Damage control abdomen: single-stage reconstruction using a vicryl mesh buttress.

PURPOSE: Damage control laparotomy has become an accepted approach for patients with life-threatening abdominal conditions. This method compromises fascial integrity creating functionally and aesthetically debilitating hernias. The purpose of this study is to present our technique and outcomes with these complex abdominal wall reconstructions. METHODS: A retrospective review was conducted on 56 patients with previous damage control laparotomies who underwent elective single-stage abdominal wall reconstruction between 1999 and 2006. Mean age was 42 years. Reconstruction consisted of a double-layer, subfascial Vicryl mesh buttress, combined with components separation and rectus muscle turnover flaps. Hernia recurrence and function were evaluated by clinical examinations and telephone surveys. RESULTS: The major etiologies of abdominal hernias were gunshot wounds, motor vehicle accidents or blunt trauma, and sepsis or perforated bowel. The mean abdominal wall defect was 865 cm, and the average interval time to definitive repair was 17 months. The average length of follow-up was 29 months. Most patients (88%) had successful repair of their abdominal wall, with no hernia recurrence. There were 7 cases of hernia. Of these, 2 cases were from reopening of abdomen because of compartment syndrome that was not repaired, 3 were small asymptomatic hernias for which patients elected not to undergo further repair. Other complications include superficial skin dehiscence, all of which healed secondarily with daily wound care 12% (7 patients) and abdominal compartment syndrome 7.1% (4 patients), resulting in 2 postoperative mortalities in the initial part of the series. There were no mesh exposures, seromas, or fistulas. In all, 29% or 52% of patients were reached by telephone. Of those, 90% surveyed and who worked full-time prior to injury returned to their jobs, and 92% were functioning at premorbid activity levels. CONCLUSION: Massive abdominal hernia following damage control laparotomy poses a great challenge to the reconstructive surgeon. This patient population is at significant risk for mortality and morbidity. We believe the use of a Vicryl mesh buttress is an important adjunctive tool in complex abdominal wall reconstruction. Functional results are excellent with most returning to work and preinjury activity levels.

Soft-tissue optimization of limb salvage with knee endoprosthesis: the 10-year experience at the Children's Hospital of Philadelphia.

PURPOSE: Limb salvage in bone sarcomas requires resection and joint and soft-tissue reconstruction. Suboptimal coverage can lead to prosthesis infection, subsequent hardware exposure, or loss with eventual amputation. In the pediatric sarcoma population, it is essential to not only have viable soft-tissue coverage but one that minimizes donor site morbidity and maximizes function and growth over time. METHODS: This is a retrospective review of all sarcoma patients with primary gastrocnemius and soleus muscle flap coverage of modular knee endoprosthesis over the 10-year period between 1997 and 2007. All patients had resection of the skin at the tibial biopsy site prior to their primary tumor resection surgery. After resection of the knee joint and proximal tibia with clear margins, the bony defect was reconstructed with an endoprosthesis. The gastrocnemius and soleus muscles were then independently rotated to cover the prosthesis and the patellar tendon. RESULTS: Eleven patients (10 male, 1 female) with an average age of 13 years (range, 10-17) underwent resection of proximal tibia. Pathology included osteosarcoma in 9 patients, Ewing in 1, and spindle cell sarcoma in 1 patient. All patients had endoprosthetic coverage by gastrocnemius and soleus flaps; 4 patients had additional split-thickness skin graft over the gastrocnemius. The average level of tibial resection was 16.5 cm distal to the articular surface of the proximal tibia. Mean soft-tissue mass volume resected with bone was 157 cm. There was one flap failure that was reconstructed with a rectus abdominis free flap. Average follow-up was 32 months (range, 8-92 months). Two patients succumbed to metastatic disease. In this series, there was no limb loss or hardware exposure or infection. All patients achieved independent ambulation. Functionally, patients were evaluated based on the Musculoskeletal Tumor Society scale. The average score was 29 (out of a perfect score of 30). Two patients had transient foot drop that resolved with ankle foot orthosis use. Anticipated leg length discrepancy was detected in 3 patients who underwent opposite limb epiphysiodesis with ultimate limb equalization. CONCLUSION: Soft-tissue reconstruction with gastrocnemius and soleus muscle flap coverage decreases wound complications and hardware exposure while maintaining function in the pediatric population.

KRAS mutations and primary resistance of lung adenocarcinomas to gefitinib or erlotinib.

BACKGROUND: Somatic mutations in the gene for the epidermal growth factor receptor (EGFR) are found in adenocarcinomas of the lung and are associated with sensitivity to the kinase inhibitors gefitinib (Iressa) and erlotinib (Tarceva). Lung adenocarcinomas also harbor activating mutations in the downstream GTPase, KRAS, and mutations in EGFR and KRAS appear to be mutually exclusive. METHODS AND FINDINGS: We sought to determine whether mutations in KRAS could be used to further enhance prediction of response to gefitinib or erlotinib. We screened 60 lung adenocarcinomas defined as sensitive or refractory to gefitinib or erlotinib for mutations in EGFR and KRAS. We show that mutations in KRAS are associated with a lack of sensitivity to either drug. CONCLUSION: Our results suggest that treatment decisions regarding use of these kinase inhibitors might be improved by determining the mutational status of both EGFR and KRAS.

Contribution of plastic surgery to a health care system: our economic value to hospital profitability.

BACKGROUND: With the fluctuating economic conditions and the health care reform taking place in the United States, it is critical for plastic surgeons to be aware of their financial value to health care systems. The authors evaluated surgeon productivity and economic contributions made to their hospital by the Division of Plastic Surgery. METHODS: Operative case logs for the departments of surgery, neurosurgery, and orthopedics were reviewed for fiscal year 2009. Margins, revenue, and surgeon total relative value units (a measure of productivity) were analyzed. RESULTS: Average relative value unit for all surgical specialties was 94,595, whereas that for the Division of Plastic Surgery was 54,288. Average value per surgeon for the health system was 12,149. For plastic surgery, average value per surgeon was 14,272, and the division was ranked fourth highest among all surgical services. The mean number of relative value units per case was 24.5 among all services; for plastic surgery, it was 31.2. Approximately one-third of all procedures performed by plastic surgery were in collaboration with another surgical specialty. The average net revenue for primary inpatient admissions per relative value unit was $381 for all surgical services and $222 for plastic surgery. A total of $2.2 to $3.7 million was the estimated savings for the hospital from complication salvage cases performed by the division. CONCLUSIONS: Plastic surgery contributes significantly to hospital bottom line in performing joint cases and salvaging complications. In the current economic environment, it is crucial for plastic surgeons to be fully cognizant of their positive influence and economic impact on the hospital margin.

Free tissue transfer in the hypercoagulable patient: a review of 58 flaps.

BACKGROUND: Hypercoagulability or thrombophilia is a group of inherited or acquired conditions associated with a predisposition to thrombosis. Most hypercoagulable states alter the blood itself or affect the vasculature, directly creating a detrimental environment for microsurgery. The authors present their series of hypercoagulable patients who underwent free flap reconstruction. METHODS: A retrospective review was conducted of all free flaps performed between January 1, 2005, and October 1, 2010, at the University of Pennsylvania. A total of 2032 flaps were performed. Forty-one patients or 58 free flaps (2.9 percent) were identified as having a diagnosed thrombophilia or previous thromboembolic event. RESULTS: Of the 41 patients, 36 were women and five were men. Diagnosis included factor V Leiden mutation, protein C deficiency, hyperhomocysteinemia, antiphospholipid antibody syndrome, prothrombin gene mutation, factor VIII elevation, anticardiolipin antibody syndrome, and essential thrombocytosis. The group of patients with prior thrombotic events (many with concomitant events and diagnoses) included deep vein thrombosis, pulmonary embolus, myocardial infarction before the age of 50, and embolic stroke. Twelve patients (29.3 percent) were actively followed by a hematologist. The rate of thrombosis was 20.7 percent (12 flaps), including those occurring intraoperatively. The salvage rate for a postoperative thrombosed flap in this group was 0 percent. The flap loss rate was 15.5 percent. CONCLUSIONS: Although hypercoagulability produces an unfavorable condition for microvascular reconstruction, free tissue transfer is feasible. In this series, the authors had an 80 percent success rate. Collaboration with a hematologist may be helpful. In this group, flap thrombosis seems to occur in the delayed period. Even with operative reexploration, salvage rates have not been promising. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

A review of 32 free flaps in patients with collagen vascular disorders.

BACKGROUND: Collagen vascular diseases affect multiple organs by the deposition of immunoglobulins along vascular basement membranes. This pathophysiology potentially makes these patients poor free flap candidates, with a possible increased risk of failure. The often concomitant finding of hypercoagulability may also compound the risk. METHODS: A retrospective review was conducted of all free flap reconstructions performed between 2005 and 2009. Of a total of 1251 flaps, 25 patients, who underwent 32 flaps, were identified with connective tissue disorders. These included Sjögren syndrome, Raynaud phenomenon, rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, scleroderma, and multicentric thrombocytosis. RESULTS: The mean age of the patients was 51 years, and the average body mass index was 28.1 kg/m(2). Seven patients were on chronic immunosuppression. Flap reconstructions included seven deep inferior epigastric perforator flaps, 21 transverse rectus abdominis musculocutaneous flaps, one gluteal flap for breast reconstruction, and one anterolateral thigh and two radial forearm flaps for head and neck reconstruction. All flaps were performed with a single arterial and venous anastomosis. None had microvascular flap complications. There was one case of postoperative deep vein thrombosis. There were three cases of wound dehiscence and one case of ventral hernia. CONCLUSIONS: Blood vessels and soft tissues are injured by inflammation as the primary target of collagen vascular diseases. The increased incidence for thrombotic events deems them potentially high-risk free tissue transfer patients. The authors demonstrate from their series, however, that there is no increased risk of thrombosis, and this patient population should not be precluded from free flap reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

CASE REPORT Type II Metacarpal Hands: Reconstruction Planning Revisited.

OBJECTIVE: Successful reconstruction of the metacarpal hand requires thorough evaluation and careful surgical planning. Effective transplantation involves 3 main considerations: residual hand function, functional needs and desires of the patient, and optimal surgical management to maximize outcome and minimize patient morbidity. METHODS: The following is a clinical example of the metacarpal hand in which the patient underwent initial reconstruction at an outside hospital and was referred to our institution. This demonstrates how the initial planning and surgical management could have been further optimized to minimize functional deficits and donor-site morbidities as well as reduce the number of subsequent revisional surgeries and rehabilitation time. RESULTS: Several important points in metacarpal hand reconstruction are described given specific level of amputation and residual function after the injury-the timing and sequence of operative strategy depending on the type of injury, the selection of donor-site digit transfers, and the overall treatment strategies for thumb and finger reconstruction. CONCLUSION: It is important to follow proper treatment algorithms in order to determine appropriate timing and sequence of toe-to-digit transfers, multi-stage versus 1-stage, as well as define the reconstructive goal to achieve a tripod pinch for a unilateral or a dominant hand injury or a pulp-to-pulp opposition for nondominant injury in bilateral cases. If adequate planning is performed, unnecessary and additional surgical procedures as well as increased patient suffering and prolonged rehabilitation time can be prevented or optimized.

Traumatic superior orbital fissure syndrome: assessment of cranial nerve recovery in 33 cases.

BACKGROUND: Superior orbital fissure syndrome is a rare complication that occurs in association with craniofacial trauma. The characteristics of superior orbital fissure syndrome are attributable to a constellation of cranial nerve III, IV, and VI palsies. This is the largest series describing traumatic superior orbital fissure syndrome that assesses the recovery of individual cranial nerve function after treatment. METHODS: In a review from 1988 to 2002, 33 patients with superior orbital fissure syndrome were identified from 11,284 patients (0.3 percent) with skull and facial fractures. Severity of cranial nerve injury and functional recovery were evaluated by extraocular muscle movement. Patients were evaluated on average 6 days after initial injury, and average follow-up was 11.8 months. RESULTS: There were 23 male patients. The average age was 31 years. The major mechanism of injury was motorcycle accident (67 percent). Twenty-two received conservative treatment, five were treated with steroids, and six patients underwent surgical decompression of the superior orbital fissure. After initial injury, cranial nerve VI suffered the most damage, whereas cranial nerve IV sustained the least. In the first 3 months, recovery was greatest in cranial nerve VI. At 9 months, function was lowest in cranial nerve VI and highest in cranial nerve IV. Eight patients (24 percent) had complete recovery of all cranial nerves. Functional recovery of all cranial nerves reached a plateau at 6 months after trauma. CONCLUSIONS: Cranial nerve IV suffered the least injury, whereas cranial nerve VI experienced the most neurologic deficits. Cranial nerve palsies improved to their final recovery endpoints by 6 months. Surgical decompression is considered when there is evidence of bony compression of the superior orbital fissure.

A 162-case review of palatal fracture: management strategy from a 10-year experience.

BACKGROUND: Palatal fractures are frequently associated with Le Fort maxillary fractures in midfacial trauma. They may present diagnostic and therapeutic challenges and result in malunion and occlusion problems if not treated properly. METHODS: In a retrospective study of 349 Le Fort maxillary fractures over 10 years, 162 patients were diagnosed with palatal fractures. The classification of fractures was based on the patterns observed on computed tomographic scans and treatment plan including type I, sagittal; type II, transverse; and type III, comminuted. Transverse palatal fractures were stabilized by standard Le Fort I buttresses and alveolar ridge fixation. Additional intermolar wiring fixation was applied for sagittal palatal fractures, and prolonged intermaxillary fixation with dental splinting was applied for comminuted palatal fractures. RESULTS: Palatal fractures accounted for 46.4 percent of Le Fort maxillary fractures in this study. Motorcycle accident (69.5 percent) was the most common trauma mechanism. In the type I group, all patients achieved satisfactory results except one patient who needed orthognathic surgery because of malocclusion. Thirteen patients required orthodontic treatment without additional surgical intervention. There were three fistula formations in the type III group that required palatal flaps for closure. CONCLUSIONS: The high incidence of concomitant palatal fractures in midfacial trauma suggests the importance of accurate diagnosis followed by appropriate management. Results of this study show that intermolar wiring fixation is a much less time-consuming and more cost-effective method for satisfactory treatment of sagittal fractures of the palate. Simultaneously, a palatal flap for closure of a palatal defect is the key to avoiding fistula formation.