Impact of Plastic Surgery and an Enhanced Prophylaxis Protocol on Cervical Spine Surgery Infection.

Background: Reduction of surgical site infections (SSIs) is important in improving cervical spine surgery outcomes. Plastic surgery involvement and an enhanced modified prophylaxis protocol may reduce infection rates. Methods: A total of 962 cervical spine operations were conducted by a single surgeon (TFC). An enhanced modified prophylaxis protocol and plastic surgery were used in some operations. Differences in infection rates, surgical approach, previous operations, prophylaxis use, and plastic surgery involvement were compared using Fisher's exact tests and multivariate linear regression. Results: Four patients (0.42%) experienced SSIs. All 4 infections involved the standard protocol, posterior approach, and did not involve plastic surgery. The infection rate was lower in the enhanced protocol group when compared to the standard protocol (ß -0.78, 95% CI -1.23 to -0.33, P = .0008). The enhanced protocol group had an increased percentage of operations with plastic surgery (ß 0.19, 95% CI 0.10 to 0.28, P < .0001). The infection rate among the plastics group was 0.00% compared to 0.60% for the non-plastics group (P = .32). The plastics group had a lower rate of anterior approach when compared to the non-plastics group (ß -0.20, 95% CI -0.24 to -0.15, P = .049). Among the posterior approach group, procedures with plastic surgery had an infection rate of 0.00% compared to 2.53% without plastic surgery (P = .13). Conclusion: The enhanced protocol was associated with a lower SSI rate and increased plastic surgery involvement. Posterior approaches were associated with increased infection rates and the likelihood of utilizing plastic surgery. Both the enhanced protocol and plastic surgery may decrease infection.

Contexte: La réduction des infections du site opératoire est importante pour améliorer les résultats de la chirurgie de la colonne cervicale. L'implication de la chirurgie plastique et d'un protocole amélioré de prophylaxie modifiée peuvent réduire les taux d'infection. Méthodes: Un total de 962 opérations sur la colonne cervicale a été effectué par un seul chirurgien (TFC). Un protocole amélioré de prophylaxie modifiée et la chirurgie plastique ont été utilisés au cours de certaines interventions. Les différences dans les taux d'infection, l'abord chirurgical, les opérations précédentes, l'utilisation de la prophylaxie et l'implication de la chirurgie plastique ont été évalués au moyen de tests exacts de Fisher et d'une régression linéaire multifactorielle. Résultats: Quatre patients (0.42%) ont présenté une infection de la cicatrice opératoire (ICO). Les quatre infections impliquaient le protocole standard, l'abord postérieur et l'absence de chirurgie plastique. Le taux d'infection a été moindre dans le groupe de protocole amélioré, comparativement au protocole standard (ß −0.78, IC à 95%: −1.23 à −0.33, P = .0008). Le pourcentage d'opérations avec chirurgie plastique était augmenté dans le groupe au protocole amélioré (ß 0.19, IC à 95%: 0.10 à 0.28, P < .0001). La fréquence des infections dans le groupe de chirurgie plastique était de 0.00%, comparée à 0.60% dans le groupe sans chirurgie plastique (P = .32). Le groupe avec chirurgie plastique avait un taux d'abord antérieur inférieur comparativement au groupe sans chirurgie plastique (ß −0.20, IC à 95%: −0.24 à −0.15, P = .049). Dans le groupe avec abord postérieur, le taux d'infections était de 0.00% avec chirurgie plastique contre 2.53% sans chirurgie plastique (P = .13). Conclusion: Le protocole amélioré a été associé à un taux d'OCI inférieur et à une plus grande implication de la chirurgie plastique. Un abord postérieur a été associé à des taux augmentés d'infection et à une plus grande probabilité d'utilisation de la chirurgie plastique. Le protocole amélioré et la chirurgie plastique peuvent tous deux réduire les infections.

Autologous Breast Reconstruction in a Patient With End-Stage Renal Disease and Systemic Lupus Erythematosus.

Background: Patients with end-stage renal disease (ESRD) secondary to systemic lupus erythematosus (SLE) have historically been deterred from free flap breast reconstruction due to perceived complication risks. Numerous studies examining patients with ESRD have cited free flap complications, including increased incidences of infection and wound breakdown, with some surgeons suggesting ESRD is an independent risk factor for flap failure.15 Due to perceived risks, autologous breast reconstruction has not been extensively explored as an option in patients with ESRD on hemodialysis with comorbid connective tissue/autoimmune disorders, such as SLE. To the authors' knowledge, there are currently no published reports of successful free flap breast reconstruction in patients with ESRD due to SLE. Methods: This case report describes a patient requiring hemodialysis for ESRD caused by SLE who underwent left mastectomy and immediate autologous breast reconstruction. Deep inferior epigastric perforator flap technique was employed. Conclusions: This successful case report suggests the use of free flaps is a feasible option that should be considered for oncologic breast reconstruction in patients with ESRD secondary to SLE who require hemodialysis. The authors believe that further investigation is warranted to evaluate the safety of autologous breast reconstruction as an option for patients with either comorbidity. While ESRD and SLE are not explicit contraindications to free flap reconstruction, careful patient selection and appropriate indication is paramount for immediate surgical and long-term reconstructive success.

Sweet Syndrome After Bilateral Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Case Report.

We describe a case of Sweet's Syndrome after bilateral deep inferior epigastric perforator flap breast reconstruction in a patient with ductal carcinoma of the left breast.

Use of antibiotic beads to salvage infected breast implants.

PURPOSE: When an implant becomes infected, implant salvage is often performed where the implant is removed, capsulectomy is performed, and a new implant is inserted. The patient is discharged with a PICC line and 6-8 weeks of intravenous (IV) antibiotics. This method has variable success and subjects the patient to long-term systemic antibiotics. In the 1960s, the use of antibiotic-impregnated beads for the treatment of chronic osteomyelitis was described. These beads deliver antibiotic directly to the site of the infection, thereby eliminating the complications of systemic IV antibiotics. This study aimed to present a case series illustrating the use of STIMULAN calcium sulfate beads loaded with vancomycin and tobramycin to increase the rate of salvage of the infected implant and forgo IV antibiotics. METHODS: A retrospective analysis was performed of patients who were treated at Mount Sinai Hospital for implant infection with salvage and antibiotic beads. RESULTS: Twelve patients were identified, 10 of whom had breast cancer. Comorbidities included hypertension, smoking, and immunocompromised status. Infections were noted anywhere from 5 days to 8 years postoperatively. Salvage was successful in 9 out of the 12 infected implants using antibiotic bead therapy without home IV antibiotics. CONCLUSIONS: The use of antibiotic beads is promising for salvaging infected breast implants without IV antibiotics. Seventy-five percent of the implants were successfully salvaged. Of the three patients who had unsalvageable implants, one was infected with antibiotic-resistant Rhodococcus that was refractory to bead therapy and one was noncompliant with postoperative instructions.

Multicenter, Prospective, Longitudinal Study of the Recurrence, Surgical Site Infection, and Quality of Life After Contaminated Ventral Hernia Repair Using Biosynthetic Absorbable Mesh: The COBRA Study.

OBJECTIVE: The aim of the study was to evaluate biosynthetic absorbable mesh in single-staged contaminated (Centers for Disease Control class II and III) ventral hernia (CVH) repair over 24 months. BACKGROUND: CVH has an increased risk of postoperative infection. CVH repair with synthetic or biologic meshes has reported chronic biomaterial infections and high hernia recurrence rates. METHODS: Patients with a contaminated or clean-contaminated operative field and a hernia defect at least 9 cm had a biosynthetic mesh (open, sublay, retrorectus, or intraperitoneal) repair with fascial closure (n = 104). Endpoints included overall Kaplan-Meier estimates for hernia recurrence and postoperative wound infection rates at 24 months, and the EQ-5D and Short Form 12 Health Survey (SF-12). Analyses were conducted on the intent-to-treat population, and health outcome measures evaluated using paired t tests. RESULTS: Patients had a mean age of 58 years, body mass index of 28 kg/m, 77% had contaminated wounds, and 84% completed 24-months follow-up. Concomitant procedures included fistula takedown (n = 24) or removal of infected previously placed mesh (n = 29). Hernia recurrence rate was 17% (n = 16). At the time of CVH repair, intraperitoneal placement of the biosynthetic mesh significantly increased the risk of recurrences (P ≤ 0.04). Surgical site infections (19/104) led to higher risk of recurrence (P < 0.01). Mean 24-month EQ-5D (index and visual analogue) and SF-12 physical component and mental scores improved from baseline (P < 0.05). CONCLUSIONS: In this prospective longitudinal study, biosynthetic absorbable mesh showed efficacy in terms of long-term recurrence and quality of life for CVH repair patients and offers an alternative to biologic and permanent synthetic meshes in these complex situations.

Use of both antegrade and retrograde internal mammary vessels in the bipedicled deep inferior epigastric perforator flap for unilateral breast reconstruction.

BACKGROUND: Autologous abdominal tissue transfer is a well-established method of breast reconstruction. The deep inferior epigastric perforator (DIEP) flap has the additional benefit of minimal donor site morbidity as it spares the muscle and fascia. Conventional DIEP flaps may not provide adequate volume in cases where the patient is thin, has midline abdominal scars, and/or has a large volume of tissue to replace. One solution is to use a bipedicled DIEP flap, incorporating all the available abdominal tissue. Bipedicled DIEP flaps have been described in a number of different configurations. The literature appears to favor intra-flap anastomosis, with a minimal exposition of two recipient vessels. It has been demonstrated that both the antegrade internal mammary artery (aIMA) and retrograde internal mammary artery (rIMA) are adequate recipient vessels. Here, the authors present a single-center experience with bipedicled DIEP flaps to both the aIMA and rIMA, showing their feasibility and safety. METHODS: A retrospective review of patients who underwent unilateral breast reconstruction using bipedicled DIEP flaps was performed to assess outcomes. RESULTS: A total of 20 patients who underwent unilateral breast reconstruction using a bipedicled DIEP flap were selected for this study. All of them were previously diagnosed with cancer. There were zero flap failure and zero instance of abdominal hernia or issue with abdominal wall functionality following the surgeries. CONCLUSIONS: The series of surgeries described in this study resulted in successful breast reconstruction in 20 women using a bipedicled DIEP flap. The results show that this approach allows for reconstruction in places where a conventional DIEP does not provide adequate volume, achieved safely, and does not increase morbidity. The bipedicled DIEP flap is a viable option for large-volume autologous breast reconstruction, providing ample tissue for successful reconstruction while also allowing for shorter recovery and limited donor site morbidity.

Squamous cell carcinoma of the vulva arising in the setting of chronic hidradenitis suppurativa: A case report.

•Highlights the sheer mass of tumor encountered with hidradenitis suppurativa.•Reviews the complexity of wound healing with hidradenitis suppurativa.•Overview of multi-team approach to a vulvar cancer.

The Use of a Hyaluronic Acid-Carboxymethylcellulose Membrane as an Adhesion Barrier during Nipple Delay before Nipple-preserving Mastectomy.

The desire for nipple-preserving mastectomies has increased over the past decade as studies have proven that the procedure has comparable oncologic risk as a traditional mastectomy in both therapeutic and prophylactic cases. Partial or complete nipple necrosis is a well-known complication of this procedure with rates in the literature ranging between 1% and 9%. In high-risk patients, surgeons are performing a delay procedure before the mastectomy to help improve nipple vascularity and decrease necrosis rates. We present a technique of using a short-lasting bioresorbable hyaluronate-carboxymethylcellulose membrane (Seprafilm; Genzyme, Cambridge, Mass.) during the delay procedure as an interpositional sheet, which prevents adhesion of the anterior breast skin from the underlying gland to both block revascularization to improve nipple perfusion and prevent the need for redissection of the previously created plane during the final mastectomy.

Chest wall reconstruction in thoracoabdominal ectopia cordis: using the pedicled osteomuscular latissimus dorsi composite flap.

Ectopia cordis is a rare congenital defect characterized by complete or partial displacement of the heart outside the thoracic cavity. Repair of ectopia cordis can present a reconstructive challenge often requiring a staged approach. Ideally, structural integrity and protection of the heart are restored using autologous tissues capable of growth. In addition, reconstruction of the thorax must proceed without compromise to pulmonary or cardiovascular stability. The following article describes repair of thoracoabdominal ectopia cordis in a patient with pentalogy of Cantrell. Reconstruction of the chest wall was accomplished using a musculoosseus composite flap involving segments of the 9th and 10th ribs and overlying pedicled latissimus dorsi muscle. This is the first report known to the authors of such a repair.

Thoracoacromial vessels as the recipients for supercharged muscle-sparing transverse rectus abdominis myocutaneous flaps.

We describe the use of the thoracoacromial vessels in microvascular transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction in two cases. The thoracoacromial vessels, used as recipient vessels for supercharged TRAM flaps, offer several advantages. Their location high on the anterior chest wall is ideal for anastomotic repair under the microscope and lends itself to medial placement of the TRAM flap. The thoracoacromial vessels are relatively easily exposed and are suited for microsurgical anastomosis by virtue of their caliber and topology. The dissection of these vessels takes less time than either the internal mammary or thoracodorsal systems. The location of the thoracoacromial vessels allows the flexibility of using either the ipsilateral pedicle for supercharging (deep inferior epigastric vessels on the same side as the superior epigastric pedicle) or contralateral supercharging (deep inferior epigastric vessels on the opposite side of the superior epigastric pedicle). The thoracoacromial vessels make an excellent alternative recipient for microvascular anastomosis in breast reconstruction.