The Role of the Fascia-Only Anterolateral Thigh Flap in Extremity Reconstruction: The Fascia-Only Anterolateral Thigh Flap.

BACKGROUND: Free flap selection in extremity reconstruction can be challenging. The ideal flap has to be thin and pliable to achieve optimal contour and function. We explore the role of the fascia-only anterolateral thigh (fALT) flap in extremity reconstruction. METHODS: We conducted a retrospective review of our experience using fALT-free flap for extremity reconstruction over a 2-year period. Patient demographics, mechanism of injury, flap characteristics, complications- and follow-up were recorded. Descriptive statistics were calculated. RESULTS: Twelve patients were included. The median (interquartile range [IQR]) age was 34 (28-52) years. One fALT flap was used for upper extremity reconstruction, while 11 flaps were used for lower extremity reconstruction (4 for lower third of the leg, 4 for dorsum of foot, and 3 for heel). The median (IQR) flap surface area was 90 (63-120) cm2 and time from injury to reconstruction was 10 (6-16) days. The postoperative course was uneventful for all flaps except for 1 flap failure and 1 delayed healing. The median (IQR) follow-up was 2 (1-4) months. In all cases, durable soft tissue reconstruction was achieved with no need for revisions. CONCLUSIONS: The fALT-free flap can be successfully used in extremity reconstruction. The ALT fascia has robust perfusion that allows for the harvest of a large flap that can be surfaced with a split thickness skin graft. Its thin pliable tissue provides excellent contour for the hand, distal leg, and foot that does not require future thinning, optimizing the cosmetic and functional result.

Noninstrumented Free Fibula Flap for Cervical Osteomyelitis.

BACKGROUND AND IMPORTANCE: Severe cases of cervical vertebral osteomyelitis can pose a challenge regarding reconstruction, stability/alignment, and infection eradication. Here we describe the application of vascularized free fibula (FF) flaps to reconstruct the cervical spine without instrumentation in the setting of severe osteomyelitis. CLINICAL PRESENTATION: Two patients presented with symptomatic multilevel cervical osteomyelitis. Both patients were treated with corpectomy and FF flap without instrumentation using a novel wedging and distraction technique to secure the flap into position. Clinical outcomes were based on neurological recovery and infection management. Computed tomography (CT) and CT angiography with 3-dimensional reconstruction were used to measure fusion status and patency of the anastomoses. CT of the cervical spine completed 8 weeks postoperatively demonstrated robust fusion of the fibula flaps to adjacent cervical vertebrae. In both patients, CT angiography demonstrated patency of the arterial anastomoses. Both flaps maintained persistent deformity correction. Both patients made full neurological recovery. DISCUSSION: This reconstructive approach represents a salvage technique that offers advantages in cases of prior hardware failure or unfavorable host factors with rapid fusion and definitive treatment with a single surgery. CONCLUSION: The use of FF flap without instrumentation seems to be a safe and effective option for cervical spine reconstruction in the setting of severe osteomyelitis.

Back to the Beginning: An Algorithmic Approach to Neonatal Myelomeningocele Repair.

INTRODUCTION: Myelomeningoceles are formed by prenatal failure of neural tube closure and can cause hydrocephalus, motor abnormalities, and developmental delay. Although small defects are amenable to primary closure, larger defects often require complex reconstruction. Our goal was to identify factors associated with postoperative soft tissue complications and develop a systematic approach for myelomeningocele closure. METHODS: A retrospective review was performed at the Children's Memorial Hermann Hospital from January 2013 to January 2019. Patients were identified using International Classification of Diseases, Ninth Revision/Tenth Revision , codes for myelomeningocele. Cohorts were stratified by reconstruction type and defect location. Primary outcomes were incidence of complications including cerebrospinal fluid leak, superficial and deep infection, and wound dehiscence. In addition, we developed an algorithm to standardize closure approach for patients with myelomeningoceles. RESULTS: A total of 172 patients with myelomeningocele were identified with 73 patients undergoing postnatal repair. Overall, 72% of defects were >5 cm. Defects were in the lumbar (9%), sacral (8%), and junctional (83%) regions. Overall, 30.1% patients underwent lumbar myofascial repair with 39.7% requiring fasciocutaneous flaps. Larger defects (>5 cm) were more likely to be closed with complex fasciocutaneous flaps (82.8% vs 66.0%, P = 0.11). No significant differences were observed in complication rates. CONCLUSIONS: In this series, patients with larger myelomeningoceles appear to benefit from complex flap closure. We propose a 5-layer closure for patients with myelomeningocele including the routine use of a myofascial layer. Cutaneous closure technique should be tailored based on specific defect characteristics as outlined in our algorithm. This approach streamlines myelomeningocele repair while optimizing outcomes and decreasing downstream complications.

Bilateral Outpatient Breast Reconstruction with Stacked DIEP and Vertical PAP Flaps.

BACKGROUND: Stacking free flaps for breast reconstruction is far from novel, even in the case of a deep inferior epigastric perforator (DIEP) plus profunda artery perforator (PAP) configuration, where the latter is always described in the traditional transverse configuration. We present a series of consecutive patients undergoing bilateral breast reconstruction with stacked DIEP and vertical PAP flaps. METHODS: Patients with inadequate abdominal donor tissue were offered the possibility of a stacking breast reconstruction. The DIEP flap was harvested via microfascial incisions, whereas the vertical PAP flap was harvested in the lithotomy position, following the course of the gracilis muscle. RESULTS: In total, 28 consecutive patients with a mean BMI of 24.9 underwent bilateral breast reconstruction with stacked DIEP and vertical PAP flaps. The internal mammary artery and vein were used as recipient vessels in all 56 stacked flaps. Fifty-three PAP flaps were anastomosed to the distal portion of the (primary) DIEP flaps utilizing a sequential flap anastomosis technique, and one DIEP flap was anastomosed to the distal portion of the (primary) PAP flap. Hospitalization for the initial eight patients averaged 35 hours, whereas the following 20 patients were discharged within 23 hours. There were no postoperative takebacks or vascular complications. CONCLUSIONS: Stacked DIEP/PAP flaps offer an excellent option for patients who require more volume than available from DIEP flaps alone. When compared with transverse PAP flaps, the vertical PAP offers excellent variability of volume and ease of shaping to allow for excellent results, while minimizing donor site tension in the seated position and preserving the gluteal fold.

The Influence of Obesity on Outcomes After Pediatric Reduction Mammaplasty: A Retrospective Analysis of the Pediatric National Surgical Quality Improvement Program-Pediatric Database.

BACKGROUND: Symptomatic macromastia causes negative physical and psychosocial effects, which support the need for early intervention, even in the adolescent population (Plast Reconstr Surg 2012;130:785-789). Reduction mammaplasty is a proven treatment that reliably addresses symptoms from macromastia. The National Surgical Quality Improvement Program-Pediatric is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care (Pediatrics 2012;130:e339-e346). In adults, obesity is associated with increased early postoperative complications after mammaplasty (Pediatrics 2017;140(5)). We hypothesized that obesity would increase the incidence of postoperative complications in pediatric patients undergoing reduction mammaplasty. METHODS: The National Surgical Quality Improvement Program-Pediatric database was queried for female patients 18 years or younger who underwent reduction mammaplasty from January 2012 to December 2017 using Current Procedural Terminology code 19318. Demographic, clinical, and outcomes data were abstracted from the database. A composite postoperative adverse events variable was created from a list of 21 individual adverse events. Patients were stratified by presence of obesity (body mass index ≥30 kg/m) on univariate analyses. Multivariable logistic regression was used to determine factors associated with any postoperative adverse events. RESULTS: A total of 542 female patients underwent reduction mammaplasty, with 48% of the cohort being obese. Patients were similar in age (median, 17 years) and comorbidities between obese and nonobese groups. Obese patients were more likely to be African American, have higher American Society of Anesthesiologists class, and endure longer operations. Composite adverse event rates were significantly higher in the obese group (7% vs 2%, P = 0.013). Individual adverse events were similar between groups, with the exception of 30-day readmissions, which was higher in the obese group (3% vs 1%, P = 0.04). On multivariable logistic regression, obesity increased the odds of having a postoperative adverse event by 3-fold after adjusting for operative duration. CONCLUSIONS: Obesity was significantly associated with greater postoperative adverse events in obese adolescent females after reduction mammaplasty compared with their nonobese counterparts. Although recorded rates of adverse events after reduction mammaplasty were low, preoperative weight loss programs may further improve outcomes for obese pediatric populations undergoing reduction mammaplasty.

Safety and Efficacy of Smooth Surface Tissue Expander Breast Reconstruction.

BACKGROUND: Traditional 2-stage breast reconstruction involves placement of a textured-surface tissue expander (TTE). Recent studies have demonstrated textured surface devices have higher propensity for bacterial contamination and biofilm formation. OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of smooth surface tissue expanders (STE) in immediate breast reconstruction. METHODS: The authors retrospectively reviewed consecutive women who underwent STE breast reconstruction from 2016 to 2017 at 3 institutions. Indications and outcomes were evaluated. RESULTS: A total 112 patients underwent STE reconstruction (75 subpectoral, 37 prepectoral placement), receiving 173 devices and monitored for a mean follow-up of 14.1 months. Demographics of patients included average age of 53 years and average BMI of 27.2 kg/m2, and 18.6% received postmastectomy radiation therapy. Overall complication rates were 15.6% and included mastectomy skin flap necrosis (10.4%), seroma (5.2%), expander malposition (2.9%), and infection requiring intravenous antibiotic therapy (3.5%). Six (3.5%) unplanned reoperations with explantation were reported for 3 infections and 3 patients requesting change of plan with no reconstruction. CONCLUSIONS: STEs represent a safe and efficacious alternative to TTE breast reconstruction with at least equitable outcomes. Technique modification including tab fixation, strict pocket control, postoperative bra support, and suture choice may contribute to observed favorable outcomes and are reviewed. Early results for infection control and explantation rate are encouraging and warrant comparative evaluation for potential superiority over TTEs in a prospective randomized trial.

Finding Consensus After Two Decades of Breast Implant-Associated Anaplastic Large Cell Lymphoma.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an emerging and indolent, but potentially fatal cancer of the immune system that can develop around textured-surface breast implants. The World Health Organization first recognized BIA-ALCL as a unique clinical entity in 2016. To date, over 600 confirmed cases have been reported worldwide. BIA-ALCL most commonly presents with disease confined to the capsule, as a seroma or a mass adjacent to the implant. While BIA-ALCL has a fairly indolent clinical course, with an excellent prognosis in early stage disease, disseminated cancer and death have also been reported. In this review, the authors focus on the early diagnosis and treatment, including reconstructing the breast following BIA-ALCL, and also discuss recently updated National Comprehensive Cancer Network guidelines. They also review the current epidemiology and risk factors associated with BIA-ALCL. Finally, they discuss important medicolegal considerations and the bioethics surrounding the continued use of textured-surface breast implants.

Frequency and Predictors of 30-Day Surgical Site Complications in Autologous Breast Reconstruction Surgery.

BACKGROUND: Surgical site complication (SSC) is one of the known complications following autologous breast reconstruction. The aim of this study was to evaluate the frequency and predictors of 30-day surgical site complications in autologous breast reconstruction. METHODS: American College of Surgeons National Surgery Quality Improvement Project (ACS-NSQIP) database was used to identify patients who underwent autologous breast reconstruction during 2011-2015. Multivariate regression analysis was performed to identify independent perioperative risk factors of SSC. RESULTS: Totally, 7,257 patients who underwent autologous breast reconstruction surgery were identified. The majority of the procedures were free flap (60%) versus pedicled flap (40%). The mean age was 51 years and the majority of patients were classified as American Society of Anesthesiologists (ASA)-II (60%) and 15% of patients had BMI>35. The overall 30-day SSC rate was 6.3%. The overall frequency of different types of SSC were superficial incisional infection (3.2%), wound dehiscence (1.8%), deep incisional infection (1.4%) and organ space infection (0.6%). BMI>35 (adjusted odds ratio [AOR]=2.38), smoking (AOR=2.0), diabetes mellitus (AOR=1.67) and hypertension (AOR=1.38) were significant risk factors of SSC. There was no association with age, ASA classification, steroid use, or reconstruction type. CONCLUSION: The rate of 30-day SSC in autologous breast reconstruction was noticeable. The strongest independent risk factor for SSC in autologous breast reconstruction was BMI>35. The type of autologous breast reconstruction was not a predictive risk factor for SSC. Plastic surgeons should inform patients about their risk for SSC and optimizing these risk factors to minimize the rate of surgical site complications.

Sarcopenia and frailty in elderly trauma patients.

BACKGROUND: Sarcopenia describes a loss of muscle mass and resultant decrease in strength, mobility, and function that can be quantified by CT. We hypothesized that sarcopenia and related frailty characteristics are related to discharge disposition after blunt traumatic injury in the elderly. METHODS: We reviewed charts of 252 elderly blunt trauma patients who underwent abdominal CT prior to hospital admission. Data for thirteen frailty characteristics were abstracted. Sarcopenia was measured by obtaining skeletal muscle cross-sectional area (CSA) from each patient's psoas major muscle using Slice-O-Matic(®) software. Dispositions were grouped as dependent and independent based on discharge location. χ (2), Fisher's exact, and logistic regression were used to determine factors associated with discharge dependence. RESULTS: Mean age 76 years, 49 % male, median ISS 9.0 (IQR = 8.0-17.0). Discharge destination was independent in 61.5 %, dependent in 29 %, and 9.5 % of patients died. Each 1 cm(2) increase in psoas muscle CSA was associated with a 20 % decrease in dependent living (p < 0.0001). Gender, weakness, hospital complication, and cognitive impairment were also associated with disposition; ISS was not (p = 0.4754). CONCLUSIONS: Lower psoas major muscle CSA is related to discharge destination in elderly trauma patients and can be obtained from the admission CT. Lower psoas muscle CSA is related to loss of independence upon discharge in the elderly. The early availability of this variable during the hospitalization of elderly trauma patients may aid in discharge planning and the transition to dependent living.