The Biomechanical Properties of Meshed versus Perforated Acellular Dermal Matrices (ADMs).

Acellular dermal matrices (ADMs) are used for soft tissue augmentation across surgical specialties. Since allograft incorporation depends on direct opposition between the ADM and a vascular bed, seroma formation can be detrimental to incorporation. Since most ADM products are available in many meshed and perforated forms, there is a lack of consistency between manufacture designs. We set out to determine the fluid egress properties and increase in surface area resulting from common cut patterns. METHODS: Three ADM cut patterns were studied: 1 meshed and 2 perforated. We calculated the surface area of these modified ADM samples. Fluid was passed through each ADM, and time required for fluid passage was recorded. An ANOVA (P < 0.05) was used to determine if there was a significant difference in egress properties across the 3 patterns. RESULTS: Meshing in a 1:1 pattern resulted in a 97.50% increase in surface area compared with the uncut product. In comparison, only a 0.30% increase resulted from Perforation Pattern #1 and a 0.59% increase resulted from Perforation Pattern #2. There was a significant difference in egress properties across the three cut patterns (P = 0.000). The average egress time of Mesh Pattern #1 was 1.974 seconds. The average egress time of Perforation Pattern #2 was 6.504 seconds, and of Perforation Pattern #1 was 10.369 seconds. CONCLUSIONS: Quantitative comparison revealed that meshing ADM significantly improves fluid egress and increases the surface area. Therefore, the use of meshed ADM tissue could improve the incorporation of ADM with the recipient, with improved patient outcomes.

Inpatient Flap Monitoring after Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction: How Long Is Long Enough?

BACKGROUND: There is a growing trend across health care to perform increasingly complex procedures in less acute settings. This shift has been fueled, in part, by enhanced recovery protocols, which have shortened hospital stays after major surgeries. We set out to determine the timing of microvascular complications after deep inferior epigastric artery perforator (DIEP) free flap breast reconstruction in a high-volume practice using continuous flap monitoring technologies. METHODS: The medical charts of all patients who underwent breast reconstruction with DIEP flaps over 24 consecutive months were reviewed. Postoperatively, all flaps were monitored according to a protocol that included continuous tissue oximetry with near-infrared spectroscopy. The primary end points evaluated included any unplanned return to the operating room, time to takeback, and flap loss rate. RESULTS: A total of 196 patients underwent breast reconstruction with a total of 301 DIEP flaps. Five of the flaps (1.7%) were taken back to the operating room for microvascular issues, and nine (3.0%) were taken back for nonvascular issues. Of patients who were brought back for microvascular issues, all five (100.0%) were initially identified by continuous noninvasive monitoring and taken back to the operating room within the first 14 hours (range: 1.2-13.6 hours). In the series, the flap failure rate was 0.66% (n = 2). CONCLUSION: All of the microvascular issues were detected in the initial 23 hours after surgery, leading to prompt flap salvage. The results of this study bring into question the need for lengthy flap monitoring protocols and suggest that shorter inpatient, or even observation admissions, may be reasonable, particularly when flap monitoring protocols incorporating continuous noninvasive flap monitoring are used.

Evidence-Based Performance Measures: Quality Metrics for the Care of Patients Undergoing Breast Reconstruction.

The American Society of Plastic Surgeons commissioned the Breast Reconstruction Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing breast reconstruction surgery. Two outcome measures were identified. The first desired outcome was to reduce the number of returns to the operating room following reconstruction within 60 days of the initial reconstructive procedure. The second desired outcome was to reduce flap loss within 30 days of the initial reconstructive procedure. All measures in this report were approved by the American Society of Plastic Surgeons Breast Reconstruction Performance Measures Work Group and the American Society of Plastic Surgeons Executive Committee. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, American Society of Plastic Surgeons' Qualified Clinical Data Registry reporting, and national quality reporting programs.

A Therapeutic Role for Survivin in Mitigating the Harmful Effects of Ionizing Radiation.

Background. Radiation therapy is a form of adjuvant care used in many oncological treatment protocols. However, nonmalignant neighboring tissues are harmed as a result of this treatment. Therefore, the goal of this study was to induce the production of survivin, an antiapoptotic protein, to determine if this protein could provide protection to noncancerous cells during radiation exposure. Methods. Using a murine model, a recombinant adenoassociated virus (rAAV) was used to deliver survivin to the treatment group and yellow fluorescence protein (YFP) to the control group. Both groups received targeted radiation. Visual inspection, gait analysis, and tissue histology were used to determine the extent of damage caused by the radiation. Results. The YFP group demonstrated ulceration of the irradiated area while the survivin treated mice exhibited only hair loss. Histology showed that the YFP treated mice experienced dermal thickening, as well as an increase in collagen that was not present in the survivin treated mice. Gait analysis demonstrated a difference between the two groups, with the YFP mice averaging a lower speed. Conclusions. The use of gene-modification to induce survivin expression in normal tissues allows for the protection of nontarget areas from the negative side effects normally associated with ionizing radiation.

Patient attitudes toward resident participation in cosmetic vs reconstructive outpatient consultations.

OBJECTIVES: The goal of residency programs is to provide trainees with exposure to all aspects of their chosen field so that they exit the program ready to be independent practitioners. However, it is common in some plastic surgery residency training programs to exclude residents from participation in consultations with patients who are seeking cosmetic surgery. The purpose of this study was to determine whether cosmetic surgery patients had a different view about resident involvement than reconstructive surgery patients and to evaluate what factors might be linked to patient attitudes on this topic. PARTICIPANTS: All new patients older than 18 years presenting to either academic or nonacademic locations were asked to complete the voluntary survey at their initial consultation. SETTING: The study was conducted at both the Ohio State University (academic) and Advanced Aesthetic and Laser Surgery (private practice) in Columbus, Ohio. DESIGN: The survey asked patients to identify their surgical concern as either cosmetic or reconstructive and to indicate the location on their body where they were having surgery. Additionally, a series of statements regarding resident involvement was presented with a 5-point Likert-type rating system to assess each patient's attitudes about a range of factors, such as resident sex and seniority. RESULTS: In total, 119 patients participated in the study by completing the survey. Of this population, 59.7% (n = 71) were classified as reconstructive surgery patients and 40.3% (n = 48) were classified as cosmetic surgery patients. Based on responses, it was determined that reconstructive surgery patients were more approving of resident involvement in their care than cosmetic surgery patients were. When other factors were analyzed, the patients seeking breast surgery were found to be more apprehensive about resident participation than non-breast surgery patients were. CONCLUSION: Although there were some differences in the way resident participation was perceived by cosmetic and reconstructive surgery patient populations, neither group strongly believed that resident participation decreased the quality of patient care. Based on these findings, plastic surgery training programs should begin to allow residents to become more involved in the care of cosmetic surgery patients.

Improvement in stress urinary incontinence after abdominoplasty.

BACKGROUND: Abdominoplasty is indicated in cosmetic surgery to improve body contour. Results from several studies suggest that abdominoplasty also could be therapeutic for certain individuals with urinary incontinence. OBJECTIVES: The authors sought to determine the potential therapeutic effect of abdominoplasty on urinary incontinence in a large population to confirm the findings of smaller studies and to identify common characteristics of patients who experience the greatest improvement in these symptoms postoperatively. METHODS: Through a retrospective chart review, the authors identified 250 patients who underwent cosmetic abdominoplasty. These patients were invited to participate in a survey to ascertain changes in stress urinary incontinence (SUI) symptoms after abdominoplasty. Patients were subgrouped according to postoperative changes in their urinary incontinence symptoms, and the subgroups were evaluated for common within-group characteristics. RESULTS: Of the 250 patients who underwent abdominoplasty during the period of interest, 100 (40%) completed the survey, half of whom (n=50) reported incontinence preoperatively. After abdominoplasty, 30 (60%) of these 50 patients noted improvement in their symptoms, and the other 20 (40%) reported no improvement. Lack of previous cesarean section was a predictor of improvement in SUI symptoms after abdominoplasty. CONCLUSIONS: Abdominoplasty to improve body contour also may alleviate symptoms of SUI, especially among patients who have not undergone previous cesarean section. LEVEL OF EVIDENCE: 4.

Biologic matrices in oncologic breast reconstruction after mastectomy.

As the demand for post-mastectomy breast reconstruction has continued to rise, options for the implantable soft-tissue replacement products which enhance the aesthetic and reconstructive outcome of these procedures has grown as well. While the most common product used in an alloplastic breast reconstruction is an acellular dermal matrix derived from human sources, many other options are currently available, each offering their own unique properties and benefits. This review presents a concise description of each of the biologic matrices currently available and discusses their use in the context of one-stage and two-stage breast reconstructions.

A review of devices used in the monitoring of microvascular free tissue transfers.

The use of microvascular anastomoses to allow transfer of viable tissue is a fundamental technique of reconstructive surgery, and is used to treat a broad spectrum of clinical problems. The primary threat to this type of reconstructive surgery is anastomotic vascular thrombosis, which can lead to complete loss of tissue with potentially devastating consequences. Monitoring of tissue perfusion postoperatively is critical, since early recognition of vascular compromise and prompt surgical intervention is correlated with the ability for tissue salvage. Traditionally, physical examination was the primary means of monitoring, but possesses several limitations. Medical devices introduced for the purposes of flap monitoring address many of these deficiencies, and have greatly enhanced this critical aspect of the reconstructive surgery process.

Optimizing the closed suction surgical drainage system.

BACKGROUND: Closed suction drains are indicated in a wide array of postoperative settings, with many distinct drainage systems available to the surgeon. The purpose of this study was to compare the suction gradients achieved using 2 different sizes of suction reservoirs and 2 different techniques for generating negative pressure. MATERIALS AND METHODS: Drainage reservoirs of 100 and 400 ml were chosen to evaluate their ability to achieve suction. Suction was established in both sizes of drains by pressing the sides of the reservoir together or by pushing the bottom of the reservoir toward the top. Negative pressures were recorded with the reservoir empty, and after every 10-ml addition of saline. Averages were graphed to illustrate the applied suction over a range of drain volumes. RESULTS: The 100-ml drainage system reached a peak suction of -117.6 mmHg, while the 400-ml drainage system reached only a peak suction of -71.4 mmHg. Both of the maximum suction readings were achieved using the full-squeeze technique. The bottom-pushed-in technique did not result in any sustained measurable levels of suction using either of the reservoir volumes. CONCLUSIONS: Smaller drain reservoirs are more successful in generating a high initial suction than larger reservoirs, especially when the volume of fluid in the drain is relatively low. In all sizes of drains, compressing the sides of the reservoir is a far better technique for establishing negative pressure than pressing the bottom of the drain up toward the top.

Fat grafting as a vehicle for the delivery of recombinant adenoassociated viral vectors to achieve gene modification of muscle flaps.

BACKGROUND: The combination of gene therapy and plastic surgery may have the potential to improve the specificity that is needed to achieve clinically applicable treatment regimens. Our goal was to develop a method for gene modification that would yield sustainable production of gene products but would be less time consuming than existing protocols. METHODS: An adenoassociated virus was used to deliver gene products to pectoralis muscle flaps. Gene modification was accomplished via either direct injection or novel fat grafting techniques. RESULTS: The production of gene product was observable by both in vivo imaging and immunohistochemical staining. Gene products were not detected in tissues that were not in contact with the fat grafts that were incubated with the viral vector, indicating that the transduction stayed local to the flap. CONCLUSIONS: Using novel recombinant adenoassociated virus vectors, we have developed a method for gene delivery that is highly efficient and applicable to muscle flaps.

The use of free microvascular techniques to improve the results of Van Nes rotationplasty.

Van Nes rotationplasty is a limb-salvage used for reconstruction after resection of a distal femoral or proximal tibial osteosarcoma in the pediatric patient. After resection, the distal leg is reapproximated to the level of tumor resection. The goal is to optimize extremity functionality such that the ankle functions as a knee joint. Traditionally, the vessels and nerves around the tumor are preserved within the distal leg. In the first case of our series, this method resulted in thrombosis, flap loss, and ultimately amputation secondary to venous torsion and thrombosis. In the following 2 cases, the intervening vasculature was resected along with the tumor, and the distal pedicles were anastomosed to their proximal counterparts using microvascular techniques. In addition to expediting resection of the tumor as well as allowing wider tumor resection margins, this technique also precludes thrombosis and subsequent flap loss.

Can the DermaClose device contribute to periwound tissue ischemia and necrosis: a case presentation and discussion?

The anterolateral thigh flaps allows for a large amount of vascularized skin and subcutaneous tissue for transfer as a locoregional flap or for microvascular free tissue transfer. In the settings of a large flap, primary closure of the donor site can be difficult. Multiple techniques, including the use of tissue expansion, can be used to assist with donor site closure. The DermaClose external tissue expander can be employed in such situations. We describe two cases with a unique use of the DermaClose system and postoperative complications.

A reliable method for the preoperative estimation of tissue to be removed during reduction mammaplasty.

BACKGROUND: Insurance requirements for prior authorization of reduction mammaplasty are becoming increasingly stringent, with the sole criterion determined by the surgeon being the estimation of the amount of tissue to be removed. Previous formulas for predicting resected tissue weights have been inconsistent and particularly unreliable in smaller reductions. This study describes a dependable, surgeon-specific method based on two simple preoperative measurements to estimate tissue resection weights in patients undergoing reduction mammaplasty. METHODS: The medical charts of 72 consecutive patients who underwent reduction mammaplasty were reviewed. Preoperatively obtained measurements from the first 15 patients in the authors' series were plotted against the actual corresponding amount of breast tissue removed at the time of surgery. Linear regression of this plot was used to generate a mathematical formula that was then used to predict resection weights of the subsequent 57 patients. The results were compared with the actual weights recorded intraoperatively. RESULTS: Several measurements were evaluated and Pearson coefficients generated. The mathematical product of two unique breast-only surface measurements along horizontal and vertical planes generated the linear regression formula with the greatest accuracy (r = 0.95) for predicting the weight of tissue to be resected compared with either measurement alone or sternal notch-to-nipple distance. CONCLUSION: By using two simple preoperative measurements correlated with tissue resection weights in a small series of procedures, any reconstructive surgeon can create his or her own reliable formula for predicting breast tissue resection weights for reduction mammaplasty.

Distal interphalangeal joint arthrodesis with the Herbert headless compression screw: outcomes and complications in 64 consecutively treated joints.

BACKGROUND: Arthrodesis of the distal interphalangeal (DIP) joint is indicated for the treatment of arthritis. While several techniques have been recommended, the use of headless compression screws has grown in popularity. Rates of union reported vary widely, ranging from 80% to 100%, with most studies based on small series. The purpose of this study was to review the outcomes and complications associated with DIP joint arthrodesis using the Herbert headless compression screw in a large case series. METHODS: The medical charts, surgical reports, and X-rays for patients undergoing DIP joint arthrodesis with a Herbert screw between January 1996 and May 2006 were retrospectively reviewed to determine the frequency and types of complications. All operations were performed by the senior author at a single institution. RESULTS: Of 64 joints in 51 patients that were treated with the Herbert screw, a total of 95% (n = 61) went on to union. Union within 3 months occurred in 89% (n = 57) while delayed union (between 3 and 6 months) occurred in 6% (n = 4). Nonunion requiring subsequent revision arthrodesis occurred in 5% (n = 3). Screw removal for symptomatic hardware was required in 8% (n = 5). CONCLUSIONS: Fusion of the DIP joint with the Herbert screw can be achieved at rates that are comparable to other techniques and other headless compressive screws. However, while complications do occur, the Herbert screw provides an acceptable rate of union and ease of operative technique, making it a suitable procedure for DIP joint arthrodesis.

One versus two venous anastomoses in microvascular free flap surgery.

BACKGROUND: The authors' goal was to determine whether one or two venous anastomoses results in superior blood flow through microvascular free flaps. METHODS: During flap harvest, blood velocity was measured in each of two venae comitantes using Doppler ultrasonography. Next, one of the two veins was occluded with a microvascular clamp and blood velocity was measured in the open vein. The clamp was then removed and placed on the other vein, and blood velocity was measured in the first vein. The pedicle was divided and microvascular anastomosis of either one or two veins was performed. Venous blood velocity was then compared between flaps with one versus two venous anastomoses. RESULTS: Eighty-one free flaps were performed. Before pedicle division, the peak venous blood velocity in each of the two venae comitantes averaged 6.3±4.8 cm/second. When one of the veins was occluded, the peak venous blood velocity increased to 19.5±17.3 cm/second (p<0.00001). One venous anastomosis was performed in 69 flaps and two venous anastomoses were performed in 12 flaps. The mean blood velocity in flaps in which one venous anastomosis was performed was greater than the mean blood velocity in either vein when two venous anastomoses were performed (13.1±7.3 cm/second versus 7.5±4.3 cm/second, respectively; p=0.001). CONCLUSIONS: When one vena comitans is occluded, blood velocity in the second vena comitans increases significantly. Venous blood velocity is significantly greater after a single venous anastomosis than in either of two veins when two venous anastomoses are performed. These results argue against routinely performing two venous anastomoses.

Combined use of preoperative 18F FDG-PET imaging and intraoperative gamma probe detection for accurate assessment of tumor recurrence in patients with colorectal cancer.

BACKGROUND: The purpose of this study was to combine intraoperative gamma probe (GP) detection with preoperative fluorine 18-fluoro-2-deoxy-glucose positron emission tomography (18F FDG-PET) imaging in order to improve detection of tumor recurrence in colorectal cancer (CRC) patients. METHODS: Twenty-one patients (12 females, 9 males) with a mean age of 54 years (range 31-78) were enrolled. Patients were suspected to have recurrent CRC by elevated CEA (n = 11), suspicious CT findings (n = 1), and clinically suspicious findings (n = 9). Preoperative FDG-PET scan and intraoperative GP study were performed in all patients. Mean time interval between preoperative FDG-PET scan and surgery was 16 days (range 1-41 days) in 19 patients. For intraoperative GP studies, 19 patients were injected with a dose of 10-15 mCi 18F FDG at approximately 30 minutes before the planned surgery time. In two patients, the intraoperative GP study was performed immediately after preoperative FDG-PET scan. RESULTS: Preoperative FDG-PET and intraoperative GP detected 48 and 45 lesions, respectively. A total of 50 presumed site of recurrent disease from 20 patients were resected. Thirty-seven of 50 presumed sites of recurrent disease were histological-proven tumor positive and 13 of 50 presumed sites of recurrent disease were histological-proven tumor negative. When correlated with final histopathology, the number of true positive lesions and false positive lesions by preoperative FDG-PET and intraoperative GP were 31/9 and 35/8, respectively. Both preoperative FDG-PET and intraoperative GP were true positive in 29 lesions. Intraoperative GP detected additional small lesions in the omentum and pelvis which were not seen on preoperative FDG-PET scan. FDG-PET scan demonstrated additional liver metastases which were not detected by intraoperative GP. Preoperative FDG-PET detected distant metastasis in the lung in one patient. The estimated radiation dose received by a surgeon during a single 18F FDG GP surgery was below the occupational limit. CONCLUSION: The combined use of preoperative FDG-PET and intraoperative GP is potentially helpful to the surgeon as a roadmap for accurately locating and determining the extent of tumor recurrence in patients with CRC. While intraoperative GP appears to be more sensitive in detecting the extent of abdominal and pelvic recurrence, preoperative FDG-PET appears to be more sensitive in detecting liver metastases. FDG-PET is also a valuable method in detecting distant metastases.

B7-deficient autoreactive T cells are highly susceptible to suppression by CD4(+)CD25(+) regulatory T cells.

CD4(+)CD25(+) regulatory T cells (Tregs) suppress immunity to infections and tumors as well as autoimmunity and graft-vs-host disease. Since Tregs constitutively express CTLA-4 and activated T cells express B7-1 and B7-2, it has been suggested that the interaction between CTLA-4 on Tregs and B7-1/2 on the effector T cells may be required for immune suppression. In this study, we report that autopathogenic T cells from B7-deficient mice cause multiorgan inflammation when adoptively transferred into syngeneic RAG-1-deficient hosts. More importantly, this inflammation is suppressed by adoptive transfer of purified wild-type (WT) CD4(+)CD25(+) T cells. WT Tregs also inhibited lymphoproliferation and acquisition of activation markers by the B7-deficient T cells. An in vitro suppressor assay revealed that WT and B7-deficient T cells are equally susceptible to WT Treg regulation. These results demonstrate that B7-deficient T cells are highly susceptible to immune suppression by WT Tregs and refute the hypothesis that B7-CTLA-4 interaction between effector T cells and Tregs plays an essential role in Treg function.