Subdermal Plexus Density as It Relates to Obesity and Wound Complications in Patients Undergoing Reduction Mammaplasty.

Background: Reduction mammaplasty is one of the most common reconstructive procedures performed in plastic surgery. Multiple comorbidities play a role in postoperative wound healing complications; however, there are insufficient data on the subdermal plexus (SDP) as it relates to these comorbidities. The purpose of this study is to evaluate the relationship between body mass index (BMI) and SDP of the superficial breast tissues and examine the association between SDP and postoperative complications. Methods: After Institutional Review Board approval, screening, and informed consent, patients undergoing reduction mammaplasty were selected. Tissue to be discarded was sent to pathology for analysis of immunohistochemistry directed against endothelial cells to determine the density of the SDP. Patients with BMI <35 and ≥35 kg/m2 were compared. Statistical analysis, including 2-tailed t test and Pearson correlation, was conducted. Results: A significant difference in SDP density (standard deviation) was identified between patients with a BMI ≥35 versus <35 kg/m2 (2.65 capillaries/mm2 ± 1.8 vs 1.56 capillaries/mm2 ± 1.2; P = .033). Patients with no historical use of tobacco versus those who used tobacco showed a significantly increased SDP (2.11 capillaries/mm2 ± 1.6 vs 1.20 capillaries/mm2 ± 0.5; P = .009). A significant relationship between postoperative infection (1.00 capillaries/mm2 ± 1.1; P = .041) and hematoma/seroma (0.788 capillaries/mm2 ± 0.1; P = .003) was identified. No significant relationship was found between SDP and delayed wound healing, nipple-areolar complex complications, fat/flap necrosis, or symptomatic scar occurrence. Conclusions: There is a statistically significant increase in SDP seen with increasing BMI, which does not explain the higher rate of wound healing complications after reduction mammaplasty typically seen in the higher BMI patient population. The association between BMI and complications after reduction mammaplasty remains unclear.

Comparison of inferior gluteal artery perforator flaps versus vertical rectus abdominis musculocutaneous flaps in the reconstruction of perineal wounds.

BACKGROUND: Achieving a healed perineal wound following chemoradiotherapy and abdominoperineal resection (APR) is challenging for surgeons and patients. Prior studies have shown trunk-based flaps, including vertical rectus abdominis myocutaneous (VRAM) flaps, are superior to both primary closure and thigh-based flaps; however, there has been no direct comparison with gluteal fasciocutaneous flaps. This study evaluates postoperative complications after various methods of perineal flap closure of APR and pelvic exenteration defects. METHODS: Retrospective review of patients who underwent APR or pelvic exenteration from April 2008 through September 2020 was analyzed for postoperative complications. Flap closure techniques, including VRAM, unilateral (IGAP), and bilateral (BIGAP) inferior gluteal artery perforator fasciocutaneous flaps, were compared. RESULTS: Of 116 patients included, the majority underwent fasciocutaneous (BIGAP/IGAP) flap reconstruction (n = 69, 59.6%), followed by VRAM (n = 47, 40.5%). There were no significant differences between group patient demographics, comorbidities, body mass index, or cancer stage. There were no significant differences between BIGAP/IGAP and VRAM groups in minor complications (57% versus 49%, p = 0.426) or major complications (45% versus 36%, p = 0.351), including major/minor perineal wounds. CONCLUSIONS: Prior studies have shown flap closure is preferable to primary closure after APR and neoadjuvant radiation but lack consensus on which flap offers superior postoperative morbidity. This study comparing outcomes of perineal flap closure showed no significant difference in postoperative complications. Fasciocutaneous flaps are a viable choice for the reconstruction of these challenging defects.

Microcirculatory Effects of Botulinum Toxin A in the Rat: Acute and Chronic Vasodilation.

BACKGROUND: Botulinum toxin-A (BTX) has numerous cosmetic and therapeutic applications. Our previous studies have found that BTX augments pedicled flap survival through both vasodilatory effects and attenuation of the inflammatory response to ischemia in the rat. This study examines the effect of chronic BTX on microcirculatory vascular tone and its response to acute topical vasodilators in muscle flaps. METHODS: The spinotrapezius muscle of Sprague-Dawley rats underwent a single 2-week pretreatment of 0.2 mL saline either with (n = 5) or without (n = 5) 2u BTX. After surgical elevation, an arcade arteriole was observed using a video caliper device. Vessel diameter was measured at 30-second intervals after sequential superfusion of nitroglycerin (100 and 200 µg/mL), multiple concentrations of lidocaine, and a combination of adenosine (10 µM) and nitroprusside (10 µM) to induce maximum dilation. RESULTS: Baseline and dilation diameters were expressed as ratios of pharmacologically induced maximum dilation, whereas percent dilation was defined as the change in diameter over baseline diameter. We found a significant increase in resting diameter with BTX pretreatment (P = 0.0028). Compared with the control group, mean baseline diameter was 15% greater, and percent dilation was 25% less in BTX-pretreated flaps. There was no significant relationship between BTX pretreatment and dilation diameter (P = 0.2895) after adjusting for the effect of acute vasodilators. CONCLUSIONS: Pretreatment with BTX may induce the arteriolar resting diameter to be closer to their maximum potential diameter. Additionally, BTX does not display a synergistic effect with topical vasodilators on vasodilation.

The Effect of Activated Protein C on Attenuation of Ischemia-Reperfusion Injury in a Rat Muscle Flap Model.

Ischemia-reperfusion injury is often the final and irreversible factor causing flap failure in microsurgery. The salvage of a microsurgical flap with an ischemia-reperfusion injury contributes to the success of microsurgical flap transfers. Activated protein C (APC), a serine protease with anticoagulant and anti-inflammatory activities, has been shown to improve ischemic flap survival. To date, APC has yet to be applied to models of free flap with ischemia-reperfusion injury. In this study, we aimed to investigate the effect of APC on gracilis flap ischemia-reperfusion injury induced by gracilis vessels clamping and reopening. Sixty male Sprague-Dawley rats were randomly divided into 2 groups. After 4 hours of clamping for ischemia, flaps were reperfused and recombinant human APC (25 µg/kg) or saline was injected in the flaps through pedicles. At 0, 1, 4, 18, and 24 hours after injection (n = 6 for each time point), the tissue samples were harvested. The muscle viability at 24 hours in saline group was 54.8% (15.1%), whereas the APC-treated group was 90.0% (4.3%) (P < 0.05). The induced nitric oxide synthase (iNOS) mRNA expression increased with the time after reperfusion, which were 0.93 (0.25) to 2.09 (0.22) in saline group, and 0.197 (0.15) to 0.711 (0.15) in the APC-treated group. iNOS mRNA expression in the APC-treated group was significantly higher than the saline group at 1, 18, and 24 hours (P < 0.05). Numerous inflammatory cells were observed infiltrating and invading the muscle fibers in the saline group more than the APC-treated group. Increased number of polymorphonuclear cells was also noted in the saline group compared with the APC-treated group (P < 0.05). In conclusion, APC treatment can significantly attenuate ischemia-reperfusion injury and increase the survival of the free flap through down-regulating iNOS mRNA expression and reducing the inflammatory cells. Further research is still needed to be done on various mechanisms in which APC is protective to prevent tissue damage.

Intrathoracic migration of a breast implant after minimally invasive cardiac surgery.

The aging population, in combination with the popularity of breast augmentation with implants, presents surgeons with a growing number of cases involving women undergoing minimally invasive cardiac surgery (MICS) who have breast implants. We present an unusual complication involving the delayed migration of a subpectoral implant into the chest cavity through an iatrogenic defect after a minimally invasive mitral valve repair. This chest wall defect was ultimately repaired with a latissimus dorsi flap. Although MICS has been described in women with breast implants, the documented experience remains limited. Most authors classically recommend explantation of the prosthesis to provide access to the chest wall; however, some have later suggested preserving the implant capsule in situ while performing the cardiac procedure with gentle retraction. From our literature review and experience, we recommend that the posterior capsule should remain intact. If this is not possible, then the chest wall closure should be reinforced with either mesh, soft tissue, or both. Soft tissue options include the conversion from a subpectoral to a subglandular position to use the pectoralis major, or a latissimus dorsi muscle flap. With the increasing number of these cases along with the complexities of minimally invasive procedures, close communication and planning should be undertaken between both cardiothoracic and plastic surgeons when taking care of these patients. Above all, when faced with postoperative complications after MICS, the plastic surgeon must maintain a high index of clinical suspicion and consider the possibility of intrathoracic migration of an implant so that proper workup and planning may be initiated.

Inflammatory response and survival of pedicled abdominal flaps in a rat model after perivascular application of botulinum toxin type A.

BACKGROUND: In addition to the numerous applications of botulinum toxin type A, the authors have documented improvements in surgical flap survival through vasoactive effects. This study aimed to investigate its effect on the expression of inflammatory mediators. METHODS: In 54 male Sprague-Dawley rats, cutaneous flaps based on the superficial epigastric vessels were elevated. Botulinum toxin type A, lidocaine, or saline was administered to the vascular pedicle. After 1, 2, and 7 days, mRNA expression for tumor necrosis factor-α, interleukin-1, and vascular endothelial growth factor-165 was compared along with flap survival. RESULTS: Vascular endothelial growth factor-165 mRNA expression was lower in the botulinum toxin type A group compared with (1) the saline group at days 1 and 2 (p < 0.01) and (2) the lidocaine group at day 2 (p < 0.05). The expression of interleukin-1 was significantly less at each time point in the botulinum toxin type A group compared with the lidocaine group (p < 0.02), and at day 2 compared with the saline group (p < 0.01). Tumor necrosis factor-α mRNA expression in the botulinum toxin type A group was lower at 2 days and 7 days compared with both other groups (p < 0.04). Finally, both the botulinum toxin type A and lidocaine groups had a greater survival area (p < 0.05) compared with the saline group. CONCLUSION: The presence of botulinum toxin type A in the postsurgical flap microenvironment augments tissue perfusion and its inflammatory response and, ultimately, survival.

T. asahii pulmonary infection as a complication of TNF-inhibitor and steroids: posaconazole pharmacotherapy and risk analysis.

We report the first documented Trichosporon asahii infection in a patient with connective tissue disease treated with a Tumor Necrosis Factor (TNF) inhibitor and describe an institutional root cause analysis for TNF inhibitor-associated infections. Fourteen patients with incident fungal infections during TNF inhibitor treatment were identified. They were matched with uncomplicated patients receiving TNF inhibitors or with rheumatoid arthritis (RA) patients managed without TNF inhibitors. We found that patients acquiring fungal infections were more likely to have graft versus host disease (GVHD) (p<0.05). Furthermore, infected patients were more likely (OR=24.4) to have multiple immunosuppressive therapies over the controls as well as several risk factors identified by the Infectious Disease Society ofAmerica (IDSA). The 3 patient deaths in our study were associated with GVHD and infliximab. Trichosporon was isolated in 1 patient receiving adalimumab. Our results suggest that these high risk patients be monitored closely for fungal infection.

Clinical applications of venous flaps in the reconstruction of hands and fingers.

In recent years, the venous flap has been highly regarded in microsurgical and reconstructive surgeries, especially in the reconstruction of hand and digit injuries. It is easily designed and harvested with good quality. It is thin and pliable, without the need of sacrificing a major artery at the donor site, and has no limitation on the donor site. It can be transferred not only as a pure skin flap, but also as a composite flap including tendons and nerves as well as vein grafts. All these advantages make it an optimal candidate for hand and digit reconstruction when conventional flaps are limited or unavailable. In this article, we review its classifications and the selection of donor sites, update its clinical applications, and summarize its indications for all types of venous flaps in hand and digit reconstruction.

Vein grafting in fingertip replantations.

In this retrospective study, the survival rates of fingertip replantation with and without vein grafting were evaluated along with their postoperative functional and cosmetic results. One hundred twenty-one-fingertip amputations were performed in 103 patients between September 2002 and July 2007. Thirty-four amputated fingertips were replanted without vein grafting, while 87 amputated fingertips were replanted with vein grafting for arterial and/or venous repairs. The overall survival rates of the replantations with and without vein grafting were 90% (78/87) and 85% (29/34), respectively. The survival rates were 88% (36/41) with venous repair, 93% (25/27) with arterial repair, and 89% (17/19) with both. Nineteen patients without vein grafting and 48 patients with vein grafting had a follow-up period of more than one year. Good cosmetic and functional outcomes were observed in both groups of patients. The results show that vein grafting is a reliable technique in fingertip replantations, showing no significant difference (P > 0.05) in survival between those with and without vein grafting. Furthermore, no significant difference (P > 0.05) in survival was found between cases with vein grafts for arterial and/or venous repairs. In fingertip replantations with vein grafting, favorable functional and esthetic results can be achieved without sacrificing replantation survival.