Significant predictors of complications after sternal wound reconstruction: a 21-year experience.

BACKGROUND: We sought to identify patient comorbidities that predict complications after tissue flap sternal reconstruction. METHODS: A retrospective study, December 1989 to December 2010, analyzed numerous comorbidities, including diabetes mellitus (DM), hypertension (HTN), coronary artery disease, congestive heart failure (CHF), and renal insufficiency, as independent risk factors for postoperative complications. Pearson χ2 test, Fisher exact test, 2-sample t test, and median-unbiased estimation were used for data analysis. Significance was P≤0.05. RESULTS: In all, 106 patients received 161 sternal tissue flap repairs. Nineteen patients (18%) required reoperation because of complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Our analysis found DM, HTN, and CHF as significant predictors of complications after sternal reconstruction (P=0.014, 0.012, and 0.006). CONCLUSIONS: Results suggest DM, HTN, and CHF may contribute to complications after tissue flap repair of sternal wounds, possibly through impaired perfusion and healing of repairs.

Facial Fracture Patterns Associated with Traumatic Optic Neuropathy.

Traumatic optic neuropathy (TON) is rare. The heterogeneity of injury patterns and patient condition on presentation makes diagnosis difficult. Fracture patterns associated with TON have never been evaluated. Retrospective review of 42 patients diagnosed with TON at the R. Adams Cowley Shock Trauma Center from May 1998 to August 2010 was performed. Thirty-three patients met criteria for study inclusion of fracture patterns. Additional variables measured included patient demographics and mechanism. Cluster analysis was used to form homogenous groups of patients based on different fracture patterns. Fracture frequency was analyzed by group and study population. Visual depiction of fracture patterns was created for each group. Cluster analysis of fracture patterns yielded five common "groups" or fracture patterns among the study population. Group 1 ( n = 3, 9%) revealed contralateral lateral orbital wall (100%), zygoma (67%), and nasal bone (67%) fractures. Group 2 ( n = 7, 21%) demonstrated fractures of the frontal bone (86%), nasal bones (71%), and ipsilateral orbital roof (57%). Group 3 ( n = 14, 43%) involved fractures of the ipsilateral zygoma (100%), lateral orbital wall (29%), as well as frontal and nasal bones (21% each). Group 4 ( n = 5, 15%) consisted of mid- and upper-face fractures; 100% fractured the ipsilateral orbital floor, medial and lateral walls, maxilla, and zygoma; 80% fractured the orbital roof and bilateral zygoma. Group 5 ( n = 4, 12%) was characterized by fractures of the ipsilateral orbital floor, medial and lateral orbital walls (75% each), and orbital roof (50%). A notably high 15 of 33 patients (45%) sustained penetrating trauma. Our study demonstrates five fracture pattern groups associated with TON. Zygomatic, frontal, nasal, and orbital fractures were the most common. Fractures with a combination of frontal, nasal, and orbital fractures are particularly concerning and warrant close attention to the eye.

Preemptive CD20+ B cell Depletion Attenuates Cardiac Allograft Vasculopathy in CD154-Treated Monkeys.

BACKGROUND: Anti-CD154 monotherapy is associated with antidonor allo-antibody (Ab) elaboration, cardiac allograft vasculopathy (CAV), and allograft failure in preclinical primate cell and organ transplant models. In the context of calcineurin inhibitors (CNI), these pathogenic phenomena are delayed by preemptive "induction" B cell depletion. METHODS: αCD154 (IDEC-131)-treated cynomolgus monkey heart allograft recipients were given peritransplant rituximab (αCD20) alone or with rabbit antihuman thymocyte globulin. RESULTS: Relative to previously reported reference groups, αCD20 significantly prolonged survival, delayed Ab detection, and attenuated CAV within 3 months in αCD154-treated recipients (αCD154 + αCD20 graft median survival time > 90 days, n = 7, vs 28 days for αCD154 alone (IDEC-131), n = 21; P = 0.05). Addition of rabbit antihuman thymocyte globulin to αCD154 (n = 6) or αCD154 + αCD20 (n = 10) improved graft protection from graft rejection and failure during treatment but was associated with significant morbidity in 8 of 16 recipients (6 infections, 2 drug-related complications). In αCD20-treated animals, detection of antidonor Ab and relatively severe CAV were anticipated by appearance of CD20 cells (>1% of lymphocytes) in peripheral blood and were associated with low αCD154 trough levels (below 100 µg/mL). CONCLUSIONS: These observations support the hypothesis that efficient preemptive "induction" CD20 B cell depletion consistently modulates pathogenic alloimmunity and attenuates CAV in this translational model, extending our prior findings with calcineurin inhibitors to the context of CD154 blockade.

Alloimmunity in primate heart recipients with CD154 blockade: evidence for alternative costimulation mechanisms.

BACKGROUND: CD154 mediates key facets of humoral and cellular immunity to alloantigens, and is tolerogenic to influenza antigens in primates. Barriers to CD154-based tolerance induction for primate cardiac allografts have not previously been defined. METHODS: Heterotopic cardiac allograft outcomes in cynomolgus monkeys treated with a CD154 inhibitor, IDEC-131 (n=27), were compared to no treatment (n=4) or cyclosporine A (n=6). RESULTS: CD154 blockade significantly prolonged median allograft survival, from 6.2 (range 6, 7, n=4) days in untreated controls, to 39 (8,112, n=16) days with intensive monotherapy and 93 (>25, 386; n=3) days with added antithymocyte globulin (ATG), but did not yield tolerance. Alloantibody production was delayed but not prevented by IDEC-131 alone or with ATG, and was exacerbated by infusion of donor bone marrow (n=8). Expression of ICOS was prominent in graft infiltrating lymphocytes, and preceded elaboration of antidonor antibody and vasculopathy. CONCLUSION: CD154 monotherapy modulates primate cardiac alloimmunity, but does not readily induce tolerance. Targeting alternative costimulation pathways, including ICOS, may facilitate tolerance induction based on CD154 blockade.

Recalcitrant verrucous lesion: verrucous hyperplasia or epithelioma cuniculatum (verrucous carcinoma).

A 37-year-old woman originally presented in May 2003 with a nonhealing, painless ulcer on the plantar surface of her right foot that had been slowly increasing in size for the previous 1.5 years. Two weeks before presentation, a biopsy of the lesion, performed at another institution, had indicated a probable verrucous carcinoma. After preoperative workup, the patient underwent resection of the lesion, with clear margins and full-thickness skin grafting. The final pathologic findings were not consistent with verrucous carcinoma. A recurrent lesion was noted during a follow-up visit, and a second biopsy revealed a hyperkeratotic papillomatous verrucous lesion, type unclassified. No viral particles were isolated in the random biopsy samples. This recurrent lesion was refractory to treatment with topical acyclovir. Subsequent treatments consisted of imiquimod and CO(2) laser ablation, which succeeded in reducing the lesion. Verrucous lesions can be frustrating, and the diagnosis of epithelioma cuniculatum can be difficult to prove. We report a case highly suggestive of but not definitively diagnosed as epithelioma cuniculatum and summarize the literature on this entity.

Plastic Surgery of the Breast: Keeping the Nipple Sensitive.

INTRODUCTION: Since its inception, reduction mammaplasty has matured considerably. Primary evolution in clinical research and practice has focused on preserving tissue viability. Surgery involves preserving not only tissue viability but also function and sensation. The nipple serves as the sensate unit of the breast and is a valuable part of women's psychological and sexual health, making preservation of nipple sensation of utmost important. Studies regarding primary innervation to the nipple are few and often contradictory. We propose an unsafe zone in which dissection during reduction mammoplasty ought to be avoided to preserve nipple sensation. METHODS: Circumareolar dissection of 22 cadaveric breasts was performed. Primary nerve branches to the nipple-areola complex were identified and dissected to their origin. RESULTS: Three to 5 branches of the fourth intercostal nerve primarily innervated the nipple on 18 of 22 breast dissections. Two breasts received innervation from the third intercostal nerve and 2 from the fifth intercostal nerve. In half of the specimens, accessory innervation from the third and fifth intercostal nerves provided medial branches to the nipple. CONCLUSIONS: The fourth intercostal nerve provides the major innervation to the nipple-areola complex. Avoiding dissection in inferolateral quadrant "unsafe zone" of the breast during reduction mammaplasty and other breast surgical procedures can reliably spare nipple sensation and maximize patient outcomes.

Preemptive CD20+ B cell depletion attenuates cardiac allograft vasculopathy in cyclosporine-treated monkeys.

Chronic rejection currently limits the long-term efficacy of clinical transplantation. Although B cells have recently been shown to play a pivotal role in the induction of alloimmunity and are being targeted in other transplant contexts, the efficacy of preemptive B cell depletion to modulate alloimmunity or attenuate cardiac allograft vasculopathy (CAV) (classic chronic rejection lesions found in transplanted hearts) in a translational model has not previously been described. We report here that the CD20-specific antibody (alphaCD20) rituximab depleted CD20+ B cells in peripheral blood, secondary lymphoid organs, and the graft in cynomolgus monkey recipients of heterotopic cardiac allografts. Furthermore, CD20+ B cell depletion therapy combined with the calcineurin inhibitor cyclosporine A (CsA) prolonged median primary graft survival relative to treatment with alphaCD20 or CsA alone. In animals treated with both alphaCD20 and CsA that achieved efficient B cell depletion, alloantibody production was substantially inhibited and the CAV severity score was markedly reduced. We conclude therefore that efficient preemptive depletion of CD20+ B cells is effective in a preclinical model to modulate pathogenic alloimmunity and to attenuate chronic rejection when used in conjunction with a conventional clinical immunosuppressant. This study suggests that use of this treatment combination may improve the efficacy of transplantation in the clinic.

Is simultaneous surgical management of advanced craniofacial osteoradionecrosis cost-effective?

BACKGROUND: Osteoradionecrosis is a serious complication of head and neck radiotherapy. Advanced cases are not amenable to periodic debridement, systemic antibiotics, or hyperbaric oxygen therapy. The authors sought to describe a cost-effective approach for patients with advanced craniofacial osteoradionecrosis. METHODS: Fifteen consecutive patients with craniofacial osteoradionecrosis were treated with radical resection and immediate microvascular free flap reconstruction at Johns Hopkins Hospital or R Adams Cowley Shock Trauma Center from 2002 to 2008. Demographic data were reviewed, and procedure costs were used to compare treatment options. RESULTS: All patients presented with intractable osteoradionecrosis, and most failed conservative therapy. Most cases (60 percent) involved the mandible, and the fibula was the flap of choice (73 percent). The median follow-up was 14 months, with 13 percent complications. Relative cost analysis for hyperbaric oxygen, surgical debridement, and a hospital stay was $25,010; simultaneous resection-microvascular free flap reconstruction and 7-day hospital stay were $30,030. The majority of patients, however, had prior attempts at conservative therapy followed by simultaneous resection and reconstruction; therefore, the average total relative cost per patient was $55,040 ($25,010 + $30,030). CONCLUSION: Definitive treatment of advanced or intractable osteoradionecrosis with simultaneous resection and microvascular composite flap reconstruction is not only definitive but financially sound.