We Are Not Speaking the Same Language: Current Procedural Terminology Coding and Provision of Care in Lymphatic Reconstruction.

INTRODUCTION: Current Procedural Terminology (CPT) codes provide a uniform language for medical billing, but specific codes have not been assigned for lymphatic reconstruction techniques. The authors hypothesized that inadequate codes would contribute to heterogeneous coding practices and reimbursement challenges, ultimately limiting surgeons' ability to treat patients. METHODS: A 22-item virtual questionnaire was offered to 959 members of the American Society of Reconstructive Microsurgeons to assess the volume of lymphatic reconstruction procedures performed, CPT codes used for each procedure, and challenges related to coding and providing care. RESULTS: The survey was completed by 66 board-certified/board-eligible plastic surgeons (6.9%), who unanimously agreed that lymphatic surgery is integral to cancer care, with 86.4% indicating that immediate lymphatic reconstruction should be offered after lymphadenectomy. Most performed lymphovenous bypass, immediate lymphatic reconstruction, liposuction, and vascularized lymph node transfer.Respondents reported that available CPT codes failed to reflect procedural scope. A wide variety of CPT codes was used to report each type of procedure. Insurance coverage problems led to 69.7% of respondents forgoing operations and 32% reducing treatment offerings. Insurance coverage and CPT codes were identified as significant barriers to care by 98.5% and 95.5% of respondents, respectively. CONCLUSIONS: Respondents unanimously agreed on the importance of lymphatic reconstruction in cancer care, and most identified inadequate CPT codes as causing billing issues, which hindered their ability to offer surgical treatment. Appropriate and specific CPT codes are necessary to ensure accuracy and consistency of reporting and ultimately to improve patient access to care.

Surgical Treatment of Breast Lymphedema: A Distinct Pathology With Unique Challenges.

BACKGROUND: Supermicrosurgical advances such as lymphovenous bypass (LVB) have enabled effective physiologic treatment of lymphedema affecting the extremities. Reports of surgical treatment for breast lymphedema (BL) are sparse, consisting of case reports and almost exclusively LVB. We report our experience with BL, including a case of mastectomy and breast reconstruction with abdominal free flap and inguinal vascularized lymph node transfer (VLNT) for BL. We compare our series with the surgical literature to discern unique characteristics and treatment limitations inherent to this disease. METHODS: A database was prospectively maintained from September 2020 to May 2023 including all patients diagnosed with BL who were referred to our institution. Breast lymphedema was diagnosed using clinical criteria, and relevant patient data were recorded. Patients interested in surgical management underwent indocyanine green lymphography to determine candidacy for LVB or other interventions. All patients, including those surgically managed, were treated with complex decongestive therapy. RESULTS: Nine patients with BL were included. Eight had undergone breast-conserving therapy for breast cancer with whole breast irradiation. One patient was treated for Hodgkin lymphoma with axillary lymphadenectomy and axillary radiation. Indocyanine green lymphography was performed in 6 patients, of which 4 patients had diffuse dermal backflow. Two patients had lymphatic targets suitable for LVB, including the patient without breast irradiation. Three patients were managed surgically. One patient without bypass targets underwent breast reduction with partial symptomatic relief, later followed by a mastectomy with abdominal free flap reconstruction and VLNT. Two patients with suitable bypass targets underwent LVB, with resolution of breast swelling and subjective symptoms. CONCLUSIONS: The diffuse lymphatic obliteration due to radiation field effect in BL results in a distinct pathophysiology compared with extremity lymphedema. Although published reports of surgical BL treatment almost exclusively describe LVB, other surgical options may be more frequently required. Ablative strategies such as mastectomy and regenerative techniques such as VLNT should be considered potential first-line treatment options for these patients.

Commercial Insurance Rates and Coding for Lymphedema Procedures: The Current State of Confusion and Need for Consensus.

BACKGROUND: Surgical treatment of lymphedema has outpaced coding paradigms. In the setting of ambiguity regarding coding for physiologic procedures [lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT)], we hypothesized that there would be variation in commercial reimbursement based on coding pattern. METHODS: The authors performed a cross-sectional analysis of 2021 nationwide hospital pricing data for 21 CPT codes encompassing excisional (direct excision, liposuction), physiologic (LVB, VLNT), and ancillary (lymphangiography) procedures. Within-hospital ratios (WHRs) and across-hospital ratios (AHRs) for adjusted commercial rates per CPT code quantified price variation. Mixed effects linear regression modeled associations of commercial rate with public payer (Medicare and Medicaid), self-pay, and chargemaster rates. RESULTS: A total of 270,254 commercial rates, including 95,774 rates for physiologic procedures, were extracted from 2863 hospitals. Lymphangiography codes varied most in commercial price (WHR, 1.76 to 3.89; AHR, 8.12 to 44.38). For physiologic codes, WHRs ranged from 1.01 (VLNT; free omental flap) to 3.03 (LVB; unlisted lymphatic procedure), and AHRs ranged from 5.23 (LVB; lymphatic channel incision) to 10.36 (LVB; unlisted lymphatic procedure). Median adjusted commercial rates for excisional procedures ($3635.84) were higher than for physiologic procedures ($2560.40; P < 0.001). Commercial rate positively correlated with Medicare rate for all physiologic codes combined, although regression coefficients varied by code. CONCLUSIONS: Commercial payer-negotiated rates for physiologic procedures were highly variable both within and across hospitals, reflective of variation in CPT codes. Physiologic procedures may be undervalued relative to excisional procedures. Consistent coding nomenclature should be developed for physiologic and ancillary procedures.

Combined Liposuction and Physiologic Treatment Achieves Durable Limb Volume Normalization in Class II-III Lymphedema: A Treatment Algorithm to Optimize Outcomes.

INTRODUCTION: Outcomes of surgical lymphedema treatment are currently suboptimal. Physiologic procedures including lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) reestablish lymphatic flow but cannot correct fibroadipose deposition, whereas liposuction alone cannot prevent disease progression. We propose a treatment algorithm combining liposuction with LVA or VLNT that can achieve normal limb volumes and prevent disease progression in stage II-III lymphedema. METHODS: We performed a retrospective chart review of patients undergoing liposuction and physiologic lymphedema operations at our institution between January 2016 and June 2019. Patients were assigned to treatment groups according to their clinical presentation: physiologic first, followed by no further treatment (physiologic only) or liposuction (physiologic then liposuction); liposuction then physiologic; or simultaneous. Preoperative patient characteristics and sequence of operations were recorded. Compression garment usage was self-reported. Limb volumes were approximated as a truncated cone. RESULTS: Twenty-one patients met the inclusion criteria. The liposuction then physiologic group had significantly higher stage and excess limb volume at baseline, whereas the physiologic first groups had lower excess volume. While the physiologic only group had predominantly stage I disease, the patients who later required liposuction (physiologic then liposuction group) all had stage II disease. All groups achieved 82% to 106% mean excess volume reduction, and volume reduction was maintained for up to 2.4 years. Compression garment class was not reduced, but mean postoperative compression duration decreased from 12.5 to 7.5 h/d (P = 0.003). Ten of 11 patients with history of cellulitis had no further recurrence. CONCLUSION: Lymphedema represents a continuum of fluid and fibroadipose disease. Accurate staging and timely treatment with physiologic procedures and liposuction can normalize limb volume. We propose a treatment algorithm to optimize outcomes. Patients with predominantly nonpitting presentation benefit from liposuction to maximize removal of fibroadipose tissue and optimize postoperative compression, followed by LVA or VLNT to improve lymphatic drainage. Patients with primarily pitting edema are best treated with physiologic procedures initially, reserving selective liposuction as a second stage. Patients with mixed presentation are best served by single-stage combination procedures.

Vascularized Bone Marrow Cellular Depletion or Discontinuity Abrogates Protection of Vascularized Composite Allografts in Nonhuman Primates.

BACKGROUND: Vascularized composite allografts (VCA) have demonstrated good clinical outcomes dependent on chronic immunosuppression. Previous work by our group and others supports that cotransplanted vascularized bone marrow (VBM) as a component of VCA offers immunologic protection to prolong graft survival. We aimed to characterize the requirements and potential mechanisms of VBM-mediated protection of VCA by modifying grafts through various strategies. METHODS: Experimental groups of mismatched cynomolgus macaque recipients received VCA transplants modified by the following approaches: heterotopic separation of the VCA and VBM components; T-cell depletion of either donor or recipient; irradiation of donor VCA; and infusion of donor bone marrow. All groups received standard immunosuppression with tacrolimus and mycophenolate mofetil. RESULTS: Experimental modifications to donor, recipient, or graft all demonstrated short-graft survivals (31 d). Chimerism levels without bone marrow infusion were transient and minimal when detected and were not associated with prolonged survival. Donor bone marrow infusion increased levels of chimerism but resulted in alloantibody production and did not improve graft survival. CONCLUSIONS: VCA graft survival is significantly reduced compared with previously reported VCA with VBM transplants (348 d; P = 0.01) when the hematopoietic niche is removed, altered, or destroyed via irradiation, depletion, or topographical rearrangement. These experimental manipulations resulted in similar outcomes to VCA grafts without cotransplanted VBM (25 d). These data support the presence of a radiosensitive, T-cell population within the VBM compartment not reconstituted by reinfusion of bone marrow cells.

Minimally invasive donor nephrectomy: current state of the art.

BACKGROUND: The concept of a minimally invasive live donor nephrectomy developed over 20 years ago. Surgeons gained expertise with the laparoscopic technique and utilized multiple variations that are now utilized in transplant centers throughout the world. Recent modifications include laparoendoscopic single-site and robotic approaches that have been adopted by an additional smaller set of programs. PURPOSE: Review was performed of the following eight different surgical approaches to a "minimally invasive" live donor nephrectomy: laparoscopic (LDN), hand-assisted laparoscopic (HALDN), retroperitoneoscopic (RLDN), hand-assisted retroperitoneoscopic (HARS), single-port laparoscopic (LESS), robotic-assisted laparoscopic (RALDN), mini open, and natural orifice transluminal endoscopic (NOTES). The techniques are described and summaries of available outcomes and complications are presented. CONCLUSIONS: Traditional surgical techniques of open donor nephrectomy have transitioned to minimally invasive techniques. With adoption of these techniques as the preferred approach, several variations have and continue to evolve. The current minimally invasive donor nephrectomy techniques share low complication rates and excellent outcomes.

Recellularization via the bile duct supports functional allogenic and xenogenic cell growth on a decellularized rat liver scaffold.

Recent years have seen a proliferation of methods leading to successful organ decellularization. In this experiment we examine the feasibility of a decellularized liver construct to support growth of functional multilineage cells. Bio-chamber systems were used to perfuse adult rat livers with 0.1% SDS for 24 hours yielding decellularized liver scaffolds. Initially, we recellularized liver scaffolds using a human tumor cell line (HepG2, introduced via the bile duct). Subsequent studies were performed using either human tumor cells co-cultured with human umbilical vein endothelial cells (HUVECs, introduced via the portal vein) or rat neonatal cell slurry (introduced via the bile duct). Bio-chambers were used to circulate oxygenated growth medium via the portal vein at 37C for 5-7 days. Human HepG2 cells grew readily on the scaffold (n = 20). HepG2 cells co-cultured with HUVECs demonstrated viable human endothelial lining with concurrent hepatocyte growth (n = 10). In the series of neonatal cell slurry infusion (n = 10), distinct foci of neonatal hepatocytes were observed to repopulate the parenchyma of the scaffold. The presence of cholangiocytes was verified by CK-7 positivity. Quantitative albumin measurement from the grafts showed increasing albumin levels after seven days of perfusion. Graft albumin production was higher than that observed in traditional cell culture. This data shows that rat liver scaffolds support human cell ingrowth. The scaffold likewise supported the engraftment and survival of neonatal rat liver cell slurry. Recellularization of liver scaffolds thus presents a promising model for functional liver engineering.

Vascularized Composite Allotransplantation: Medical Complications.

The objective of this review is to summarize the collective knowledge regarding the risks and complications in vascularized composite tissue allotransplantation (VCA), focusing on upper extremity and facial transplantation. The field of VCA has entered its second decade with an increasing experience in both the impressive good outcomes, as well as defining challenges, risks, and experienced poor results. The limited and selective publishing of negative outcomes in this relatively new field makes it difficult to conclusively evaluate outcomes of graft and patient survival and morbidities. Therefore, published data, conference proceedings, and communications were summarized in an attempt to provide a current outline of complications. These data on the medical complications of VCA should allow for precautions to avoid poor outcomes, data to better provide informed consent to potential recipients, and result in improvements in graft and patient outcomes as VCA finds a place as a therapeutic option for selected patients.

Facial transplantation: the first 9 years.

Since the first facial transplantation in 2005, 28 have been done worldwide with encouraging immunological, functional, psychological, and aesthetic outcomes. Unlike solid organ transplantation, which is potentially life-saving, facial transplantation is life-changing. This difference has generated ethical concerns about the exposure of otherwise young and healthy individuals to the sequelae of lifelong, high-dose, multidrug immunosuppression. Nevertheless, advances in immunomodulatory and immunosuppressive protocols, microsurgical techniques, and computer-aided surgical planning have enabled broader clinical application of this procedure to patients. Although episodes of acute skin rejection continue to pose a serious threat to face transplant recipients, all cases have been controlled with conventional immunosuppressive regimens, and no cases of chronic rejection have been reported.

Found in space: computer-assisted orthognathic alignment of a total face allograft in six degrees of freedom.

PURPOSE: Full facial osteomyocutaneous transplantation requires correct 3-dimensional (3D) alignment of donor osseous structures to a new cranial base with minimal reference points and 6 degrees of potential movement. We investigated whether computer-assisted design and manufacturing (CAD/CAM) could enable accurate placement of the facial skeleton. MATERIALS AND METHODS: A prospective single-cohort study of Le Fort III-based maxillary-mandibular segment allotransplantation was performed in 5 cadaver pairs and 1 clinical pair. The osteotomies were modeled using computed tomography (CT) data and 3D modeling software and then translated to the donor-recipient pairs using surgical navigation and osteotomy cutting guides. The predicted values were calculated about all rotational axes (pitch, yaw, and roll) and along all translational axes (vertical, horizontal, and anteroposterior) and used as the independent variable. The primary outcome variable of the actual postoperative CT values was compared for fidelity to the prediction using the intraclass correlation coefficient (ICC). The similarity to the donor versus recipient values was calculated as a secondary independent variable, and both predicted and actual measurements were compared with it as a percentage. RESULTS: The postoperative fidelity to the plan was adequate to excellent (ICC 0.520 to 0.975) with the exception of lateral translation (2.94 ± 1.31 mm predicted left vs 3.92 ± 2.17 mm right actual displacement; ICC 0.243). The predicted and actual values were not consistently skewed toward the donor or recipient values. CONCLUSIONS: We have demonstrated a novel application of CAD/CAM that enables orthognathic alignment of a maxillary-mandibular segment to a new cranial base. Quantification of the alignment in all 6 degrees of freedom delivers precise control compared with the planned changes and allows postoperative quality control.

Engineering bone grafts with enhanced bone marrow and native scaffolds.

The translation of tissue engineering approaches to the clinic has been hampered by the inability to find suitable multipotent cell sources requiring minimal in vitro expansion. Enhanced bone marrow (eBM), which is obtained by reaming long bone medullary canals and isolating the solid marrow putty, has large quantities of stem cells and demonstrates significant potential to regenerate bone tissues. eBM, however, cannot impart immediate load-bearing mechanical integrity or maintain the gross anatomical structure to guide bone healing. Yet, its putty-like consistency creates a challenge for obtaining the uniform seeding necessary to effectively combine it with porous scaffolds. In this study, we examined the potential for combining eBM with mechanically strong, osteoinductive trabecular bone scaffolds for bone regeneration by creating channels into scaffolds for seeding the eBM. eBM was extracted from the femurs of adult Yorkshire pigs using a Synthes reamer-irrigator-aspirator device, analyzed histologically, and digested to extract cells and characterize their differentiation potential. To evaluate bone tissue formation, eBM was seeded into the channels in collagen-coated or noncoated scaffolds, cultured in osteogenic conditions for 4 weeks, harvested and assessed for tissue distribution and bone formation. Our data demonstrates that eBM is a heterogenous tissue containing multipotent cell populations. Furthermore, coating scaffolds with a collagen hydrogel significantly enhanced cellular migration, promoted uniform tissue development and increased bone mineral deposition. These findings suggest the potential for generating customized autologous bone grafts for treating critical-sized bone defects by combining a readily available eBM cell source with decellularized trabecular bone scaffolds.

A review of propeller flaps for distal lower extremity soft tissue reconstruction: Is flap loss too high?

Soft tissue coverage in the distal lower extremity remains a significant challenge. While free flaps are often utilized for larger defects, local perforator-based propeller flaps may be ideal for smaller wounds requiring coverage. Propeller flaps can provide excellent form and function for both traumatic and atraumatic defects with minimal donor site morbidity but can have concerning rates of flap loss. We reviewed the literature, identifying 21 studies presenting 310 propeller flaps for distal lower extremity reconstruction. Total flap necrosis was noted in 5.5% of flaps, with partial necrosis in 11.6%. While these flaps do enable transfer of local, healthy tissue to the defect site without the need for a microsurgical anastomosis, this rate of flap loss is concerning and appropriate patient selection is crucial. This review provides a brief history and overview of the clinical application and research into distal lower extremity perforator propeller flaps to place this technique into a clinical context.

Regulatory T cells are not predictive of outcomes in a nonhuman primate model of vascularized composite allotransplantation.

BACKGROUND: T regulatory cells (Tregs) have been associated with prolonged allograft survival and tolerance across a wide variety of species and organ types. We used our nonhuman primate model of facial vascularized composite allotransplantation (VCA) to study the association of Tregs with graft outcomes. METHODS: We quantified Tregs in peripheral blood and allograft biopsies from nonhuman primates after heterotopic partial facial segment allotransplantation from major histocompatibility complex class I-mismatched donors using flow cytometry and immunohistochemistry. Immunosuppression consisted of tacrolimus and mycophenolate mofetil without induction or depletional therapies. Circulating and graft skin Treg values were compared with graft outcomes and with histologic grade from concurrent biopsies. RESULTS: Treg proportion in peripheral blood ranged from 0.156% to 9.00% with a mean of 3.34%±0.22%. FoxP3 staining was observed in 3 of 29 graft biopsies. Median circulating Treg value did not predict time to Banff grade II rejection (hazard ratio, 0.9; confidence interval, 0.4-2.2) or graft loss (hazard ratio, 0.5; confidence interval, 0.01-5.3). Animals that experienced rejection did not have significantly different peripheral blood or graft skin Treg values from those that did not. Biopsy specimens with grade I or II rejection were more likely to contain Tregs (25% vs. 0%; P=0.044) despite no difference in concurrent circulating Tregs (3.56% vs. 3.36%; P=0.704). CONCLUSIONS: These findings in a clinically relevant model suggest that Tregs may have limited prognostic value with standard immunosuppressive protocols used in VCA. Further studies are necessary to determine the specific role of Tregs in VCA and any role of Treg monitoring in clinical practice.

Total face, double jaw, and tongue transplant research procurement: an educational model.

BACKGROUND: Transplantation of a facial vascularized composite allograft is a highly complex procedure that requires meticulous planning and affords little room for error. Although cadaveric dissections are an essential preparatory exercise, they cannot simulate the true clinical experience of facial vascularized composite allograft recovery. METHODS: After obtaining institutional review board approval to perform a facial vascularized composite allograft research procurement, a 66-year-old, brain-dead donor was identified. The family graciously consented to donation of a total face, double jaw, and tongue allograft and multiple solid organs. RESULTS: A craniofacial computed tomographic angiogram was obtained preoperatively to define the vascular anatomy and facilitate virtual computerized surgical planning. The allograft was procured in 10 hours, with an additional 2 hours required for an open tracheostomy and silicone facial impression. The donor was coagulopathic throughout the recovery, resulting in an estimated blood loss of 1500 ml. Fluorescence angiography confirmed adequate perfusion of the entire allograft based on lingual and facial arterial and external jugular and thyrolinguofacial venous pedicles. The solid organ transplant team initiated abdominal organ isolation while the facial allograft procurement was in progress. After completion of allograft recovery, the kidneys and liver were recovered without complication. CONCLUSIONS: Before conducting a clinical face transplant, adequate preparation is critical to maximize vascularized composite allotransplantation outcomes and preserve solid organ allograft function. As more centers begin to perform facial transplantation, research procurement of a facial vascularized composite allograft offers a unique educational opportunity for the surgical and anesthesia teams, the organ procurement organization, and the institution.

The anterior tibialis artery perforator (ATAP) flap for traumatic knee and patella defects: clinical cases and anatomic study.

UNLABELLED: Soft-tissue reconstruction of traumatic patella and proximal tibial defects is challenging. Pedicled perforator-based adipocutaneous rotation flaps are a versatile local option as they have axial perfusion and greater freedom of transposition compared with random-pattern flaps, and replace the ideal tissue properties of this anatomic region. EXPERIMENTAL: Anatomic dissections were performed on 15 fresh cadaver legs and location of the dominant perforator measured. Clinical: A retrospective review was conducted at the University of Maryland/R Adams Cowley Shock Trauma Center evaluating patients over a 3-year period. EXPERIMENTAL: Cadaver dissections confirmed a principal perforator at 11.4 +/- 1.6 cm inferior to the patella. This vessel is consistently suitable in length and caliber for large rotation flap design. Clinical: Anterior tibial artery perforator flaps were performed on 4 patients following Gustilo IIIB wounds to the patella and tibial plateau. Two patients had rotation flap reconstructions to salvage failed gastrocnemius muscle flaps. All flaps were successful, however, one patient had overwhelming hardware infection several months later despite successfully healed flap.Local anterior tibial artery perforator flaps based on predictable perforators provide reliable coverage of patella and knee defects, bestowing versatility and flexibility to the reconstructive surgeon's armamentarium.

Intraoperative detection of intimal lipid in the radial artery predicts degree of postoperative spasm.

BACKGROUND: The radial artery's (RA) tendency to spasm when used as a bypass graft may relate to features of the RA itself. We imaged RA conduits before and after CABG in order to characterize intimal abnormalities that might relate to the risk of spasm. METHODS: RA conduits from thirty-two CABG patients were imaged intraoperatively using catheter-based optical coherence tomography (OCT) and again on day 5 using 64-channel MDCT angiography. The change in luminal diameter between timepoints was measured in the proximal, mid and distal RA. "Spasm" was defined as focal or diffuse luminal narrowing to a diameter less than the target coronary. Lipid content in the RA was quantified by the degree of light attenuation on the OCT image. RESULTS: Postoperative spasm was diagnosed in 18 of 32 (56%) RA grafts with the distal RA showing the most severe change versus the mid and proximal portions (-24.1+/-43.2% vs. -15.3+/-40.7%, -9.0+/-42.5% change in diameter respectively, p<0.01). The degree of attenuation of the OCT signal produced by the RA was strongly correlated with % diameter change (R=0.64, p=0.0005) and was significantly more pronounced in grafts with spasm versus no spasm (-1.97+/-0.61mm(-1) vs. -0.81+/-0.57mm(-1), p<0.0001). Histology confirmed lipid deposits in areas of RA with strong attenuation. CONCLUSIONS: RA conduits otherwise considered acceptable for bypass grafting were often found by OCT imaging to have a substantial amount of lipid, which in turn strongly relates to the risk of postoperative spasm. Screening conduits based on characteristics of intimal quality may improve results following RA grafting.