraluminal prolapse of excess soft tissues, thus maintaining stomal patency.

Annals of Plastic Surgery, Mar 1, 2001

This study provides a retrospective analysis of 60 patients who underwent thoracic reconstruction... more This study provides a retrospective analysis of 60 patients who underwent thoracic reconstruction with the omentum. Patients were identified by searching several databases to determine demographics, indications for surgery, operative technique, and postoperative course, including donor and recipient site morbidity. From January 1975 to May 2000, the authors harvested and transferred the omentum successfully (57 pedicled, 3 free) in 60 patients (mean age, 60 years; age range, 21-86 years) for sternal wound infections (N = 34), chest wall resections (N = 17), pectus deformities (N = 2), intrathoracic defects (N = 4), and breast reconstruction (N = 3). The omentum was used as a primary flap in 39 patients and as a salvage flap in 21 patients. Average operative time was 3.9 hours and average hospital stay was 34.3 days. Partial flap loss occurred in 7 patients, with no total flap failures. Morbidity included six abdominal wound infections and seven epigastric hernias. Mortality was 11.7%. The omentum can be harvested safely and used reliably to reconstruct varying thoracic wounds and defects. Specific indications from this series include osteoradionecrosis, chest wall tumors, massive sternal wounds, and refractory mediastinitis. Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: indications, complications, and results.

Breast Case, Mar 25, 2014

Giant fibroadenomas are rare breast masses that occur largely in a juvenile population. These tum... more Giant fibroadenomas are rare breast masses that occur largely in a juvenile population. These tumors are benign and clinically are very similar to phyllodes tumors of the breast. Given their extremely large size, giant fibroadenomas can cause significant breast disfigurement and be difficult to surgically treat. We present a case of a 12 year old who presented with a rapidly enlarging breast mass diagnosed as a juvenile fibroadenoma. She successfully underwent surgical excision through a periareolar incision and had satisfactory cosmetic results with no recurrences.

International Journal of Radiation Oncology Biology Physics, Dec 22, 2011

The safety and efficacy of skin-sparing mastectomy (SSM) with immediate reconstruction (IR) in pa... more The safety and efficacy of skin-sparing mastectomy (SSM) with immediate reconstruction (IR) in patients with locally advanced breast cancer are unclear. The purpose of this study is to compare the outcomes of women with noninflammatory Stage III SSM with IR vs. non-SSM-treated women who underwent neoadjuvant chemotherapy and adjuvant radiation therapy (XRT). Between October 1997 and March 2010, 100 consecutive patients (40 SSM with IR vs. 60 non-SSM) with Stage III breast cancer received anthracycline- and/or taxane-based neoadjuvant chemotherapy, mastectomy, and adjuvant XRT. Clinical stage (SSM with IR vs. for non-SSM) was IIIA (75% vs. 67%), IIIB (8% vs. 18%), and IIIC (8% vs. 8%). Tumors greater than 5 cm were found in 74% vs. 69%; 97% of patients in both groups were clinically node positive; and 8% vs. 18% had T4b disease. The time from initial biopsy to XRT was prolonged for SSM-IR patients (274 vs. 254 days, p = 0.04), and there was a trend toward XRT delay of more than 8 weeks (52% vs. 31%, p = 0.07) after surgery. The rate of complications requiring surgical intervention was higher in the SSM-IR group (37.5% vs. 5%, p < 0.001). The 2-year actuarial locoregional control, breast cancer-specific survival, and overall survival rates for SSM with IR vs. non-SSM were 94.7% vs. 97.4%, 91.5% vs. 86.3%, and 87.4% vs. 84.8%, respectively (p = not significant). In our small study with limited follow-up, SSM with IR prolonged overall cancer treatment time and trended toward delaying XRT but did not impair oncologic outcomes. Complication rates were significantly higher in this group. Longer follow-up is needed.

Annals of Plastic Surgery, Mar 1, 2011

Autologous fat grafting has become a common technique for revisional breast surgery. The purpose ... more Autologous fat grafting has become a common technique for revisional breast surgery. The purpose of this series is to review our experience with fat grafting for the correction of acquired breast deformities. A retrospective review was performed on 107 patients with a history of breast cancer between 1996 and 2010, who had autologous fat grafting at the time of secondary breast reconstruction. The indications were for improvement in contour, shape, and volume of the breast following transverse rectus abdominis myocutaneous (TRAM) flap reconstruction (n = 55), latissimus dorsi with or without implant (n = 20), implant reconstruction (n = 20), and breast conservation therapy deformity (n = 12). The average volume of injection was 40 mL (range, 5-150 mL), the most common location being upper and medial quadrants. Fat was harvested mainly from the abdomen, thighs, and flanks. Complications occurred in 11% of the patients, and included fat necrosis, erythema, keloid scarring, and pain. Complications were higher when performed with implant reconstructions. Repeat fat injection was performed in 25% (n = 27/107), which increased with the length of follow-up. Patients with a history of radiation therapy had an increased incidence of repeat injections (36% vs. 18%). Patients with >6 months follow-up reported an improvement of about 83%. Autologous fat grafting is a safe and effective tool for secondary breast reconstruction. It is helpful in all types of reconstructions to improve contour, volume, and overall breast shape and symmetry. Repeat injections are often required and this is more common in patients with longer follow-up and in those with a history of radiation therapy. The popularity of this approach in reconstructive breast surgery will likely continue to increase.

Annals of Plastic Surgery, Mar 1, 2011

Autologous fat grafting has become a common technique for revisional breast surgery. The purpose ... more Autologous fat grafting has become a common technique for revisional breast surgery. The purpose of this series is to review our experience with fat grafting for the correction of acquired breast deformities. A retrospective review was performed on 107 patients with a history of breast cancer between 1996 and 2010, who had autologous fat grafting at the time of secondary breast reconstruction. The indications were for improvement in contour, shape, and volume of the breast following transverse rectus abdominis myocutaneous (TRAM) flap reconstruction (n = 55), latissimus dorsi with or without implant (n = 20), implant reconstruction (n = 20), and breast conservation therapy deformity (n = 12). The average volume of injection was 40 mL (range, 5-150 mL), the most common location being upper and medial quadrants. Fat was harvested mainly from the abdomen, thighs, and flanks. Complications occurred in 11% of the patients, and included fat necrosis, erythema, keloid scarring, and pain. Complications were higher when performed with implant reconstructions. Repeat fat injection was performed in 25% (n = 27/107), which increased with the length of follow-up. Patients with a history of radiation therapy had an increased incidence of repeat injections (36% vs. 18%). Patients with >6 months follow-up reported an improvement of about 83%. Autologous fat grafting is a safe and effective tool for secondary breast reconstruction. It is helpful in all types of reconstructions to improve contour, volume, and overall breast shape and symmetry. Repeat injections are often required and this is more common in patients with longer follow-up and in those with a history of radiation therapy. The popularity of this approach in reconstructive breast surgery will likely continue to increase.

The American Surgeon, Mar 1, 2014

Malignant cutaneous adnexal tumors (MCATs) are rare neoplasms that do not have a well-studied tre... more Malignant cutaneous adnexal tumors (MCATs) are rare neoplasms that do not have a well-studied treatment algorithm. They are generally treated by excision alone. Given its successful application in other cutaneous malignancies, sentinel lymph node biopsy (SLNB) has been advocated by some for use in MCATs. A retrospective chart review was performed. Clinicopathological factors, recurrence patterns, and long-term follow-up were documented. Survival analysis was performed. Forty-eight subjects were identified. Mean age was 69 years with locations on the face (52%), including periocular sites (16%), extremities (25%), and all other sites (7%). Histologic distribution was sebaceous carcinoma (56%), porocarcinoma (17%), eccrine carcinoma (13%), adenocarcinoma (10%), and hidradenocarcinoma (4%). Mean follow-up was 3.9 years (range, 0 to 17 years). Nine subjects (18.8%) recurred locally, and recurrence was inversely associated with age (P = 0.04). Four (8.3%) demonstrated lymph node involvement, none without first developing local recurrence. Five-year disease-specific survival was 97 per cent (confidence interval, 81.4 to 99.6%). Despite being one of the largest reported analyses of MCATs, this study is limited by the small number of subjects. MCATs seemingly develop nodal recurrence only after demonstrating aggressive local biology. SLNB may best be applied selectively, possibly only in patients with local recurrence.

Annals of Plastic Surgery, Aug 1, 2002

The presence of a preexisting subcostal incision alters the approach to breast reconstruction and... more The presence of a preexisting subcostal incision alters the approach to breast reconstruction and is thought to predispose to donor site skin complications and flap loss. The purpose of this study was to determine whether the presence of a subcostal scar affects breast or donor site morbidity adversely after transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. Twenty-six patients with a right subcostal incision (group A) underwent TRAM flap breast reconstruction (13 immediate, 13 delayed). The average age was 51 years, and the patients had an average body mass index of 25.3. There were 15 right, 10 left, and 1 bilateral reconstruction (4 free flaps, 22 pedicled). Outcome measures were compared with 126 age- and risk-matched patients (group B) who underwent TRAM flap reconstruction without any preexisting abdominal scar. The average age in group B was 46.7 years, and the patients had an average body mass index of 24.8. The average length of stay in group A was 5.9 days, compared with 4.8 days in group B ( < 0.05). There were no significant differences in breast-related complications. Donor site complications were higher in group A, with abdominal wall skin necrosis being significantly higher in patients with a subcostal incision (25%) compared with those patients without abdominal wall scars (5%; = 0.02). Multivariate analysis revealed a 6.5-fold increase in donor site complications in patients with a subcostal incision and a smoking history ( < 0.05). When adjusted for radiation treatment, the increased incidence in donor site complication rate was only marginally significant ( = 0.08). TRAM flap breast reconstruction in patients with preexisting right subcostal scars is effective with certain technical modifications; however, there is a slight predisposition to increased abdominal wall complications. Smoking influenced outcome further in patients with a subcostal incision, stressing the importance of proper patient selection.

Journal of Surgical Oncology, 2015

Melanoma is steadily increasing over the past decade. Recent studies confirmed a link between tan... more Melanoma is steadily increasing over the past decade. Recent studies confirmed a link between tanning bed use and melanoma. We sought to determine the prevalence and frequency of tanning bed among young patients with melanoma. We retrospectively analyzed tanning bed use among young melanoma patients compared to controls selected from the hospital medical records. A telephone survey investigated family history of melanoma or skin cancer, hair color, eye color, skin type, tanning bed use, and patient awareness of dangers of tanning bed use. A total of 601 melanoma cases were identified; 265 (44%) completed the telephone survey as did 195 (31%) controls. Of these 460 subjects, 260 were female. Females were 3.0 times more likely to have used a tanning bed. Melanoma patients had natural light color hair, blue-green eyes, and 2.0 times more likely to use a tanning bed than controls. Among the tanning bed users, 90% were aware of danger of tanning bed. Our study found that tanning beds were more likely to be used by young women, the majority of whom are aware of the associated risks. Eliminating the use of tanning beds should be considered to decrease the incidence of melanoma. J. Surg. Oncol. © 2015 Wiley Periodicals, Inc.

Cancer, 2005

CONCLUSIONS. The combination of breast DL with SELDI-TOF MS offers a unique and powerful techniqu... more CONCLUSIONS. The combination of breast DL with SELDI-TOF MS offers a unique and powerful technique for the detection and monitoring of breast carcinoma. This method has the potential to enhance the diagnostic utility of conventional DL cytology. Cancer (Cancer Cytopathol) 2005;105:178 -83.

Seminars in Plastic Surgery, 1993

Current Breast Cancer Reports, 2013

ABSTRACT Tailored therapy for breast cancer with conservation of uninvolved tissue is becoming in... more ABSTRACT Tailored therapy for breast cancer with conservation of uninvolved tissue is becoming increasingly important, especially as the benefits of breast reconstruction are recognized. Preservation of the nipple areolar complex during mastectomy is emerging as a viable option in selected patients. Technical considerations for prevention of adverse outcomes such as nipple necrosis are reviewed, along with implications for reconstructive method and outcomes. Finally, the oncologic efficacy of nipple-sparing mastectomy is discussed in the context of occult nipple disease and local recurrence. Standardization of technique, optimization of aesthetic outcome, and examination of long-term prognosis represent future areas of development.

A Textbook of Perioperative Medicine, 2013

Plastic and Reconstructive Surgery, 2014

The first silicone breast implant was inserted in 1962. In 1997, the first case of anaplastic lar... more The first silicone breast implant was inserted in 1962. In 1997, the first case of anaplastic large cell lymphoma (ALCL) in association with a silicone breast implant was reported. The authors reviewed 37 articles in the world literature reporting on 79 patients and collected another 94 unreported cases as of the date of submission. The world literature was reviewed. Missing clinical and laboratory information was solicited from the authors and treating physicians. As several different specialties were involved, information was not in one place. Many (but not all) authors and treating physicians were responsive, resulting in incomplete data. ALCL lesions first presented as late peri-implant seromas, a mass attached to the capsule, tumor erosion through the skin, in a regional node, or discovered during revision surgery. The clinical course varied widely from a single positive cytology result followed by apparent spontaneous resolution, to disseminated treatment-resistant tumor and death. There was no preference for saline or silicone fill or for cosmetic or reconstructive indications. Where implant history was known, the patient had received at least one textured-surface device. Extracapsular dissemination occurred in 18 cases; nine of those were fatal. Histochemical markers were primarily CD-30 and Alk-1. Other markers occurred at a lower frequency. Risk estimates ranged from one in 500,000 to one in 3 million women with implants. Breast implant-associated ALCL is a novel manifestation of site- and material-specific lymphoma originating in a specific scar location, presenting a wide array of diverse characteristics and suggesting a multifactorial cause.

Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery, Jan 8, 2014

Body dysmorphic disorder (BDD) is characterized by a preoccupation with a slight or imagined defe... more Body dysmorphic disorder (BDD) is characterized by a preoccupation with a slight or imagined defect in physical appearance. It has significant implications for patients who desire breast reconstruction, because patient satisfaction with the aesthetic outcome is a substantial contributor to the success of the procedure. The authors estimated the prevalence of BDD among women seeking breast reconstruction by surveying patients with the previously validated Dysmorphic Concerns Questionnaire (DCQ). One hundred eighty-eight women who presented for immediate or delayed breast reconstruction completed the DCQ anonymously, during initial consultation with a plastic surgeon. Two groups of respondents were identified: those who desired immediate reconstruction and those who planned to undergo delayed reconstruction. The prevalence of BDD among breast reconstruction patients was compared between the 2 groups, and the overall prevalence was compared with published rates for the general public. ...

Transactions of the ... Meeting of the American Surgical Association, 2008

Sentinel lymph node (SLN) biopsy has shown great utility in the management of melanoma. An analys... more Sentinel lymph node (SLN) biopsy has shown great utility in the management of melanoma. An analysis of regional recurrence in previously mapped negative SLN basins as the first site of relapse is performed. A retrospective query of a prospective melanoma database from 1994 to 2006 identified 1287 patients who underwent successful SLN biopsy. One thousand sixty patients (82.4%) were SLN negative and 227 (17.6%) patients SLN positive. Clinical variables were examined for the impact on regional recurrence by multivariate analysis. Mean follow-up was 44.3 months (range 3-155 months). Thirty-five patients (3.3%) presented with false-negative (FN) SLN biopsy. Pathologic review of the SLNs harvested from these basins found 7 (20.0%) samples positive for metastatic melanoma. Multivariate analysis found head and neck site [hazard ratio 3.67; 95% confidence interval (CI), 1.77-7.60, P < 0.001] and tumor thickness (hazard ratio 1.16; 95% CI, 1.04-1.30, P = 0.01) to be predictive of FN SLN biopsy. The 5-year melanoma specific survival calculated from the date of the SLN biopsy was 57.6% (95%CI, 35.7-41.9) in the FN group, which was not statistically different than the SLN positive group 60.0% (95% CI, 29.6-40.1; P = 0.14). Head and neck tumor site and tumor thickness are predictors of a FN SLN biopsy. Mechanisms other than pathologic SLN sampling error may contribute to the failure of the SLN biopsy in some patients. Patients with regional recurrence after negative SLN biopsy have a similar 5-year survival compared with patients with positive SLNs.

Archives of Plastic Surgery, 2013

Oncoplastic Breast Surgery, 2010

Skin sparing mastectomy (SSM) removes the breast, nipple-areola complex, previous biopsy incision... more Skin sparing mastectomy (SSM) removes the breast, nipple-areola complex, previous biopsy incisions, and skin overlying superficial tumors. Nipple sparing mastectomy (NSM) preserves the nipple-areolar complex (NAC) as well. Preservation of the inframammary fold, native skin, and potentially the NAC greatly enhances the aesthetic result of immediate breast reconstruction. Theses techniques facilitate breast shaping and the abundant native skin reduces the

Annals of Plastic Surgery, 2014

A recent survey of plastic surgeons showed that the majority prescribed prophylactic antibiotics ... more A recent survey of plastic surgeons showed that the majority prescribed prophylactic antibiotics after hospital discharge for breast reconstruction. There is no clinical evidence that this practice reduces surgical site infection (SSI) after immediate tissue expander breast reconstruction. Furthermore, multiple studies have suggested that current antibiotic choices may not be appropriately covering the causative organisms of SSI. An institutional breast reconstruction database from January 2005 to December 2011 was queried to identify patients undergoing immediate tissue expander reconstruction of the breast. The bacteriology of the infection, prophylactic and empiric antibiotic use, and antibiotic sensitivities were analyzed. In 557 cases of immediate tissue expander breast reconstruction performed in 378 patients, SSIs were diagnosed in 50 (9.0%) cases. Two hundred patients were given oral antibiotics at discharge; 178 did not receive antibiotics. Surgical site infection developed in 12.0% of patients given oral antibiotics and in 13.5% of those not receiving antibiotics (P = 0.67). Wound culture data were obtained in 34 SSIs. Twenty-nine had positive cultures. The most common offending organisms were methicillin-sensitive (11) and methicillin-resistant (6) Staphylococcus aureus. Despite increased use of postoperative prophylaxis over the years, SSI incidence remained unchanged. However, trends toward increased resistance of SSI organisms to the preoperative and postoperative prophylaxis agents were observed. When first-generation cephalosporins were used as prophylaxis, SSI organisms showed resistance rates of 20.5% (preoperative cefazolin) and 54.5% (postoperative cephalexin). Administration of extended prophylactic antibiotics does not reduce overall risk of SSI after expander-based breast reconstruction but may influence antibiotic resistance patterns when infections occur. The organisms most commonly responsible for SSI are often resistant to cefazolin.

Plastic and Reconstructive Surgery, May 1, 2005

Combined defects of the skin, larynx, pharynx, and esophagus after central compartment exenterati... more Combined defects of the skin, larynx, pharynx, and esophagus after central compartment exenteration of the neck can be extremely difficult to reconstruct. The objective of this article is to evaluate reconstruction of the central compartment using a combination of free jejunal transfer for pharyngoesophageal reconstruction, together with regional deltopectoral flaps for tracheostomal reconstruction and cutaneous resurfacing. Myocutaneous flaps, such as pectoralis major and latissimus dorsi flaps, have been used previously for external coverage but can be bulky, causing obstruction of the tracheostoma. From 1995 to 2002, seven patients underwent reconstruction of the central compartment with seven jejunal and nine deltopectoral flaps. Five patients required resection for tracheostomal recurrence of squamous cell carcinoma, and two patients required resection for massive pharyngocutaneous fistulas. Flap survival, complications, and outcomes were evaluated retrospectively. The mean age of the patients was 68.7 years and the mean length of follow-up was 1.9 years. Overall free jejunal and deltopectoral flap survival was 100 percent, with no partial loss. All patients maintained an adequate airway with stomal patency. These complicated defects can be effectively repaired with free jejunal transfers to restore continuity of the alimentary tract and deltopectoral flaps to reconstruct the tracheostoma and surrounding cutaneous defects. The deltopectoral flap provides a large volume of well-vascularized tissue that provides reliable coverage of the newly reconstructed cervical esophagus and exposed major vessels following exenteration of the central compartment. Its thin, pliable nature allows suturing of the tracheal remnants to skin edges without tension and avoids intraluminal prolapse of excess soft tissues, thus maintaining stomal patency.

Annals of Plastic Surgery, Mar 1, 2001

This study provides a retrospective analysis of 60 patients who underwent thoracic reconstruction... more This study provides a retrospective analysis of 60 patients who underwent thoracic reconstruction with the omentum. Patients were identified by searching several databases to determine demographics, indications for surgery, operative technique, and postoperative course, including donor and recipient site morbidity. From January 1975 to May 2000, the authors harvested and transferred the omentum successfully (57 pedicled, 3 free) in 60 patients (mean age, 60 years; age range, 21-86 years) for sternal wound infections (N = 34), chest wall resections (N = 17), pectus deformities (N = 2), intrathoracic defects (N = 4), and breast reconstruction (N = 3). The omentum was used as a primary flap in 39 patients and as a salvage flap in 21 patients. Average operative time was 3.9 hours and average hospital stay was 34.3 days. Partial flap loss occurred in 7 patients, with no total flap failures. Morbidity included six abdominal wound infections and seven epigastric hernias. Mortality was 11.7%. The omentum can be harvested safely and used reliably to reconstruct varying thoracic wounds and defects. Specific indications from this series include osteoradionecrosis, chest wall tumors, massive sternal wounds, and refractory mediastinitis. Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: indications, complications, and results.

Breast Case, Mar 25, 2014

Giant fibroadenomas are rare breast masses that occur largely in a juvenile population. These tum... more Giant fibroadenomas are rare breast masses that occur largely in a juvenile population. These tumors are benign and clinically are very similar to phyllodes tumors of the breast. Given their extremely large size, giant fibroadenomas can cause significant breast disfigurement and be difficult to surgically treat. We present a case of a 12 year old who presented with a rapidly enlarging breast mass diagnosed as a juvenile fibroadenoma. She successfully underwent surgical excision through a periareolar incision and had satisfactory cosmetic results with no recurrences.

International Journal of Radiation Oncology Biology Physics, Dec 22, 2011

The safety and efficacy of skin-sparing mastectomy (SSM) with immediate reconstruction (IR) in pa... more The safety and efficacy of skin-sparing mastectomy (SSM) with immediate reconstruction (IR) in patients with locally advanced breast cancer are unclear. The purpose of this study is to compare the outcomes of women with noninflammatory Stage III SSM with IR vs. non-SSM-treated women who underwent neoadjuvant chemotherapy and adjuvant radiation therapy (XRT). Between October 1997 and March 2010, 100 consecutive patients (40 SSM with IR vs. 60 non-SSM) with Stage III breast cancer received anthracycline- and/or taxane-based neoadjuvant chemotherapy, mastectomy, and adjuvant XRT. Clinical stage (SSM with IR vs. for non-SSM) was IIIA (75% vs. 67%), IIIB (8% vs. 18%), and IIIC (8% vs. 8%). Tumors greater than 5 cm were found in 74% vs. 69%; 97% of patients in both groups were clinically node positive; and 8% vs. 18% had T4b disease. The time from initial biopsy to XRT was prolonged for SSM-IR patients (274 vs. 254 days, p = 0.04), and there was a trend toward XRT delay of more than 8 weeks (52% vs. 31%, p = 0.07) after surgery. The rate of complications requiring surgical intervention was higher in the SSM-IR group (37.5% vs. 5%, p < 0.001). The 2-year actuarial locoregional control, breast cancer-specific survival, and overall survival rates for SSM with IR vs. non-SSM were 94.7% vs. 97.4%, 91.5% vs. 86.3%, and 87.4% vs. 84.8%, respectively (p = not significant). In our small study with limited follow-up, SSM with IR prolonged overall cancer treatment time and trended toward delaying XRT but did not impair oncologic outcomes. Complication rates were significantly higher in this group. Longer follow-up is needed.

Annals of Plastic Surgery, Mar 1, 2011

Autologous fat grafting has become a common technique for revisional breast surgery. The purpose ... more Autologous fat grafting has become a common technique for revisional breast surgery. The purpose of this series is to review our experience with fat grafting for the correction of acquired breast deformities. A retrospective review was performed on 107 patients with a history of breast cancer between 1996 and 2010, who had autologous fat grafting at the time of secondary breast reconstruction. The indications were for improvement in contour, shape, and volume of the breast following transverse rectus abdominis myocutaneous (TRAM) flap reconstruction (n = 55), latissimus dorsi with or without implant (n = 20), implant reconstruction (n = 20), and breast conservation therapy deformity (n = 12). The average volume of injection was 40 mL (range, 5-150 mL), the most common location being upper and medial quadrants. Fat was harvested mainly from the abdomen, thighs, and flanks. Complications occurred in 11% of the patients, and included fat necrosis, erythema, keloid scarring, and pain. Complications were higher when performed with implant reconstructions. Repeat fat injection was performed in 25% (n = 27/107), which increased with the length of follow-up. Patients with a history of radiation therapy had an increased incidence of repeat injections (36% vs. 18%). Patients with >6 months follow-up reported an improvement of about 83%. Autologous fat grafting is a safe and effective tool for secondary breast reconstruction. It is helpful in all types of reconstructions to improve contour, volume, and overall breast shape and symmetry. Repeat injections are often required and this is more common in patients with longer follow-up and in those with a history of radiation therapy. The popularity of this approach in reconstructive breast surgery will likely continue to increase.

Annals of Plastic Surgery, Mar 1, 2011

Autologous fat grafting has become a common technique for revisional breast surgery. The purpose ... more Autologous fat grafting has become a common technique for revisional breast surgery. The purpose of this series is to review our experience with fat grafting for the correction of acquired breast deformities. A retrospective review was performed on 107 patients with a history of breast cancer between 1996 and 2010, who had autologous fat grafting at the time of secondary breast reconstruction. The indications were for improvement in contour, shape, and volume of the breast following transverse rectus abdominis myocutaneous (TRAM) flap reconstruction (n = 55), latissimus dorsi with or without implant (n = 20), implant reconstruction (n = 20), and breast conservation therapy deformity (n = 12). The average volume of injection was 40 mL (range, 5-150 mL), the most common location being upper and medial quadrants. Fat was harvested mainly from the abdomen, thighs, and flanks. Complications occurred in 11% of the patients, and included fat necrosis, erythema, keloid scarring, and pain. Complications were higher when performed with implant reconstructions. Repeat fat injection was performed in 25% (n = 27/107), which increased with the length of follow-up. Patients with a history of radiation therapy had an increased incidence of repeat injections (36% vs. 18%). Patients with >6 months follow-up reported an improvement of about 83%. Autologous fat grafting is a safe and effective tool for secondary breast reconstruction. It is helpful in all types of reconstructions to improve contour, volume, and overall breast shape and symmetry. Repeat injections are often required and this is more common in patients with longer follow-up and in those with a history of radiation therapy. The popularity of this approach in reconstructive breast surgery will likely continue to increase.

The American Surgeon, Mar 1, 2014

Malignant cutaneous adnexal tumors (MCATs) are rare neoplasms that do not have a well-studied tre... more Malignant cutaneous adnexal tumors (MCATs) are rare neoplasms that do not have a well-studied treatment algorithm. They are generally treated by excision alone. Given its successful application in other cutaneous malignancies, sentinel lymph node biopsy (SLNB) has been advocated by some for use in MCATs. A retrospective chart review was performed. Clinicopathological factors, recurrence patterns, and long-term follow-up were documented. Survival analysis was performed. Forty-eight subjects were identified. Mean age was 69 years with locations on the face (52%), including periocular sites (16%), extremities (25%), and all other sites (7%). Histologic distribution was sebaceous carcinoma (56%), porocarcinoma (17%), eccrine carcinoma (13%), adenocarcinoma (10%), and hidradenocarcinoma (4%). Mean follow-up was 3.9 years (range, 0 to 17 years). Nine subjects (18.8%) recurred locally, and recurrence was inversely associated with age (P = 0.04). Four (8.3%) demonstrated lymph node involvement, none without first developing local recurrence. Five-year disease-specific survival was 97 per cent (confidence interval, 81.4 to 99.6%). Despite being one of the largest reported analyses of MCATs, this study is limited by the small number of subjects. MCATs seemingly develop nodal recurrence only after demonstrating aggressive local biology. SLNB may best be applied selectively, possibly only in patients with local recurrence.

Annals of Plastic Surgery, Aug 1, 2002

The presence of a preexisting subcostal incision alters the approach to breast reconstruction and... more The presence of a preexisting subcostal incision alters the approach to breast reconstruction and is thought to predispose to donor site skin complications and flap loss. The purpose of this study was to determine whether the presence of a subcostal scar affects breast or donor site morbidity adversely after transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. Twenty-six patients with a right subcostal incision (group A) underwent TRAM flap breast reconstruction (13 immediate, 13 delayed). The average age was 51 years, and the patients had an average body mass index of 25.3. There were 15 right, 10 left, and 1 bilateral reconstruction (4 free flaps, 22 pedicled). Outcome measures were compared with 126 age- and risk-matched patients (group B) who underwent TRAM flap reconstruction without any preexisting abdominal scar. The average age in group B was 46.7 years, and the patients had an average body mass index of 24.8. The average length of stay in group A was 5.9 days, compared with 4.8 days in group B ( < 0.05). There were no significant differences in breast-related complications. Donor site complications were higher in group A, with abdominal wall skin necrosis being significantly higher in patients with a subcostal incision (25%) compared with those patients without abdominal wall scars (5%; = 0.02). Multivariate analysis revealed a 6.5-fold increase in donor site complications in patients with a subcostal incision and a smoking history ( < 0.05). When adjusted for radiation treatment, the increased incidence in donor site complication rate was only marginally significant ( = 0.08). TRAM flap breast reconstruction in patients with preexisting right subcostal scars is effective with certain technical modifications; however, there is a slight predisposition to increased abdominal wall complications. Smoking influenced outcome further in patients with a subcostal incision, stressing the importance of proper patient selection.

Journal of Surgical Oncology, 2015

Melanoma is steadily increasing over the past decade. Recent studies confirmed a link between tan... more Melanoma is steadily increasing over the past decade. Recent studies confirmed a link between tanning bed use and melanoma. We sought to determine the prevalence and frequency of tanning bed among young patients with melanoma. We retrospectively analyzed tanning bed use among young melanoma patients compared to controls selected from the hospital medical records. A telephone survey investigated family history of melanoma or skin cancer, hair color, eye color, skin type, tanning bed use, and patient awareness of dangers of tanning bed use. A total of 601 melanoma cases were identified; 265 (44%) completed the telephone survey as did 195 (31%) controls. Of these 460 subjects, 260 were female. Females were 3.0 times more likely to have used a tanning bed. Melanoma patients had natural light color hair, blue-green eyes, and 2.0 times more likely to use a tanning bed than controls. Among the tanning bed users, 90% were aware of danger of tanning bed. Our study found that tanning beds were more likely to be used by young women, the majority of whom are aware of the associated risks. Eliminating the use of tanning beds should be considered to decrease the incidence of melanoma. J. Surg. Oncol. © 2015 Wiley Periodicals, Inc.

Cancer, 2005

CONCLUSIONS. The combination of breast DL with SELDI-TOF MS offers a unique and powerful techniqu... more CONCLUSIONS. The combination of breast DL with SELDI-TOF MS offers a unique and powerful technique for the detection and monitoring of breast carcinoma. This method has the potential to enhance the diagnostic utility of conventional DL cytology. Cancer (Cancer Cytopathol) 2005;105:178 -83.

Seminars in Plastic Surgery, 1993

Current Breast Cancer Reports, 2013

ABSTRACT Tailored therapy for breast cancer with conservation of uninvolved tissue is becoming in... more ABSTRACT Tailored therapy for breast cancer with conservation of uninvolved tissue is becoming increasingly important, especially as the benefits of breast reconstruction are recognized. Preservation of the nipple areolar complex during mastectomy is emerging as a viable option in selected patients. Technical considerations for prevention of adverse outcomes such as nipple necrosis are reviewed, along with implications for reconstructive method and outcomes. Finally, the oncologic efficacy of nipple-sparing mastectomy is discussed in the context of occult nipple disease and local recurrence. Standardization of technique, optimization of aesthetic outcome, and examination of long-term prognosis represent future areas of development.

A Textbook of Perioperative Medicine, 2013

Plastic and Reconstructive Surgery, 2014

The first silicone breast implant was inserted in 1962. In 1997, the first case of anaplastic lar... more The first silicone breast implant was inserted in 1962. In 1997, the first case of anaplastic large cell lymphoma (ALCL) in association with a silicone breast implant was reported. The authors reviewed 37 articles in the world literature reporting on 79 patients and collected another 94 unreported cases as of the date of submission. The world literature was reviewed. Missing clinical and laboratory information was solicited from the authors and treating physicians. As several different specialties were involved, information was not in one place. Many (but not all) authors and treating physicians were responsive, resulting in incomplete data. ALCL lesions first presented as late peri-implant seromas, a mass attached to the capsule, tumor erosion through the skin, in a regional node, or discovered during revision surgery. The clinical course varied widely from a single positive cytology result followed by apparent spontaneous resolution, to disseminated treatment-resistant tumor and death. There was no preference for saline or silicone fill or for cosmetic or reconstructive indications. Where implant history was known, the patient had received at least one textured-surface device. Extracapsular dissemination occurred in 18 cases; nine of those were fatal. Histochemical markers were primarily CD-30 and Alk-1. Other markers occurred at a lower frequency. Risk estimates ranged from one in 500,000 to one in 3 million women with implants. Breast implant-associated ALCL is a novel manifestation of site- and material-specific lymphoma originating in a specific scar location, presenting a wide array of diverse characteristics and suggesting a multifactorial cause.

Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery, Jan 8, 2014

Body dysmorphic disorder (BDD) is characterized by a preoccupation with a slight or imagined defe... more Body dysmorphic disorder (BDD) is characterized by a preoccupation with a slight or imagined defect in physical appearance. It has significant implications for patients who desire breast reconstruction, because patient satisfaction with the aesthetic outcome is a substantial contributor to the success of the procedure. The authors estimated the prevalence of BDD among women seeking breast reconstruction by surveying patients with the previously validated Dysmorphic Concerns Questionnaire (DCQ). One hundred eighty-eight women who presented for immediate or delayed breast reconstruction completed the DCQ anonymously, during initial consultation with a plastic surgeon. Two groups of respondents were identified: those who desired immediate reconstruction and those who planned to undergo delayed reconstruction. The prevalence of BDD among breast reconstruction patients was compared between the 2 groups, and the overall prevalence was compared with published rates for the general public. ...

Transactions of the ... Meeting of the American Surgical Association, 2008

Sentinel lymph node (SLN) biopsy has shown great utility in the management of melanoma. An analys... more Sentinel lymph node (SLN) biopsy has shown great utility in the management of melanoma. An analysis of regional recurrence in previously mapped negative SLN basins as the first site of relapse is performed. A retrospective query of a prospective melanoma database from 1994 to 2006 identified 1287 patients who underwent successful SLN biopsy. One thousand sixty patients (82.4%) were SLN negative and 227 (17.6%) patients SLN positive. Clinical variables were examined for the impact on regional recurrence by multivariate analysis. Mean follow-up was 44.3 months (range 3-155 months). Thirty-five patients (3.3%) presented with false-negative (FN) SLN biopsy. Pathologic review of the SLNs harvested from these basins found 7 (20.0%) samples positive for metastatic melanoma. Multivariate analysis found head and neck site [hazard ratio 3.67; 95% confidence interval (CI), 1.77-7.60, P < 0.001] and tumor thickness (hazard ratio 1.16; 95% CI, 1.04-1.30, P = 0.01) to be predictive of FN SLN biopsy. The 5-year melanoma specific survival calculated from the date of the SLN biopsy was 57.6% (95%CI, 35.7-41.9) in the FN group, which was not statistically different than the SLN positive group 60.0% (95% CI, 29.6-40.1; P = 0.14). Head and neck tumor site and tumor thickness are predictors of a FN SLN biopsy. Mechanisms other than pathologic SLN sampling error may contribute to the failure of the SLN biopsy in some patients. Patients with regional recurrence after negative SLN biopsy have a similar 5-year survival compared with patients with positive SLNs.

Archives of Plastic Surgery, 2013

Oncoplastic Breast Surgery, 2010

Skin sparing mastectomy (SSM) removes the breast, nipple-areola complex, previous biopsy incision... more Skin sparing mastectomy (SSM) removes the breast, nipple-areola complex, previous biopsy incisions, and skin overlying superficial tumors. Nipple sparing mastectomy (NSM) preserves the nipple-areolar complex (NAC) as well. Preservation of the inframammary fold, native skin, and potentially the NAC greatly enhances the aesthetic result of immediate breast reconstruction. Theses techniques facilitate breast shaping and the abundant native skin reduces the

Annals of Plastic Surgery, 2014

A recent survey of plastic surgeons showed that the majority prescribed prophylactic antibiotics ... more A recent survey of plastic surgeons showed that the majority prescribed prophylactic antibiotics after hospital discharge for breast reconstruction. There is no clinical evidence that this practice reduces surgical site infection (SSI) after immediate tissue expander breast reconstruction. Furthermore, multiple studies have suggested that current antibiotic choices may not be appropriately covering the causative organisms of SSI. An institutional breast reconstruction database from January 2005 to December 2011 was queried to identify patients undergoing immediate tissue expander reconstruction of the breast. The bacteriology of the infection, prophylactic and empiric antibiotic use, and antibiotic sensitivities were analyzed. In 557 cases of immediate tissue expander breast reconstruction performed in 378 patients, SSIs were diagnosed in 50 (9.0%) cases. Two hundred patients were given oral antibiotics at discharge; 178 did not receive antibiotics. Surgical site infection developed in 12.0% of patients given oral antibiotics and in 13.5% of those not receiving antibiotics (P = 0.67). Wound culture data were obtained in 34 SSIs. Twenty-nine had positive cultures. The most common offending organisms were methicillin-sensitive (11) and methicillin-resistant (6) Staphylococcus aureus. Despite increased use of postoperative prophylaxis over the years, SSI incidence remained unchanged. However, trends toward increased resistance of SSI organisms to the preoperative and postoperative prophylaxis agents were observed. When first-generation cephalosporins were used as prophylaxis, SSI organisms showed resistance rates of 20.5% (preoperative cefazolin) and 54.5% (postoperative cephalexin). Administration of extended prophylactic antibiotics does not reduce overall risk of SSI after expander-based breast reconstruction but may influence antibiotic resistance patterns when infections occur. The organisms most commonly responsible for SSI are often resistant to cefazolin.