Contemporary Microsurgical Breast Reconstruction: Abdominally Based Flaps.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the types of abdominally based flaps, their anatomy, and their drawbacks. 2. Understand important aspects of the history and physical examination of patients wishing to undergo these procedures. 3. Understand the benefits of preoperative planning and its role in avoiding complication. 4. Understand the operative steps of the procedures and tips to increase efficiency. 5. Understand the postoperative care of these patients and the role of enhanced recovery pathways. SUMMARY: In this article, the authors review the history, current state, and future directions related to abdominally based microsurgical breast reconstruction. This article covers preoperative, intraoperative, and postoperative considerations intended to improve patient outcomes and prevent complications. Evidence-based findings are reported when available to comprehensively review important aspects of these procedures.

The Full Continuum of Robotic Breast Surgery: Robotic-assisted Mastectomy, Robotic DIEP Flap, and Robotic Supermicrosurgery.

In recent years, robotic surgery has rapidly expanded to improve surgical outcomes in a variety of surgical subspecialties. Although plastic surgery has taken longer to integrate robotic surgery into practice, the advantages of robotic-assisted surgery, including improved visualization and resolution, minimally invasive approaches, and the ability to surpass human precision and scale, have driven its more recent adoption into plastic surgery. Currently, procedures performed with robotic assistance that are considered part of the continuum of surgical treatment of breast cancer include robotic-assisted nipple-sparing mastectomy, reconstruction with the robotic latissimus dorsi flap or the deep inferior epigastric artery perforator flap, and robotic microsurgery for the flap anastomosis and/or the surgical treatment of lymphedema. The authors provide an overview of robotic surgery and how it has been integrated into the field of plastic surgery, as well as a review of the most common procedures within the field where robotic assistance can be incorporated: nipple-sparing mastectomy, robotic latissimus flap, robotic deep inferior epigastric artery perforator flap breast reconstruction, and microvascular anastomoses.

Functional Outcomes for Basilar Joint Arthroplasty with Meniscus Allograft Compared with Trapeziectomy Alone.

BACKGROUND: Advanced thumb carpometacarpal (CMC) joint arthritis is widely treated with trapeziectomy. To obviate the need for autologous tissue, maintain thumb length, and reduce the risk of scaphoid impingement, the senior author developed an interposition arthroplasty technique using meniscal allograft. We hypothesize that the use of meniscus improves outcomes and subsequent functionality compared with trapeziectomy alone. METHODS: Twenty-three patients with Eaton stage III-IV CMC osteoarthritis underwent arthroplasty with meniscal allograft, and 7 patients underwent trapeziectomy alone. Preoperative Disabilities of the Arm, Shoulder, and Hand (DASH), pain, grip and pinch strength, and range of motion scores were compared with postoperative scores at 6 weeks, 6 months, and 1 year. RESULTS: The study group consisted of 17 women and 6 men, and the control group consisted of 5 women and 2 men. The mean age was similar at 61.4 (48-72) years and 65.7 (56-78) years for the study and control groups, respectively. The DASH scores dropped by 61.8% in the study group compared with 38.8% in the control group (<0.01), whereas pain decreased 86.0% and 69.8%, respectively (P < .01). Strength and range of motion improvement was similar between the groups. Subsidence of the joint space was 1% in the study group compared with 18.4% in the control group. There were no surgical complications in either group. CONCLUSIONS: Joint resurfacing with meniscal allograft represents a viable joint salvage option in severe cases of CMC arthritis. Early results suggest that, compared with trapeziectomy alone, the approach results in greater reduction in subjective pain and disability scores, similar improvement in strength measures and range of motion, and less subsidence.

Ethnic Disparities in Thrombotic and Bleeding Diatheses Revisited: A Systematic Review of Microsurgical Breast Reconstruction across the East and West.

BACKGROUND: Ethnicity has been shown to play a role in disparate coagulative responses between East Asian and Caucasian patients undergoing nonmicrovascular surgery. In this study, we sought to further investigate this hematologic phenomenon between the two ethnic groups within the field of microsurgical breast reconstruction. METHODS: A systematic review examining the reported incidence of microvascular thrombosis and all-site bleeding among breast free flaps in East Asians and Westerners was performed. Statistical analysis was performed using the chi-square test. RESULTS: Ten East Asian studies with 581 flaps and 99 Western studies with 30,767 flaps were included. A statistically significant higher rate of thrombotic complications was found in Westerners compared with East Asians (4.2 vs. 2.2%, p = 0.02). Conversely, bleeding events were more common in East Asians compared with Westerners (2.6 vs. 1.2%, p = 0.002). CONCLUSION: There appears to be an ethnicity-based propensity for thrombosis in Westerners and, conversely, for bleeding in East Asians, as evident by the current systematic review of microvascular breast reconstruction data. It is therefore advisable to consider ethnicity in the comprehensive evaluation of patients undergoing microsurgical procedures.

Functional Outcomes for Meniscal Allograft Interposition Arthroplasty of the Hand.

BACKGROUND: Osteochondral defects of the carpometacarpal (CMC), metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints often necessitate arthrodesis or arthroplasty. Meniscal allograft has been used for large joint resurfacing, but its application to smaller joints is less well understood. We propose its use for hand joint resurfacing as an off-the-shelf alternative to address osteochondral defects and restore articular function. METHODS: Thirty-one patients with osteoarthritis of the CMC, MCP, or PIP joints underwent arthroplasty with meniscal allograft. Patient demographics and operative information were recorded. Preoperative Disability of the Shoulder, Arm, and Hand, Wong Baker pain, grip and pinch strength, and range of motion were compared to postoperative scores at 6 weeks, 6 months, and 1 year. RESULTS: Twenty-three women and 8 men, mean age 62.8 years, underwent 39 joint reconstructions, including CMC (n = 26), thumb MP (n = 2), thumb IP (n = 2), digit MP (n = 2), and digit PIP (n = 7). At 1 year, mean Disability of the Shoulder, Arm, and Hand scores decreased from 41.3 to 15.6 (P < 0.001) and pain scores from 6.9 to 1.0 (P < 0.001). Grip strength increased from 38.1 to 42.9 (P = 0.017) and radial and palmar abduction from 43.1 to 49.2 (P = 0.039) and 43.7 to 51.6 (P = 0.098), respectively. There were no complications related to the meniscus. CONCLUSIONS: Meniscal allograft represents an alternative to arthrodesis which obviates the need for a donor site and avoids many of the complications inherent to synthetic alternatives. Our early results demonstrate its successful use to reduce subjective pain and disability scores, improve objective strength measures, and maintain range of motion.

Venous Thromboembolism Chemoprophylaxis in Burn Patients: A Literature Review and Single-Institution Experience.

Hospitalized burn patients meet the criteria for Virchow's triad (endothelial damage, hypercoagulability, and stasis), predisposing them to venous thromboembolism (VTE). Although the disease burden of VTE suggests a need for prevention in this population, unreliable reported VTE rates, costly and complicated prophylaxis regimens, and chemoprophylaxis risks have prevented the establishment of a universal protocol. This paper reviews thromboprophylaxis practices both in the literature and at our own institution. A systematic review was conducted according to PRISMA guidelines identifying studies pertaining to VTE chemoprophylaxis in burn patients. Additionally, medical records of patients admitted to an American Burn Association-verified burn center between June 2015 and June 2019 were retrospectively reviewed for demographics, chemoprophylaxis, and presence of VTE defined as either deep vein thrombosis (DVT) or pulmonary embolism (PE). Thirty-eight studies met inclusion criteria. In the 12 studies that reported VTE incidence, rates ranged widely from 0.25% to 47.1%. The two largest retrospective studies (n = 33,637 and 36,638) reported a VTE incidence of 0.61% and 0.8% in populations with unknown or inconsistently recorded chemoprophylaxis. Throughout the literature, prevention protocols were mixed, though a trend toward using dose-adjusted subcutaneous low molecular weight heparin based on serum anti-factor Xa level was noted. At our burn center, 1,068 patients met study criteria. At-risk patients received a simple chemoprophylaxis regimen of 5000U of subcutaneous unfractionated heparin every 8 hours. No routine monitoring tests were performed to limit cost. Nine cases of DVT and two cases of PE were identified with an incidence of 0.84% and 0.19%, respectively, and a total VTE incidence of 1.03%. Only one patient developed heparin-induced thrombocytopenia (HIT). No cases of other heparin-associated complications were observed. VTE incidence rates reported in the literature are wide-ranging and poorly capture the effect of any one chemoprophylaxis regimen in the burn population. Our center uses a single, safe, and cost-effective protocol effecting a low VTE rate comparable to that of large national retrospective studies.

The State of Burn Care Training During Plastic Surgery Residency.

INTRODUCTION: There is an ongoing shortage of burn specialists, and workforce reports suggest possible hurdles attracting plastic surgeons into burn care. The purpose of this study was to (1) determine the state of burn care in plastic surgery residency and (2) identify what barriers might exist for plastic surgeons pursuing a practice that involves burn care. METHODS: Surveys were distributed to North American plastic surgery program directors and residents, respectively, during the 2018-2019 academic year. RESULTS: Fifty-eight program directors (response, 54%) and 320 plastic surgery residents (response, 30%) participated. Burn care was felt to be an important component in training by most program directors (USA, 88%; Canada, 100%) and residents (USA, 87%; Canada, 99%). The majority of program directors included a burn unit rotation (USA, 88%; Canada, 90%). Rotations for integrated residents averaged 2.5 months and most commonly occurred during second year; independent residents spent 1.2 months on rotation, usually in first year. Three-quarters of American residents were interested in a career that involves burn care in some capacity, primarily burn reconstruction (40%). Factors that would discourage a trainee from practicing burn care in the future included the nature of burn care (60%) and burn operations (45%), the on-call commitment (39%), and a narrow scope of practice (38%). DISCUSSION: This study challenges the belief that plastic surgery trainees are disinterested in burn care. Burn surgery remains an important component of training programs, and we propose several steps to encourage greater interest and participation in the burn surgery workforce.

Ocular Reconstruction Using Bone-Anchored Implants in Irradiated Facial Deformities After Tumor Extirpation.

BACKGROUND: Surgical resection of ocular malignancies can result in complex craniofacial defects that can be difficult to reconstruct with conventional reconstruction techniques. Craniofacial prosthesis supported by bone-anchored implants has evolved as a reliable alternative in such scenarios. METHODS: The authors describe a patient who underwent extensive facial resection secondary to squamous cell carcinoma resulting in significant facial deformities. A bone-anchored osseointegrated implant was used to perform facial reconstruction. RESULTS: The patient had successful reconstruction of her orbit with bone-anchored implant. However, her implant needed to be removed 10 months postoperatively secondary to infection. A second attempt at implant placement has been deferred due to osteonecrosis secondary to adjuvant radiotherapy. CONCLUSION: Bone-anchored implants can provide an elegant alternative in the reconstruction of complex facial defects and provide direct access to surveillance for possible tumor recurrence. However, these bone-supported prosthetics should be used with caution in patients undergoing irradiation.

Topical Minocycline Effectively Decontaminates and Reduces Inflammation in Infected Porcine Wounds.

BACKGROUND: Wound infection can impair postoperative healing. Topical antibiotics have potential to treat wound infection and inflammation and minimize the adverse effects associated with systemic antibiotics. METHODS: Full-thickness porcine wounds were infected with Staphylococcus aureus. Using polyurethane wound enclosure devices, wounds were treated with topical 100 µg/ml minocycline, topical 1000 µg/ml minocycline, topical saline control, or 4 mg/kg intravenous minocycline. Bacteria were quantified in wound tissue and fluid obtained over 9 hours. Immunosorbent assays were used to analyze inflammatory marker concentrations. Minocycline's effect on in vitro migration and proliferation of human keratinocytes and fibroblasts was tested using scratch assays and metabolic assays, respectively. RESULTS: After 6 hours, 100 and 1000 µg/ml topical minocycline decreased bacteria in wound tissue to 3.5 ± 0.87 and 2.9 ± 2.3 log colony-forming units/g respectively, compared to 8.3 ± 0.9 log colony-forming units/g in control wounds (p < 0.001) and 6.9 ± 0.2 log colony-forming units/g in wounds treated with 4 mg/kg intravenous minocycline (p < 0.01). After 2 hours, topical minocycline reduced concentrations of the inflammatory cytokines interleukin-1ß, interleukin-6, and tumor necrosis factor-α (p < 0.01), and inflammatory cell counts in wound tissue (p < 0.05). In noninfected wounds, topical minocycline significantly reduced interleukin-1ß, interleukin-6, and inflammatory cell counts after 4 hours (p < 0.01). Matrix metalloproteinase-9 concentrations decreased after 1-hour treatment (p < 0.05). Keratinocyte and fibroblast in vitro functions were not adversely affected by 10 µg/ml minocycline or less. CONCLUSIONS: Topical minocycline significantly reduces bacterial burden and inflammation in infected wounds compared with wounds treated with intravenous minocycline or control wounds. Minocycline also decreases local inflammation independently of its antimicrobial effect.

Development of a precise experimental burn model.

BACKGROUND: Porcine wounds closely mimic human wounds and are often used experimentally in burn studies. Multiple burn devices have been reported but they rarely described precise amount of heat transfer and the burn devices generally have low and varying heat capacity resulting in significant and varying temperature drop. METHODS: The authors developed a customized aluminum burn device with cork insulation and high heat capacity. A thermistor probe was embedded in the device to accurately measure the temperature of the aluminum. The burn injury was inflicted by preheating the burn device to 100°C and pressing on the dorsum of pig skin for different time points ranging from 5 to 30s using standardized force of 10N on the device. With the knowledge of the heat capacity of the aluminum block and the temperature drop, the amount of heat transferred can be calculated. RESULT: The temperature drop was 0°C, 1°C, 2°C, 3°C and 5°C for a wound-device contact time of 5, 10, 15, 20 and 30s, respectively. The depths of injury at 72h after burn were 0.46mm, 0.82mm, 1.21mm, 1.61mm and 1.91mm at 5, 10, 15, 20 and 30s respectively. 3.1mm represented a full thickness burn. The depth of the burn wounds significantly correlated with the heat transferred per cm2 (correlation coefficient=0.96, p-value=0.03). CONCLUSION: The authors describe a simple, standardized and reproducible animal burn model using a customized burn device. The high heat capacity ensures minimal temperature drop which minimizes the variability of heat transferred with a large temperature drop. The correlation between the heat transfer and the depth of injury can facilitate standardization of burn depths in future studies.

Extracellular Matrix and Dermal Fibroblast Function in the Healing Wound.

Significance: Fibroblasts play a critical role in normal wound healing. Various extracellular matrix (ECM) components, including collagens, fibrin, fibronectin, proteoglycans, glycosaminoglycans, and matricellular proteins, can be considered potent protagonists of fibroblast survival, migration, and metabolism. Recent Advances: Advances in tissue culture, tissue engineering, and ex vivo models have made the examination and precise measurements of ECM components in wound healing possible. Likewise, the development of specific transgenic animal models has created the opportunity to characterize the role of various ECM molecules in healing wounds. In addition, the recent characterization of new ECM molecules, including matricellular proteins, dermatopontin, and FACIT collagens (Fibril-Associated Collagens with Interrupted Triple helices), further demonstrates our cursory knowledge of the ECM in coordinated wound healing. Critical Issues: The manipulation and augmentation of ECM components in the healing wound is emerging in patient care, as demonstrated by the use of acellular dermal matrices, tissue scaffolds, and wound dressings or topical products bearing ECM proteins such as collagen, hyaluronan (HA), or elastin. Once thought of as neutral structural proteins, these molecules are now known to directly influence many aspects of cellular wound healing. Future Directions: The role that ECM molecules, such as CCN2, osteopontin, and secreted protein, acidic and rich in cysteine, play in signaling homing of fibroblast progenitor cells to sites of injury invites future research as we continue investigating the heterotopic origin of certain populations of fibroblasts in a healing wound. Likewise, research into differently sized fragments of the same polymeric ECM molecule is warranted as we learn that fragments of molecules such as HA and tenascin-C can have opposing effects on dermal fibroblasts.

Full-thickness porcine burns infected with Staphylococcus aureus or Pseudomonas aeruginosa can be effectively treated with topical antibiotics.

Burn and blast injuries are frequently complicated by invasive infections, which lead to poor wound healing, delay in treatment, disability, or death. Traditional approach centers on early debridement, fluid resuscitation, and adjunct intravenous antibiotics. These modalities often prove inadequate in burns, where compromised local vasculature limits the tissue penetration of systemic antibiotics. Here, we demonstrate the treatment of infected burns with topical delivery of ultrahigh concentrations of antibiotics. Standardized burns were inoculated with Staphylococcus aureus or Pseudomonas aeruginosa. After debridement, burns were treated with either gentamicin (2 mg/mL) or minocycline (1 mg/mL) at concentrations greater than 1,000 times the minimum inhibitory concentration. Amount of bacteria was quantified in tissue biopsies and wound fluid following treatment. After six days of gentamicin or minocycline treatment, S. aureus counts decreased from 4.2 to 0.31 and 0.72 log CFU/g in tissue, respectively. Similarly, P. aeruginosa counts decreased from 2.5 to 0.0 and 1.5 log CFU/g in tissue, respectively. Counts of both S. aureus and P. aeruginosa remained at a baseline of 0.0 log CFU/mL in wound fluid for both treatment groups. The findings here demonstrate that super-therapeutic concentrations of antibiotics delivered topically can rapidly reduce bacterial counts in infected full-thickness porcine burns. This treatment approach may aid wound bed preparation and accelerate time to grafting.

Topical delivery of ultrahigh concentrations of gentamicin is highly effective in reducing bacterial levels in infected porcine full-thickness wounds.

BACKGROUND: Injury to the skin can predispose individuals to invasive infection. The standard of care for infected wounds is treatment with intravenous antibiotics. However, antibiotics delivered intravenously may have poor tissue penetration and be dose limited by systemic side effects. Topical delivery of antibiotics reduces systemic complications and delivers increased drug concentrations directly to the wound. METHODS: Porcine full-thickness wounds infected with Staphylococcus aureus were treated with ultrahigh concentrations (over 1000 times the minimum inhibitory concentration) of gentamicin using an incubator-like wound healing platform. The aim of the present study was to evaluate clearance of infection and reduction in inflammation following treatment. Gentamicin cytotoxicity was evaluated by in vitro assays. RESULTS: Application of 2000 µg/ml gentamicin decreased bacterial counts in wound tissue from 7.2 ± 0.3 log colony-forming units/g to 2.6 ± 0.6 log colony-forming units/g in 6 hours, with no reduction observed in saline controls (p < 0.005). Bacterial counts in wound fluid decreased from 5.7 ± 0.9 log colony-forming units/ml to 0.0 ± 0 log colony-forming units/ml in 1 hour, with no reduction observed in saline controls (p < 0.005). Levels of interleukin-1ß were significantly reduced in gentamicin-treated wounds compared with saline controls (p < 0.005). In vitro, keratinocyte migration and proliferation were reduced at gentamicin concentrations between 100 and 1000 µg/ml. CONCLUSIONS: Topical delivery of ultrahigh concentrations of gentamicin rapidly decontaminates acutely infected wounds and maintains safe systemic levels. Treatment of infected wounds using the proposed methodology protects the wound and establishes a favorable baseline for subsequent treatment.