Scientific Abstract Presentations: Reconstructive 9 Sunday, October 29 Sun, Oct 29 10:30 a.m.-12:30 p.m. CDT

The incidence of nonmelanoma skin cancer in the U.S. is one million cases per year, and 20 percent of these occur on the nose.1 Nasal defects following tumor extirpation present reconstructive challenges given the paucity of local tissue and intricate subunits. An ideal reconstruction provides adequate match in tissue quality and is performed in a single stage.

Historically, the paramedian forehead flap (PFF) has been considered the gold standard.2 It is indicated for defects that are larger than two centimeters and is known to provide an aesthetic reconstruction.3 However, this flap introduces considerable morbidity and necessitates staging, which can pose limitations to its routine use. Additionally, this patient population frequently develops recurrences that require re-excision. Therefore, it may be prudent to preserve the PFF until necessary.

The dorsal nasal flap (DNF) utilizes local tissue to reconstruct defects in a single stage. It is classically described as a rotation-advancement flap.4 We present our experience with utilizing this versatile and robust flap to reconstruct defects that may otherwise require a PFF based on size criteria.

A retrospective chart review of patients who had undergone reconstruction by DNF following Mohs resection from 2015 to present was conducted.

The cases were categorized by six flap modifications: limited, standard, extended, double, combined, and readvanced. The defect location, defect diameter, use of cartilage graft, secondary flap, revisions, complications, and recurrences were recorded. The means and ranges of defect sizes were calculated by flap type. We present our reconstructive algorithm based on this data.

From 2015 to present, 51 patients have undergone reconstruction with a DNF. The longest follow up period was about 3 years. There is a general trend of larger defect sizes with increasingly complex flap types, consistent with our reconstructive philosophy.

Complications included minor dehiscence, delayed wound healing, donor site hematoma, and hypertrophic scarring. Note that there were no flap losses. While revision rates were low, the senior author prefers to err on preserving vascularity of the flap at the first stage, and therefore has a low threshold to debulk at a second stage. These revisions are generally performed under local anesthesia.

The present study expands the use of the DNF and redefines the nasal reconstruction algorithm. Plastic surgeons faced with complex nasal defects can utilize our principles to reconstruct larger defects which would have traditionally necessitated a PFF. We believe that our approach lowers morbidity, provides cosmetic and durable coverage, while preserving the PFF in a population at risk for recurrence and needing further reconstruction.

1. Ciążyńska M, Kamińska-Winciorek G, Lange D, et al. The incidence and clinical analysis of non-melanoma skin cancer. Scientific Reports. 2021;11(1).
2. Eren E, Beden V. Beyond Rieger's original indication; the dorsal nasal flap revisited. Journal of Cranio-Maxillofacial Surgery. 2014;42(5):412-416.
3. Khan SI, Lim AA. Sparing the paramedian forehead flap for reconstruction of large nasal and cheek defects. Dermatologic Surgery. 2020;47(8):1099-1101.
4. Redondo P, Bernad I, Moreno E, Ivars M. Elongated dorsal nasal flap to reconstruct large defects of the nose. Dermatologic Surgery. 2017;43(8):1036-1041.

INTRODUCTION The latissimus dorsi myocutaneous flap (LDMF) is commonly used in restoration of trunk defect. However, the risk of prolonged drainage and seroma at donor site is one of the major concerns for this approach. A previous study has reported that the quilting suture technique decreases the incidence of donor-site seroma and leads to earlier drain removal after LDMF harvest.1 Therefore, we conducted a study to determine whether quilting sutures, in combination with epinephrine-assisted dissection, would benefit patients undergoing LDMF breast reconstruction.

METHODS The PEQ-I technique in Immediate Breast Reconstruction with Latissimus Dorsi trial has been registered on Chinese Clinical Trial Registry (No.: ChiCTR2000031116). In this prospective three-arm controlled study, we randomly assigned 115 patients to receive LDMF-based breast reconstruction with the donor sites treated by both epinephrine-assisted dissection and quilting sutures (n=46), quilting sutures only (n=46), or electrocautery-based dissection without quilting sutures (n=23). Epinephrine-assisted dissection employed tumescent saline containing 0.5% lidocaine and 1:400,000 epinephrine for injection into the layer above latissimus dorsi muscle so that the superficial dissection can be done with curved Mayo scissors instead of electrocautery. The quilting suture technique uses 7-8 interrupted 2-0 Vicryl sutures throughout the donor site, approximately 6 cm apart. The primary end points of the study were time to drain removal and incidence of donor-site seroma. The secondary outcomes included total drain output, hospital days after surgery, and patient-reported outcomes.

RESULTS At a median follow-up of six months, the combined techniques with epinephrine-assisted dissection and quilting sutures significantly decreased the days to drain removal and total drain volume (p<0.001 versus quilting sutures group and control group, respectively). There were no significant differences among the groups regarding donor-site seroma as well as the recipient-site complications including infection, wound dehiscence, and mastectomy flap necrosis (p>0.05). Multivariate analysis found the flap harvest method affects the donor-site drain time independently (adjusted OR in the combined techniques group, 16.97; 95%CI, 6.06 to 47.55; p<0.001). The effect was significant in large latissimus dorsi muscle subgroup (adjusted OR, 14.77; 95%CI, 4.40 to 49.56; p<0.001) and in the subgroup with small muscle size (adjusted OR, 24.10; 95%CI, 3.11 to 86.75; p=0.002). The surgery duration using the combined techniques was 50 minutes longer than quilting sutures group and control group (p>0.05). The patient-reported outcomes detected by BREAST-Q were similar in the three study groups (p>0.05).

CONCLUSION The combination techniques of epinephrine-assisted dissection and quilting sutures are able to minimize the time and volume of donor-site drainage, and as a result, the hospital stay after surgery in latissimus dorsi breast reconstruction.

REFERENCE 1. Hart AM, Duggal C, Pinell-White X, et al. A Prospective Randomized Trial of the Efficacy of Fibrin Glue, Triamcinolone Acetonide, and Quilting Sutures in Seroma Prevention after Latissimus Dorsi Breast Reconstruction. Plast Reconstr Surg 2017;139(4):854e-863e.

Background : Vascularized Lymph Node Transfer (VLNT) is a surgical treatment that has shown promising results in treating advanced-stage cancer related lymphedema. However, it is important to consider the morbidity associated with the donor site. In our study, we have demonstrated that using the omentum for VLNT can be an effective and less invasive surgical approach, leading to favorable outcomes. Methods : All patients in our study presented with breast cancer-related lymphedema at stage IIb or higher, and were therefore scheduled to undergo VLNT surgery. A single-port laparoscopic approach was employed to harvest the omental lymph node flap based on the right gastroepiploic artery. The flap was then inset in the direction of lymphatic flow, with additional lymphatic connections made to the recipient vein. Results : No major operative complications were observed in any of the patients, and there were no cases of reoperation due to surgical site issues. Twelve months after surgery, the mean limb volume difference decreased from 25% to 17% compared to preoperative measurements, while the difference of interlimb impedance ration measured by bioimpedance analysis decreased from an average of 1.63 to 1.25. The Lymph Q questionnaire revealed a significant reduction in patients' discomfort related to lymphedema. Conclusions : The use of omental lymph node flap for VLNT surgery is a promising approach that can provide patients with effective results while minimizing the risk associated with the procedure. This method can be particularly beneficial for patients with advanced-stage lymphedema who have limited treatment options.

1. Scaglioni, M.F., et al., Comprehensive review of vascularized lymph node transfers for lymphedema: outcomes and complications. Microsurgery, 2018. 38(2): p. 222-229.
2. Pappalardo, M., K. Patel, and M.H. Cheng, Vascularized lymph node transfer for treatment of extremity lymphedema: an overview of current controversies regarding donor sites, recipient sites and outcomes. Journal of surgical oncology, 2018. 117(7): p. 1420-1431.
3. Ciudad, P., et al., Comparison of long‐term clinical outcomes among different vascularized lymph node transfers: 6‐year experience of a single center's approach to the treatment of lymphedema. Journal of surgical oncology, 2017. 116(6): p. 671-682.
4. Agko, M. and H.-C. Chen, Histo-anatomical basis of the gastroepiploic vascularized lymph node flap: the overlooked "micro" lymph nodes. Journal of Plastic, Reconstructive & Aesthetic Surgery, 2018. 71(1): p. 118-120.
5. Park, J.K.-H., et al., Association of lymphatic flow velocity with surgical outcomes in patients undergoing lymphovenous anastomosis for breast cancer-related lymphedema. Breast Cancer, 2022. 29(5): p. 835-843.

Background: Gunshot wounds (GSWs) to the face are destructive injuries with potentially debilitating functional and aesthetic outcomes. Management is often challenging due to the complexity of the craniofacial skeleton and the overlying soft tissue structures and surgical intervention is often required. The purpose of this study is to characterize injury patterns and operative management of the most extensive GSWs to the face that have progressed to surgical closure.

Methods: We conducted a retrospective chart review from a Level 1 metropolitan trauma registry from January 1, 2009 to December 21, 2020. Inclusion criteria were patients sustaining a GSW to the face that required four or more surgical procedures or required regional or free flap reconstruction. Data collected included demographic and injury information, airway management techniques, specific structures injured, and surgical management details including timing and the specific procedures and techniques.

Results: From 2009 to 2020, a total of 432 patients sustained a GSW to the face and 40 patients met our inclusion criteria for severe GSW to the face. The average age at presentation was 34 (range 16-68) and the majority of patients were male (85%). The primary mechanism of injury was self-inflicted (50%) followed by assault (37.5%). A total of 37 patients (95%) required tracheostomy. The average number of facial bones fractured was 3.3 (SD 1.49) and the average number of surgeries was 5.4 (range 4-11). Specific bones injured included the mandible (95%), maxilla (77.5%), orbit (52.5%), nasal bone (42.5%), zygoma (37.5%), and frontal (12.5%). 74% of the mandibles had operative repair. The average number of surgical procedures varied on the type of primary procedure used for repair. The subgroups evaluated were i) external fixation (11 patients) – 4.81 procedures; ii) open reduction/internal fixation (ORIF) (28 patients) – 5.6 procedures; iii) regional/free flap (7 patients) – 6.88 procedures. On average, patients were taken to the operating room for an irrigation and debridement 2.8 times before ORIF. Almost half (18/40) of these patients experienced an infection. The pectoralis muscle flap was the most common regional flap utilized (67%). Different free flaps (radial forearm, rectus abdominis, fibula, and latissimus dorsi) were utilized equally (25%).

Conclusions: Severe GSWs to the face have a multi-injury pattern that require complex management and are most often a result of close range, high caliber, or shotgun injuries. It is paramount to secure the airway in this patient population, not only as a life saving measure, but also to facilitate subsequent operative repair. Multiple washouts are often necessary to remove foreign debris and measure presence of necrotic tissue. The mandible was the most common facial bone involved in this severe injury group, which may reflect the likelihood of comminution, instability, and contamination from associated intraoral extension. Patients managed with regional or free flap required the greatest number of procedures, perhaps as indicative of the preparatory steps required for a technique of this complexity.

Introduction: Large defects of the nose after Mohs surgery pose a significant reconstructive challenge to both dermatologic and reconstructive surgeons. Our aim was to present our 12-year experience utilizing Integra® bilayer wound matrix for nasal reconstruction. Primary endpoints included success of Integra integration, followed by time to complete healing, complication rate, recurrence, and aesthetic intervention.

Methods: A retrospective review of patients undergoing Mohs surgery and alloplastic nasal reconstruction with Integra between 2012-2022 was performed. Patients who underwent single-stage reconstruction and dual-stage reconstruction with skin graft with at least 90 days of follow up were included.

Results: Fifty-one patients (28 males, 23 females) met inclusion criteria with a median age of 77 years of age. Non-Hispanic Caucasians made up the majority of the study (98%), with 43% having a history of tobacco use. Basal cell carcinoma (BCC) was the most common cutaneous malignancy diagnosed (61.5%), followed by squamous cell carcinoma (SCC) (13.5%), and melanoma in-situ (13.5%). A total of 53 lesions were treated, with each acquired defect repaired and reconstructed separately with Integra. The most common lesion location involved the nasal sidewall (50%), followed by the nasal tip (44.4%). The mean pre-operative lesion size was 3.3 cm2, with a mean post-Mohs surgery defect size of 10.8 cm2. 30.8% (n=16) of defect sites underwent same-day Integra reconstruction, with 69.2% (n=36) proceeding to undergo two-stage reconstruction. Integra successfully reconstructed the acquired Mohs defect in 94.2% of this population. Average time to completed healing was 145.35 + 86.0 days. No instances of disease recurrence were recorded. The total complication rate was 9.62% (n=5). The average size for successful healing without complication is 10.8 cm2. The average defect size for complications or failure of skin graft was 14.7 cm2. Only seven sites (13.46%) underwent procedures for aesthetic improvement, with all revisions occurring after two stage reconstruction.

Conclusion: When used in single or two staged reconstruction, Integra bilayer wound matrix is an adequate reconstructive option for the nose with low complication and revision rates.

Background: Since the early 2000s, Acellular Dermal Matrix has been adopted as a popular addition to prepectoral breast reconstruction to enhance aesthetic outcomes of the procedure. The objective of this study was to investigate the differences in the postoperative course of two common acellular dermal matrix companies- AlloDerm SELECT Ready To Use (Allergen, Dublin, Ireland) and DermACELL (Stryker, Kalamazoo, Michigan).

Methods: Prospective study of patients undergoing bilateral nipple and/or skin sparing mastectomies to either Tissue Expander or Silicone Implant insertion between the years 2019 to 2023 were selected for this study. The study design was to use patients as their own controls between different products used in the left or right breast. Of these patients, both Acellular Dermal Matrix companies were used, with AlloDerm randomly placed into one breast, and DermACELL into the other. Outcomes compared between the two brands included average time for drain removal, infection rate, seroma rate, incorporation rate, and average time for Tissue Expander fill. Statistical analysis was performed in order to determine the presence of significant differences, with independent clinical variables recorded to rule out confounding factors.

Results: Clinical data of 54 patients (108 breasts) was recorded for 90 days, with 51 patients undergoing tissue expander insertion and and 3 patients with direct to silicone implant surgery. There were no significant differences between time drain removal, average drain output, and time for tissue expander fill. Additionally, there were no significant differences in outcomes based on personal factors such as age, BMI, and other comorbidities. There was a higher percentage of seromas recorded in the breasts with AlloDerm (\27.78%) compared to breasts containing DermACELL (14.81%, p < 0.05). Incorporation rates of Alloderm and DermACELL were not statistically significant as they were 95.4% and 99.8%, respectively.

Conclusion: irrespective of patient demographic disparities, both AlloDerm and DermACELL have equal infection rates and drain comparisons. AlloDerm was determined to have a higher incidence of seromas as a postoperative complication, which is an important factor to be considered when choosing between the acellular dermal matrices companies.

Background Phlebolymphedema can result from venous outflow insufficiency related lymph stasis.(1) In patients presenting with isolated left lower extremity edema, left iliac vein compression or May Thurner syndrome (MTS) is a differential diagnoses.(2, 3) As venous and lymphatic pathologies are treated by different specialties, biased recognition of one entity over the other is possible and can delay appropriate intervention. We investigated the management of patients diagnosed with both May Thurner syndrome and lymphedema at our institute.

Methods An IRB-approved chart review was performed on all adult patients who presented with lower extremity lymphedema at our clinic between February 2020 and April 2022. Demographics, comorbidities, symptoms, duration of symptoms and treatment data was collected. Patients with concomitant diagnosis of MTS were included in this study. The study group was subcategorized based on whether the MTS was surgically managed (stented) or not. Stented patients were further grouped based on patient reported improvement at minimum 1-year post stenting. In the group with no improvement after iliac vein stenting, patients who subsequently underwent lymphedema surgery were identified. The pre- and post-lymphedema surgery outcomes in these patients were compared at the latest follow up. Patient reported symptoms, physical examination findings and ICG lymphography reports were used as the outcome measures.

Results A total of 16 patients were included in the study. 81% were female, average BMI was 27.1 and median age at consult was 53.7 years. The average duration of symptoms was 15.3 months and included unilateral lymphedema on the lower left extremity (75%) and bilateral swelling of the lower extremities (25%), with one patient experiencing testicular swelling as well. 12 (75%) patients had stenting of the iliac vein and 3 (18%) had stenting planned but could not be performed due to logistic and technical reasons. All 12 patients who underwent stenting reported little or no improvement after 1 year of follow-up. The ICG lymphography showed dermal backflow patterns in 11 patients, one patient was allergic to ICG. Of these patients, 2 underwent lymphaticovenous anastomosis (LVA), and 4 had debulking surgery. All 6 patients who underwent lymphatic surgery reported improvement at mean latest follow-up of 13.6 months (8.2 – 22.5 months), with favorable symptoms reduction and improved physical examination and ICG lymphography findings.

Conclusion The diagnosis of 'lymphatic insufficiency' can be missed when iliac vein compression (May Thurner syndrome) is incidentally detected in patients with lower extremity swelling. Patients who do not respond to iliac vein stent placement should have lymphatic system evaluation with ICG lymphography and be considered for lymphatic surgery when indicated.

References: 1. Lurie F, Malgor RD, Carman T et al. The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment.Phlebology.2022;37(4):252-66. 2. Sachanandani NS, Chu SY, Ho OA et al. Lymphedema and concomitant venous comorbidity in the extremity: comprehensive evaluation, management strategy, and outcomes. Journal of Surgical Oncology. 2018;118(6):941-52. 3. Gupta R, Mathijs E, Hart J et al. May-Thurner Syndrome and Lymphedema Reconstruction. Plastic and Reconstructive Surgery Global Open. 2022;10(6).

BACKGROUND: Liposuction is a time-tested treatment for solid-predominant lymphedema. However, its technical execution, physiological effects, and impacts on the pathophysiology remain debated. In this study, we report our 2-year experience of treating solid-predominant lymphedema with tumescent liposuction with simultaneous skin excision.

METHODS: All patients with solid-predominant extremity lymphedema who underwent liposuction between February 2020 and April 2022 were included. Following liposuction, those with a positive "flying squirrel" sign, which is more than 4-cm skin excess under maximal traction, underwent simultaneous skin excision. Standardized outcome tracking protocol of symptoms report, physical examination, volumetric reduction, and indocyanine green (ICG) lymphography were administered preoperatively and at predetermined intervals postoperatively.

RESULTS: 82 patients underwent liposuction with skin excision in one extremity, totaling 34 upper extremities (UE) and 48 lower extremities (LE). Liposuction was carried out using tumescence. Tourniquet was used when operating forearms and lower legs. All extremities demonstrated a positive "flying squirrel" sign and underwent immediate skin excision. Average operative time was 147 minutes for upper extremities and 174 minutes for lower extremities. Post-operative complications were seen in the lower extremities only and consisted of infection (n=3), pressure injury (n=3) and wound dehiscence/skin necrosis (n=3). The average lipoaspirate volume and percentage of adipose tissues was 2,100 cc (71%) for UEs and 3,560 cc (71%) for LEs. The average skin excised was 175 cm2 for UEs and 344 cm2 for LEs. The follow-up period averaged 10.1 ± 6.7 months for upper extremity patients and 11.5 ± 6.9 months for lower extremity patients. At the latest follow-up, volume data was available for 22/34 UE patients and 29/48 LE patients showing an average volume reduction of 28.9±11.1% (UE) and 16.39±8.49 % (LE). All patients 82/82 (100%) subjectively reported notable relief of symptoms and functional improvement, with corresponding physical examination findings. ICG lymphography showed progressive improvement in lymphatic function in all UEs 34/34 (100%) and 44/48 (92%) of the LEs. 53% (18/34) of the upper extremity patients and 50% (24/48) of lower extremity patients reported improved responsiveness to compression therapy post-operatively. All expressed satisfaction with the procedure.

CONCLUSION: "Flying squirrel" liposuction is safe and effective in treating solid-predominant lymphedema and is associated with high patient satisfaction.

Background: Lower extremity traumatic wounds pose significant challenge for management, requiring timely and aggressive debridement, a multi-specialty approach, and optimal timing of flap coverage. Pilon fractures involve an impaction injury to the ankle which results in significant soft tissue damage and poor outcomes. Our study directly compares outcomes following management with free flap coverage in patients with open pilon versus non-pilon fracture injuries to assess the efficacy of an orthoplastic protocol at a tertiary hospital, which emphasizes early joint assessment and debridement of open fractures.

Methods: A single-surgeon retrospective chart review of lower extremity reconstruction was performed from September 2017 through October 2022. Inclusion criteria selected for patients that sustained open fractures of the tibia and received treatment according to our county hospital's Orthoplastic Protocol (Figure 1). Data on demographics, wounds characteristics, and flap outcomes were collected and analyzed by wound type. Fluid collections, infection requiring hardware removal, and osteomyelitis were categorized as deep infection. Data was analyzed using independent sample T test for continuous variables and Fisher's exact test for categorical data.

Results: Forty-five patients were identified; 32 patients sustained pilon fractures and 13 patients sustained other lower leg fractures (i.e. plateau, shaft, malleolar). Patient demographics were similar in both groups. There was a higher proportion of Gustilo-Anderson grade II and IIIC fractures in the pilon group compared to the non-pilon group. Mechanisms of injury included falls, gunshot wounds, and motor vehicle or motorcycle collisions. There were 2 total flap losses in the pilon fracture cohort, with one patient required below-the-knee amputation. In the non-pilon cohort, there were 2 total and 2 partial flap losses in the non-pilon fracture cohort; two patients ultimately required amputation. The anterolateral thigh (ALT) flap was the most common free flap used for both pilon and non-pilon groups. The average follow-up time was 7 months. There was no significant difference in rates of unplanned reoperation, deep and superficial infection, malunion, non-union, need for additional flap, long term antibiotics, and other complications between the two groups.

Conclusion: While pilon and non-pilon fractures had significantly different distributions of open fracture types, outcomes following flap coverage of open pilon fractures are comparable to that of their non-pilon counterparts. The historically worse outcomes documented in the literature for pilon fractures appear to be mitigated with the new orthoplastic protocol in our hospital. Future directions include comparing outcomes of pilon fractures managed without free flaps with those requiring free flap coverage.

BACKGROUND: A palliative operation can be defined as one that is "largely intended for symptom relief or avoidance of symptoms or conditions anticipated secondary to progressive local disease and is unlikely to alter the ultimate progression of disease in his patient or significantly impact patient survival."1 Scalp defects requiring free tissue transfer often present as a result of advanced oncologic or complex traumatic etiology affecting a relatively high-risk patient population. The challenge of reconstructing large scalp defects coupled with the fact that many scalp tumors present as locally-advanced disease often only leaves free tissue coverage as the only option. 2 We propose the use of free tissue transfer for scalp reconstruction to be viewed as a palliative operation to facilitate resection of the underlying pathology.

METHODS: A retrospective analysis was performed on patients undergoing scalp reconstruction with free tissue transfer at Emory University Hospital and Grady Memorial Hospital between 2011-2021. Patient demographics, wound characteristics, operative details, and complications were recorded. Statistical analysis using univariate and multivariate models were performed.

RESULTS: 45 patients underwent free flap scalp reconstruction during the study time period. The average patient age was 58.8 years. Wound etiology was predominantly oncologic in nature (n=38, 84.4%), followed by trauma (n=5, 11.1%), infection (n=1, 2.2%), and stroke (n=1, 2.2%). 38 patients (84.4%) had calvarial involvement and 17 patients (37.8%) had involvement of the dura. The median follow-up was 350 days. There were 33 patients (73.3%) with healed flaps, 9 patients (20.0%) who had wound healing issues, and 3 patients (6.7%) with flap failures. The average hospital length of stay was 17.7 days with 35 patients (77.8%) being discharged to either home or a rehabilitation facility. The remaining 10 patients (22.2%) were discharged to hospice or died. The 30-day mortality was 6 patients (13.3%) and the 6-month mortality was 8 patients (20.5%). On univariate analysis, there was a statistically significant difference in 30-day (p=0.0001) and 6-month (p=0.003) mortality for patients >70 years in age. On multivariate analysis, there was a statistically significant difference in 6-month mortality for patients >70 years in age. No other risks factors (including patient comorbidities, smoking status, defect size, free flap type, calvarial involvement or reconstruction) contributed to rates of complications or mortality.

CONCLUSION: While age >70 years is a significant risk factor for mortality in patients undergoing free flap scalp reconstruction, this is likely related to underlying disease process. Free flap reconstruction for scalp defects have a high success rate and can be considered a palliative procedure for patients with locally-advanced disease.

1 Hofmann B, Haheim LL, Soreide JA. Ethics of palliative surgery in patients with cancer. Br J Surg 2005; 92(7): 802-9. 2 Desai SC, Sand JP, Sharon JD, Branham G, Nussenbaum B. Scalp reconstruction: an algorithmic approach and systematic review. JAMA Facial Plast Surg. 2015;17(1):56-66.

Introduction: Burn surgery teachings have long held that thicker grafts including full-thickness or thick STSG (0.025 inch) have better functional and cosmetic outcomes than standard (0.012 – 0.020 inch) and thin (0.008 – 0.011 inch) STSG, due to concern for contraction and poor color matching. This is thought to be due to the higher ratio of dermis to epidermis in thicker grafts which resist secondary contracture. As the thickness of the STSG decreases, the amount of dermis in the graft decreases. Reports in the literature estimate epidermal thickness to be between 5 and 49 micrometers in thickness (about 0.0006 – 0.0015 inch). Recently, Chacon, et al, in the largest single-surgeon experience with thin and ultra-thin STSG (

Methods: The study includes sampling from excess ultra-thin STSG on ten patients undergoing STSG to reconstruct burn injuries. STSG were harvested via air-powered dermatome at a depth of 0.004 inch (4/1000 inch). Sample thickness were recorded, including average thickness per sample and standard deviation. These samples were then preserved in formalin, formally processed by surgical pathology, and examined by a dermopathologist to determine cellular content, including harvested epidermal and dermal sub-layers and cell-thickness counts for each layer.

Results: The overall mean graft thickness was 117.0 micrometeres with a SD of 21.0 OR 4.6/1000" with a SD of 0.8/1000". Each graft contains the epidermis and a small portion of reticular dermis.

Conclusions: Our ultra-thin split-thickness skin grafts cut with a dermatome set to 4/1000 " were found to contain mostly epidermis with varying degrees of papillary dermis. The portion of hair follicle which contains stem cells is not present in our grafts. There is no reticular dermis present in our grafts. Although the dermatome was set to 4/1000" the mean thickness of our grafts was 4.6/1000" with a standard deviation of 0.8/1000".

Introduction

Cardiac pacemaker systems consist of a battery and electrodes that travel through venous system to the heart. Due to foreign nature of cardiac pacemaker systems, following implantation, pain, infection, and exposure may occur. Many surgical techniques have been defined in literature for cardiac pacemaker salvage1-3. In our study, the results of transposition of exposed cardiac pacemakers beneath pectoral fascia are presented.

Patients and Methods

Patients who underwent surgery for cardiac pacemaker transpositions were reviewed retrospectively. 22 patients who were operated and followed for at least 12 months are included in the study. Patients' age, gender, medical and surgical histories, comorbidities, time to exposure, laboratory, radiological and microbiological culture examination results, early and late complications due to salvage surgery were investigated. 

Intraoperatively, capsule around the pacemaker battery, all necrotic and infected tissues were debrided. Deep tissue cultures were taken. Pectoral fascia was identified with inferomedial dissection and a new subfascial pocket was created. The pacemaker battery was transposed to the new pocket. Muscle fascia was sutured, and drain was placed in the previous pocket which was later obliterated with subdermal sutures. Subdermal and dermal sutures were placed. Empiric antibiotherapy was later rearranged with accordance to culture results.

All patients were evaluated with ultrasonography. Battery position, pocket thickness and condition were recorded.

Results

15 patients were male and 7 were female. The mean age of patients was 68.4 ± 12.3 years (54-85). Patients had a history of coronary artery by-pass graft surgery (n=6), diabetes mellitus (n=7), hypertension (n=13), anticoagulant use (n=19), battery loss due to exposure (n=2), smoking (n=14) and chronic kidney disease (n=2). Mean time to cardiac pacemaker exposure was 30.1 ± 18.7 months (8-66), and patients had clinical signs of infection such as high fever (n=2), purulent drainage (n=19), erythema at the pacemaker site and increased temperature (n=15), high WBC count (n=19) and CRP (n=22). No early or late complications, or recurrent exposure was observed in follow-up. 3 patients were culture negative, the rest had predominantly skin flora growth. Antibiotics were prescribed due to antibiogram results. In radiologic evaluations, no fluid collection or out-of-pocket malposition was observed.

Discussion

Instrumentation with foreign bodies such as cardiac pacemakers carry specific risks. Subcutaneous tissue atrophy with aging, chronic irritation with foreign body, comorbidities, superficial placement of batteries increase the risk of exposure. Numerous flap options have been described for cardiac pacemaker salvage. The prepectoral plane, which is frequently used in breast reconstruction with implants, is a safe are for foreign body placement. Transposition of batteries to prepectoral plane for cardiac pacemaker exposure salvage is a simple and safe procedure compared to classical and complex flap options. 

1. Çiloğlu NS, Gümüş N, Eraslan T, Çiloğlu U. Salvage of the exposed cardiac pacemakers with pocket change and local flaps. Turkish Journal of Thoracic and Cardiovascular Surgery. 22(1)
2. Bonawitz SC. Management of exposure of cardiac pacemaker systems. Annals of plastic surgery. 2012;69(3):292-295.
3. Aksoy A, Dağdelen D, Sirvan SS. Ekspoze Olmuş Kalp Pillerinin Fasyakütan Lokal Flep Yardımı ile Kurtarılması. 2018;

BACKGROUND

Current dogma amongst lymphedema surgeons considers venous insufficiency a contraindication to lymphovenous anastomosis (LVA). The aim of this study is to assess if the efficacy of lymphaticovenular anastomosis (LVA) is mitigated by chronic venous insufficiency (CVI). We hypothesize that objective lymphatic flow improvement will still be seen after LVA in patients who suffer from CVI.

METHODS

A retrospective chart review of consecutive index LVAs performed by the senior author using a previously described "octopus" technique was conducted. Patients with history of CVI who underwent pre- and post-LVA delayed indocyanine green (ICG) lymphography were isolated. All patients had previously failed lymphedema therapy and underwent standardized diagnostic and tracking protocol including patient report, circumference measurements, and indocyanine green (ICG) lymphography preoperatively and at predetermined postoperative intervals.

RESULTS

Twelve patients with history of preoperatively diagnosed CVI underwent LVA procedures for primary or secondary lymphedema during the study period. Over half of patients (n=8, 67%) had been diagnosed with May-Thurner syndrome at mean 27 months pre-LVA; the remainder had developed CVI following ablation of greater saphenous vein. All patients suffered unilateral lower extremity lymphedema. Mean BMI was 26.3 (std. dev. 3.4) and mean duration of clinical symptomology was 17 months. LVA was performed in a single extremity in all cases. Dermal backflow patterns were observed in all patients preoperatively. The meaqn number of LVAs performed in each patient was 6.1 (min.-max. 5-7). Mean follow-up was 9.1 months. No complications were observed. At the time of latest follow-up, all operated limbs showed improvement in pattern of lymph flow (i.e., normalized linear flow or less-severe dermal back flow) and ICG distance traveled (i.e., more proximally-tracking ICG flow).

CONCLUSION

LVA can remain efficacious and yield clinical benefit in select patients with venous insufficiency. Criteria for patient selection and prognosis prediction remain to be elucidated.

Background/Purpose

Pectus arcuatum is a rare chest wall deformity caused by premature obliteration of the ossification centers in the sternum resulting in a unique deformity characterized by a short, z-shaped sternum with a prominent outward protrusion at the angle of Louis [1]. Pectus arcuatum is structurally different from the more common pectus excavatum and carinatum deformities, which are commonly repaired with minimally-invasive placement of a Nuss bar [2]. Placement of Nuss bar for correction of pectus arcuatum does not adequately correct the chest wall deformity and often results in worsening of the prominence at the angle of Louis. Traditional Ravitch repair is most frequently performed for surgical correction of pectus arcuatum and involves a large median sternotomy or clamshell incision and carries a significant risk of morbidity including damage to costal cartilage growth centers leading to iatrogenic deformity of the anterior chest [1]. We report results of a novel minimally-invasive approach combining anterior wedge osteotomy of the sternum and contouring of the prominent costal cartilages with Nuss bar placement for the surgical management of pectus arcuatum.

Methods

A chart review of all patients with pectus arcuatum managed with a minimally-invasive surgical approach at our institution from 2018 to 2022 was performed. Demographic data, presenting symptoms, surgical treatment, complications and outcomes were collected.

Results

Eight patients, five (62.5%) male, with a mean age of 14 years (8-18) at time of surgery were included in the study with a mean length of follow-up of 8 months. Average pre-operative Haller index was 3.45 (2.8-4.3). Plastic surgery performed sternal osteotomy and fixation and costal cartilage contouring, with Nuss bar placement by pediatric surgery if indicated. Mean length of hospital stay was 3.0 days, which is similar to length of stay for Nuss bar placement alone at our institution. Post-operative pain scores were not increased over Nuss bar placement alone, but operative times were longer. There were three patients with minor complications (all superficial wound infections) that did not require operative take-back. All patients and parents reported cosmetic improvement.

Conclusion

The described minimally-invasive surgical procedure performed for correction of pectus arcuatum results in symptomatic and cosmetic improvement and does not increase morbidity in pectus repair.

Citations

1. Gritsiuta, Andrei I., et al. "Currarino-Silverman Syndrome: Diagnosis and Treatment of Rare Chest Wall DEFORMITY, a Case Series." Journal of Thoracic Disease, vol. 13, no. 5, 2021, pp. 2968–2978., doi:10.21037/jtd-20-3472.

2. Nuss, Donald, et al. "A 10-Year Review of a Minimally Invasive Technique for the Correction of Pectus Excavatum." Journal of Pediatric Surgery, vol. 33, no. 4, 1998, pp. 545–552., doi:10.1016/s0022-3468(98)90314-1.

Heterotopic Ossification (HO) is a complex condition resulting in ossification of normal soft tissue such as fascia, muscles, and tendons. It occurs after trauma, injury, and burns resulting in impaired range of motion, joint stiffness, and decreased mobility1,2. Male gender has been shown to be a risk factor for the development of HO3. This study aims to identify the demographic of burn patients that develop HO after injury to further elucidate mechanisms for the development of HO. To determine the protective effect that female sex hormones could have in the development of HO after burns, we compared outcomes of HO in female burn patients that were prescribed hormone replacement therapy (HRT) to those that were not.

We queried the TriNetX database, a federated research network of real-world data, for ICD10 codes encompassing heterotopic ossification (HO) and burn injury. Forming two groups, A) burned patients with first time HO diagnosis on or after the incidence of burn injury, and B) burned patients with no diagnosis of HO we compared the demographic, burn location, and TBSA between groups. We then specifically identified the female burn patient population and further classified that group into female burn patients receiving HRT and female burn patients not receiving HRT. After propensity matching for age, race, and ethnicity, we investigated the rate of HO for females after burns in both the HRT and non-HRT group.

Of 631,222 patients with burns, 1,158 (0.18%) developed HO showing a right skewed distribution. Group A patients (burn patients with HO) were older (50.5± 19.1 yrs) vs Group B patient (burn patient with no HO (33.4± 23.2 yrs) (p <0.001), primarily male (58%), white (66%), and Non-Hispanic (79%) and primarily in the upper extremity and head (67.2%). In investigating the effects of hormone replacement therapy on female burn patients, we found no significant difference between female burn patients taking HRT and female burn patients not taking HRT in the development of HO with odds ratio 1.408, 95% CI [0.725, 2.735].

HO affects only 0.18% of the burn population. Those at higher risk include older age, white males with interquartile range of TBSA <30%. In particular, the use of HRT in female burn patients was not shown to offer a protective mechanism in the development of HO. This study will call for further research into the mechanism for the development of HO. In identifying the demographic information of those that develop HO, we will be able to treat eligible patients prophylactically with NSAIDs, radiotherapy, or bisphosphonates 4.

1. Sun Y, Lin Y, Chen Z, Breland A, Lineaweaver WC, Zhang F. Heterotopic Ossification in Burn Patients. Ann Plast Surg. 2022;88(2):S134-S137. doi:10.1097/SAP.0000000000002901
2. Ranganathan K, Loder S, Agarwal S, et al. Heterotopic Ossification: Basic-Science Principles and Clinical Correlates. J Bone Joint Surg Am. 2015;97(13):1101. doi:10.2106/JBJS.N.01056
3. Ranganathan K, Peterson J, Agarwal S, et al. Role of Gender in Burn-Induced Heterotopic Ossification and Mesenchymal Cell Osteogenic Differentiation. Plast Reconstr Surg. 2015;135(6):1631. doi:10.1097/PRS.0000000000001266
4. Shapira J, Yelton MJ, Chen JW, et al. Efficacy of NSAIDs versus radiotherapy for heterotopic ossification prophylaxis following total hip arthroplasty in high-risk patients: a systematic review and meta-analysis. HIP Int. 2022;32(5):576-590. doi:10.1177/1120700021991115/FORMAT/EPUB

Purpose: Historically, supermicrosurgical lymphaticovenular anastomosis (LVA) is regarded technically difficult and unachievable, and therefore contraindicated in advanced lymphedema demonstrating "diffuse" and/or absence of "linear" pattern on indocyanine green (ICG) lymphography. More invasive vascularized lymph node transplants are preferred in these cases. In this study, we describe our experience of attempting LVA in these challenging cases.

Methods: All patients with fluid-predominant lymphedema who underwent LVA between February 2020 and March 2022 were included. Patients with pre-operative ICG lymphography demonstrating "diffuse" and/or absence of "linear" pattern were included in the study group, while the remainder of LVA patients were assigned to the control group. Surgical time, number of LVAs, patient report, physical examination, and post-operative ICG scans at 3, 6, and 12 months were compared between both groups.

Results: Thirteen limbs showed "diffuse" and/or absent "linear" pattern while 70 limbs showed "linear" pattern on pre-operative immediate ICG scan. Mean follow-up time was 14.18 ± 6.46 months and 14.83 ± 9.12 months for study and control groups, respectively. Surgical times (p=0.31) and number of LVAs (p=0.25) did not vary significantly between groups. Patient-reported symptom relief and reduction in swelling were seen in 11 limbs in the study group and 65 limbs in the control group (p=0.19). Post-operative ICG scans improved in 11 limbs in the study group and 68 limbs in the control group (p=0.22). No significant differences were reported between study and control groups.

Conclusion: LVA can be performed in advanced fluid-predominant lymphedema. The technical difficulty and efficacy of LVA in this group is not significantly different from patients with "linear" patterns on ICG lymphography.

Objective: In patients with chronic lower extremity (LE) wounds, chronic osteomyelitis confers additional complexity to achieving adequate treatment.1 Previous systematic reviews demonstrate increased rates of osteomyelitis recurrence in patients who receive muscle flaps compared to fasciocutaneous flaps for LE limb salvage;1,2 however, these studies do not limit populations to atraumatic patients who receive exclusively free flaps. Thus, this study compared rates of recurrence in chronic osteomyelitis patients undergoing LE reconstruction with fasciocutaneous versus muscle free flaps.

Methods: Chronic osteomyelitis patients undergoing FTT between July 2011 and July 2021 were retrospectively reviewed. Patients were stratified into fasciocutaneous and muscle free flap groups. Primary outcomes included osteomyelitis recurrence, flap complications, limb salvage, and ambulatory status. Each patient was admitted, and wounds were debrided until all necrotic and non-viable tissue was removed, and culture results from bone specimen were negative prior to FTT.

Results: Forty-eight patients with chronic osteomyelitis of the wound bed were identified, of which 58.3% received fasciocutaneous (n=28) and 41.7% received muscle flaps (n =20). The most common comorbidities included diabetes mellitus (n=29, 60.4%), peripheral neuropathy (n=27, 56.3%) and peripheral vascular disease (n=24, 50.0%). Mean BMI was higher in the muscle flap cohort compared to the fasciocutaneous cohort (37.0 + 27.9 kg/m2, p=0.006). Mean hemoglobin A1c level was 6.6. Methicillin-resistant or -sensitive Staphylococcus aureus was the most common isolated pathogen in 18.7% (n=9) of procedures. The majority of the study population underwent a median of three debridements followed by NPWT prior to receiving FTT. There were no significant differences in preoparative anterior tibial, posterior tibial or peroneal artery patency. Post-endovascular LE intervention (i.e., balloon angioplasty) vessel run-off was similar between cohorts. Additionally, wound location, wound area, day-of-FTT tissue cultures, and bone pathogen on initial culture did not significantly differ between cohorts. End-to-side anastomosis was utilized comparably between cohorts with similar rates of recipient arterial vessels anastamosed. Calcified vessels were encountered in 25.0% of both cohorts. At a median follow-up of 14.6 months, the limb salvage and ambulatory rates were 79.2% (n=38) and 83.3% (n=40), respectively. The overall rate of microsurgical flap success was 93.8% (n=45). Osteomyelitis recurred in 25% of patients (n=12) at a median duration of 4.0 months. There were no significant differences in rates of osteomyelitis recurrence, flap complications, limb salvage, ambulation, and mortality when stratifying by flap composition. On multivariate analysis, flap composition remained a nonsignificant predictor of osteomyelitis recurrence (OR 0.975, p=0.973).

Conclusion: This study demonstrates that flap composition does not influence recurrence of osteomyelitis following free flap reconstruction of chronic lower extremity wounds, suggesting that optimal flap selection should be based on wound characteristics and patient goals.

References 1. Kovar A, Colakoglu S, Iorio ML. Choosing between Muscle and Fasciocutaneous Free Flap Reconstruction in the Treatment of Lower Extremity Osteomyelitis: Available Evidence for a Function-Specific Approach. J Reconstr Microsurg. 2020;36(3):197-203. doi:10.1055/S-0039-1698469 2. Shimbo K, Kawamoto H, Koshima I. Muscle/musculocutaneous versus fasciocutaneous free flap reconstruction in the lower extremity: A systematic review and meta-analysis. Microsurgery. 2022;42(8):835-847. doi:10.1002/MICR.30961

Introduction: Hidradenitis suppurativa (HS) is a chronic inflammatory disease affecting intertriginous skin-bearing apocrine glands. Severe HS, characterized by chronic inflammation, sinus tracts, and scarring, poses reconstructive challenges and surgical treatment often is accompanied by high complication rates. Despite these findings, risk factors for complications are not extensively studied. The objective of our study was to determine if patient-level risk factors were associated with increased complications and to characterize operative techniques at our institution. We hypothesized that smoking status, body mass index (BMI), and diabetes were associated with increased odds of complications. Methods: We performed an IRB-approved retrospective review on patients aged 0-99+ admitted for primary or secondary wide local excision of HS from 12/1/2015 to 06/02/2022. Patients who did not undergo surgical treatment at our institution or who had a follow up period of less than 90 days were excluded. Patient demographic data including age, race, ethnicity, and payer type; intraoperative data; and complications data were extracted. Complications within 90 days included delayed healing, surgical site infection, flap/graft failure, hemorrhage, hematoma, hypertrophic granulation, new disease, seroma, wound dehiscence, and unplanned return to the operating room. Long-term complications included contractures, failed healing, hypertrophic scarring, keloid scarring, neuropathic pain, recurrence at original site, and unplanned revision surgery. Both 90-day and long-term (>90 days) complications were combined into an overall complications category. Data were analyzed with descriptive statistics and Fisher's exact tests. Multiple logistic regression was used to determine the association between patient demographic factors and occurrence of any 90-day or long-term complications. Significance was set at p<0.05. All analyses were performed in RStudio 4.1.2. Results: Of 347 patients identified, 141 (40.6%) met inclusion criteria. Median age was 35 [interquartile range (IQR) 26, 46] years and median follow-up 12.4 [IQR 5.1, 34.4] months. Of the 241 total admissions, 623 surgeries were performed on 902 total sites. The most common surgery performed was excision and debridement (n=227 surgeries, 36.4%); the most common surgical site was the genital/groin region (n=260 sites, 28.8%). Eighty-four patients (59.6%) experienced 189 overall complications (30.3% of surgeries) of which 74 patients (52.5%) experienced 148 (23.8% of surgeries) 90-day complications and 30 patients (21.3%) experienced 41 (6.6% of surgeries) long-term complications. The most common complication was wound dehiscence (n=47 patients, 33.3%). Unplanned 90-day reoperations occurred at a higher rate in patients aged ≥65 years (n=1, 16.7%) compared to patients aged 30-64 (n=2, 2.4%) and those under 30 (n=0) (p=0.027). Delayed wound healing occurred at a higher rate in patients with diabetes (n=3, 17.6%) versus those without (n=3, 2.4%, p=0.023). Regression controlling for number of admissions and number of surgeries found no sociodemographic factors associated with increased odds of complications. Conclusions: Our study found that HS patients with diabetes more often experienced delayed wound healing compared to HS patients without diabetes. However, factors including smoking status and BMI were not associated with increased complications after surgical HS excision. Additional studies with larger sample sizes are needed to fully elucidate risk factors that may predispose HS patients to more post-operative complications.