Remote monitoring of head and neck free flaps using near infrared spectroscopic tissue oximetry.

PURPOSE: Near infrared spectroscopy (NIRS) measures tissue oximetry and perfusion of free tissue transfer with the advantage of remote wireless monitoring for free tissue transfer. It has been widely used in breast and extremity reconstruction but has had limited adoption in the head and neck. MATERIALS AND METHODS: A retrospective review of head and neck microvascular reconstruction by three different surgical services over 15 months at one tertiary care hospital was performed. Demographics, flap type, monitoring technique, complications, and flap outcomes were recorded. Monitoring techniques were (1) implantable/handheld Doppler or (2) NIRS. Flap monitoring outcomes were evaluated using multivariate analysis. RESULTS: 119 flaps were performed by four surgeons with a success rate of 92% (109/119). Flaps were monitored with Doppler (40%) or NIRS (60%). There was no difference in flap success based on monitoring technique. An ROC analysis identified that the optimal cutoff in immediate StO2 for classifying flap success at discharge was 68%. CONCLUSIONS: NIRS was successfully implemented in a high-volume head and neck reconstructive practice. NIRS remote monitoring allowed for flap surveillance without requiring in-hospital presence and was able to identify both arterial and venous compromise.

Reconstruction of a large external hemipelvectomy defect after chordoma resection using a 5-component chimeric rotational flap.

Management of complex lumbosacral neoplastic disease presents unique challenges and requires a multidisciplinary approach. Large pelvic tumors may require external hemipelvectomy where an entire lower extremity including the hemipelvis is removed with disarticulation of the sacroiliac joint and symphysis pubis. When external hemipelvectomy is performed, the reconstructive surgeon must consider osseous reconstruction for structural pelvic support, the elimination of dead space, protection of implanted hardware, intra-abdominal support, and skin coverage. Reconstruction must minimize wound healing morbidity, operative time and the number of operative sites, and maximize the potential for rehabilitation. We present a case demonstrating use of a rotational chimeric flap for the reconstruction of an external hemipelvectomy defect.

Timing of prophylactic hysterectomy-oophorectomy, mastectomy, and microsurgical breast reconstruction in BRCA1 and BRCA2 carriers.

BACKGROUND: BRCA (breast cancer susceptibility gene) carriers are at high risk for breast and ovarian malignancies, and often undergo prophylactic total abdominal hysterectomy-bilateral salpingo-oophorectomy (TAH-BSO), bilateral mastectomy, and microsurgical breast reconstruction. Our goal was to determine whether abdominal wall complications and flap choice are affected by the order of those procedures. METHODS: All BRCA carriers who underwent microsurgical breast reconstruction between 2007 and 2012 were studied. Abdominal wall complications and changes in the reconstructive plan were analyzed depending on the order of breast reconstruction and TAH-BSO. RESULTS: 442 patients underwent 612 microsurgical breast reconstructions, 47 of whom were BRCA carriers. TAH-BSO was not a predictor of requiring mesh for fascial closure (OR 1.1, P = 0.8), or of hernia/bulge (OR = 1.6, P = 0.65). In five patients, a DIEP flap was altered to another flap as a direct result of prior TAH-BSO. Robotic TAH-BSO after breast reconstruction took longer to perform than before breast reconstruction (4.48 ± 1.00 hours vs. 3.23 ± 0.70 hours, respectively, P = 0.023), due to abdominal wall tightness. However, none were converted to open. Full-muscle free TRAM flaps (compared to other flaps) and bilateral reconstructions (compared to unilateral) were the only predictors of mesh (OR = 9.85, P < 0.001 and 4.01, P < 0.001), and hernia/bulge (OR = 6.18, P < 0.001 and 2.13, P = 0.07). The order of TAH-BSO and breast reconstruction did not affect complications. CONCLUSIONS: In BRCA carriers, the order of TAH-BSO and microsurgical breast reconstruction does not affect complication rates. However, prior TAH-BSO may make DIEP flaps unfeasible, and robotic TAH-BSO after breast reconstruction takes longer, but can still be performed safely.

A systematic approach to emergent breast free flap takeback: Clinical outcomes, algorithm, and review of the literature.

BACKGROUND: Few evidence-based and detailed algorithms exist on the management of failing breast free flaps, including use of the numerous salvage tools that are available. The purpose of this study was to analyze our outcomes with an algorithmic approach to breast free flap salvage after vascular compromise. A review of the literature is also presented. METHODS: A retrospective review of all breast free flaps performed at our institution between 2007 and 2012 was performed. Flaps with intraoperative and postoperative vascular complications were analyzed. RESULTS: A total of 612 microsurgical breast reconstructions in 442 patients were reviewed. Of these, 72 (11.8%) flaps had intraoperative vascular complications, and 36 (5.9%) had postoperative vascular complications. The total flap loss rate was 2.8%. The most commonly used salvage modalities were anastomotic revision (72%), heparin irrigation (72%), systemic heparin (37%), Fogarty catheter thrombectomy (17.6%), thrombolytics (13%), and indocyanine green angiography (10.2%). In 53 (49.1%) cases, flap salvage involved use of 1 modality, whereas in 55 (50.9%) cases multiple modalities were used. Factors associated with failure of these flap salvage tools included intraoperative arterial rather than postoperative arterial compromise (P = 0.01), and situations requiring use of a greater number of salvage modalities (P < 0.001). CONCLUSIONS: We found that intraoperative compromise had significantly better prognosis than postoperative compromise. By organizing the numerous salvage modalities available to microsurgeons into a well-defined algorithm that is supported by the literature, we have established a best practices protocol that has achieved flap salvage rates that compare favorably to the published literature.

Lymphedema: Conventional to Cutting Edge Treatment.

Lymphedema of the extremities related to oncologic therapies such as cancer surgery, radiation therapy, and chemotherapy is a major long-term cause of morbidity for cancer patients. Both nonsurgical and surgical management strategies have been developed. The goals of these therapies are to achieve volume reduction of the affected extremity, a reduction in patient symptoms, and a reduction in associated morbidities such as recurrent soft-tissue infections. In this article, we review both nonsurgical and surgical management strategies. Traditional surgical therapy has focused on more ablative techniques such as the Charles procedure and suction-assisted lipectomy/liposuction. However, newer more physiologic surgical methods such as lymphovenous anastomoses and vascularized lymph node transfers have become a more common treatment modality for the management of this complex problem.

Barriers to Repair in Maxillofacial Trauma.

IMPORTANCE: Multiple factors can be associated with the delayed repair of maxillofacial injuries that may be associated with increased morbidity. OBJECTIVE: To assess factors affecting timing of repair and barriers which may exist in the management of maxillofacial trauma. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study at a tertiary care facility used the Current Procedural Terminology coding to identify adult patients undergoing operative repair of maxillofacial injuries between January 2010 and December 2013. Demographic information, presence and severity of concomitant injuries, as well as fracture-specific data including fracture type(s), mechanism of injury, and documented complications were recorded. Identifiable delays for medical, logistical, or other reasons were also documented. Multivariate regression modeling was used to determine factors associated with increased time to repair. A comparative analysis was used to identify association between complications and time to operative repair. MAIN OUTCOMES AND MEASURES: Time to operative repair from date of presentation; association of known operative delay and perioperative complications. RESULTS: Overall, 780 patients were included in the study. Of patients meeting inclusion criteria, mean (SD) age was 36.7 (14.2) years (range, 18-88 years), and 616 patients (79%) were male. Average time to repair was 6.5 days (range, 0-43 days), and 138 patients (17.7%) were observed to have a documented reason for delay for medical reasons (n = 62 [44.9%]), operating room logistical factors (n = 17 [12.3%]), or other reasons (n = 59 patients [42.8%]) either as a function of delayed patient presentation or failure of patients to make scheduled appointments or operations. Injury severity score (ρ = 0.45; P < .001), concurrent injuries (P < .001), decreased Glasgow Coma Scale (P < .001) and inpatient status at time of surgery (P < .001), were associated with increased time to repair. The observed complication rate was 13.6%. There was no statistically significant association between known operative delay and development of complications (χ21 = 2.92; P = .08). CONCLUSIONS AND RELEVANCE: Management of maxillofacial trauma appears to occur in a timely manner. Patient injury severity appears to have the greatest effect on timing of repair. While delays in operative repair may be unavoidable in certain circumstances, streamlining and managing causes of known delay may help improve and expedite patient care. LEVEL OF EVIDENCE: 3.

Unintentional fall injuries among US children: a study based on the National Emergency Department Sample.

This study uses national data to describe the patterns and aetiologies for childhood falls in a high-income country, the United States. We conducted a retrospective analysis of data for children aged 0-17 years from the 2007 Nationwide Emergency Department Sample (NEDS). Sample weights provided by NEDS were used to make national estimates. We estimated that in 2007 there were more than 2.3 million paediatric fall-related emergency department (ED) visits at a rate of 3217 visits per 100,000 children. Over 95% of those seen for fall injuries were treated and released. In addition, government sources made payments for just under one-third of these visits. Of those ED visits that result in hospitalisation, we found marked age patterns in bodily location of injury. The impact of fall-related injuries on EDs in the US is substantial within the paediatric population. The use of national level ED data shows age and gender patterns in paediatric fall injury not readily apparent in previous studies. There are patterns in external cause of injury and bodily location of injury that can be used to guide age specific prevention interventions.

Geographic variation and positive selection on M7 lysin, an acrosomal sperm protein in mussels (Mytilus spp.).

Successful fertilization in free-spawning marine organisms depends on the interactions between genes expressed on the surfaces of eggs and sperm. Positive selection frequently characterizes the molecular evolution of such genes, raising the possibility that some common deterministic process drives the evolution of gamete recognition genes and may even be important for understanding the evolution of prezygotic isolation and speciation in the marine realm. One hypothesis is that gamete recognition genes are subject to selection for prezygotic isolation, namely, reinforcement. In a previous study, positive selection on the gene coding for the acrosomal sperm protein M7 lysin was demonstrated among allopatric populations of mussels in the Mytilus edulis species group (M. edulis, Mytilus galloprovincialis, and Mytilus trossulus). Here, we expand sampling to include M7 lysin haplotypes from populations where mussel species are sympatric and hybridize to determine whether there is a pattern of reproductive character displacement (RCD), which would be consistent with reinforcement driving selection on this gene. We do not detect a strong pattern of RCD; neither are there unique haplotypes in sympatry nor is there consistently greater population structure in comparisons involving sympatric populations. One distinct group of haplotypes, however, is strongly affected by natural selection, and this group of haplotypes is found within M. galloprovincialis populations throughout the Northern Hemisphere concurrent with haplotypes common to M. galloprovincialis and M. edulis. We suggest that balancing selection, perhaps resulting from sexual conflicts between sperm and eggs, maintains old allelic diversity within M. galloprovincialis.