Introduction In the last decade, we have seen a steady increase in the incidence of frontal sinus trauma due to gunshot wounds and a decrease in motor vehicle trauma. Penetrating gunshot wounds to the frontal sinus present a unique challenge to the reconstructive surgeon because they require careful consideration of the management principles of plastic surgery. Despite previous reviews on frontal sinus trauma, there are no studies examining the management techniques of frontal sinus fractures due specifically to gunshot wounds. In this study, we aim to retrospectively evaluate the use of a variety of tissue flaps in intervention and associated outcomes. Methods A retrospective chart review was completed on all patients with gunshot wound(s) to the frontal sinus from January 2010 to January 2018 at a single institution. The patients were classified based on the fracture pattern (anterior vs posterior table vs both), degree of displacement, presence of nasofrontal outflow tract injury, and evidence of cerebrospinal fluid leak. Patients were then stratified according to the type of reconstruction performed (cranialization, obliteration and need for free flap) and evaluated for major and minor complications after reconstruction. Results In this study, we present outcome data from 28 cases of frontal sinus trauma due to gunshot wounds. There was a statistically significant difference (P = 0.049) in the type reconstructive strategy employed with each type of flap, with pericranial flaps primarily used in cranialization, temporal grafts were more likely to be used in obliteration, and free flaps were more likely to be used in cranialization. The overall major complication rate was 52% (P = 0.248), with the most common acute major complication was cerebrospinal fluid leak (39%) and major chronic was abscess (23.5%). Conclusions This report explores the management of frontal sinus trauma and presents short-term outcomes of treatment for penetrating gunshot wounds at a tertiary referral center.
e13530 Background: Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer that accounts for nearly 10% of breast cancer caused mortality. With an annual rate between 1-4% per year and 3-year overall survival (OS) of about 65%, timely completion of trimodal treatment including systemic therapy, surgery, and radiation therapy is essential. Prior studies have demonstrated impact of time to treatment on OS of non-IBC patients. The aim of this study was to examine the relationship between the time from diagnosis to treatment and outcomes for patients with IBC. Methods: Categorically matched patients who underwent treatment of inflammatory and non-inflammatory locally advanced breast cancer at an NCI-Designated Comprehensive Cancer Center from 2006-2016 were analyzed. Clinicopathologic factors were compared using Chi-square and Wilcoxon Rank Sum tests. Overall survival was assessed using Kaplan-Meier methods and log-rank tests. Results: Of 217 patients who underwent excision for breast cancer, 99 had an IBC diagnosis. All patients were female, 85% (n=84) white, and 98% (n=97) had single-sided breast disease. Thirty-one percent (n=31) of patients had clinically node positive (N1) disease, the majority were ER negative (53%), and 38% were HER2 positive. There was no difference in time from first abnormal mammogram to diagnosis between IBC vs non-IBC patients. Ninety-one percent (n=90) of IBC patients underwent neoadjuvant chemotherapy compared to 52% (n=61) of non-IBC patients (p<0.001). Only 27% (n=27) of IBC had a pathological complete response. IBC patients tended to present earlier with symptoms (p=0.054), begin chemotherapy sooner after diagnosis (median days: 10.5 vs 17.0, respectively; p=0.002), and were more likely to receive radiation earlier after surgery (p<0.001). However, IBC patients were also more likely to undergo surgery later (191 vs 153 days; p<0.001) and have a worse OS (p=0.006). While not statistically significant, there was a trend toward worse OS for IBC patients with delayed chemotherapy initiation (p=0.459). Conclusions: IBC is an aggressive form of breast cancer associated with poor OS. Patients with this diagnosis are more likely to receive trimodal therapy sooner, but this may not significantly improve their OS. Further studies are necessary to evaluate effect of time from presentation of initial symptoms to treatment initiation on outcomes.
Introduction: Traumatic injuries that require free tissue flaps for reconstruction may require vascular pedicle extension between the flap and recipient vessels to form a clear anastomosis. Currently, a variety of techniques are used, each with their own potential benefits and harms. In addition, reports in the literature conflict on the reliability of pedicle extensions of vessels in free flap (FF) surgery. The objective of this study is to systematically assess the available literature about outcomes of pedicle extensions in FF reconstruction. Methods: A comprehensive search was performed for relevant studies published up to January 2020. Study quality was assessed using the Cochrane Collaboration risk of bias assessment tool and a set of predetermined parameters was extracted by 2 investigators independently for further analysis. The literature review yielded 49 studies investigating pedicled extension of FF. Studies meeting inclusion criteria underwent data extraction focusing on demographics, conduit type, microsurgical technique, and postoperative outcomes. Results: The search yielded 22 retrospective studies totaling 855 procedures from 2007 to 2018 in which 159 complications (17.1%) were reported in patients aged between 39 and 78 years. Overall heterogeneity of articles included in this study was high. Free flap failure and thrombosis were the 2 most prevalent major complications noted: vein graft extension technique had the highest rate of flap failure (11%) in comparison with the arterial graft (9%) and arteriovenous loops (8%). Arteriovenous loops had a rate of thrombosis of 5% versus 6% in arterial grafts and 8% in venous grafts. Bone flaps maintained the highest overall complication rates per tissue type at 21%. The overall success rate of pedicle extensions in FFs was 91%. Arteriovenous loop extension resulted in a 63% decrease in the odds of vascular thrombosis and a 27% decrease in the odds of FF failure when compared with venous graft extensions (P < 0.05). Arterial graft extension resulted in a 25% decrease in the odds of venous thrombosis and a 19% decrease in the odds of FF failure when compared with venous graft extensions (P < 0.05). Conclusions: This systematic review strongly suggests that pedicle extensions of the FF in a high-risk complex setting are a practical and effective option. There may be a benefit to using arterial versus venous conduits, although further examination is warranted given the small number of reconstructions reported in the literature.
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