AeroForm Tissue Expander: A Case of Early Accidental Inflation.

BACKGROUND: Device-based reconstruction, the most common approach to breast reconstruction, typically occurs in 2 stages to allow for the breast envelope to be expanded serially before exchanging for a permanent implant. The AeroForm tissue expander is a carbon dioxide-based expansion system that allows for patient-initiated filling, and compared with the traditional saline expander, it has been shown to decrease the median time to full expansion and implant exchange. Furthermore, multiple changes have been incorporated into the newer V2.5 iteration resulting in reductions in device-related malfunctions, including overinflation. CASE PRESENTATION: A 57-year-old woman who had a diagnosis of stage 1 ductal carcinoma in situ (T1c = 1.3 cm, ER/PR-negative, HER2-positive) underwent bilateral nipple-sparing mastectomy with sentinel lymph node biopsy and V2.5 AeroForm expander reconstruction. The procedure and subsequent postoperative follow-up visits were unremarkable without complications. However, once she entered an magnetic resonance imaging examination room for evaluation of an incidentally found meningioma, the carbon dioxide reservoir valve in both expanders was suddenly activated, releasing filling gas and maximally inflating the device to its 800-mL capacity. She elected to retain the expanders, and they were exchanged for permanent silicone implants 1 month later. CONCLUSIONS: Although the V2.5 AeroForm expander is associated with a much lower rate of overinflation than its predecessor, our case suggests that autoexpansion remains of concern and likely occurs via a different mechanism when the device is subjected to clinical strength magnetic field. Clinicians should not order magnetic resonance imaging scans for women with AeroForm expanders due to the risk of unintended expansion.

Submuscular Placement of Baclofen Infusion Pumps: Case Series and Technique.

BACKGROUND: Baclofen pumps provide treatment of symptoms of spasticity for disease processes such as cerebral palsy and traumatic brain injury. These devices provide continuous infusion or periodic dosing of intrathecal baclofen (ITB). Traditionally, these pumps have been placed subcutaneously. Subcutaneous device placement has been associated with infection and extrusion. Baclofen pumps are large and range from 8 to 10 cm in diameter and 4 to 8 cm in width. Patients requiring device placement typically have a paucity of subcutaneous tissue. Cachexia coupled with the size and bulk of these devices leads to increased protusion and friction. Submuscular placement provides a well-vascularized pocket that directs the device inward eliminating protrusion and decreasing the potential for soft tissue breakdown. METHODS: A retrospective chart review of ITB pump placement in a submuscular plane by a single plastic surgeon at a major academic center in conjunction with a neurosurgeon was performed. Inclusion criteria were cases of primary placement or replacement of ITB pumps and spasticity requiring ITB. Major complications included infection, extrusion, and reoperation. RESULTS: Five patients during a 5-month period were treated with submuscular placement of ITB pumps. Average age of patients included was 18.4 years. Average preoperative body mass index was 18.8 kg/m, with values ranging from 15.8 to 20.1 kg/m. Medical histories of patients included diagnoses of cerebral palsy and traumatic brain injury causing spasticity. The most frequently cited reason for plastic surgical consultation preoperatively was cachexia. Two patients had previous baclofen pumps placed subcutaneously. Average follow-up was 6 months and ranged from 3 to 13 months. There were no major complications. One patient had a small seroma that spontaneously resolved. No patient had wound healing problems, and there were no extrusions of implanted devices or reoperations. CONCLUSION: Submuscular placement of baclofen pumps provides a well-vascularized and stable environment for device placement that minimizes the dangers of pump extrusion and infection. Patients who require treatment with ITB commonly have severe cachexia, which makes subcutaneous device placement high risk. Submuscular placement should be performed in all patients with body mass index less than 20 kg/m.

Socioeconomic disparities in reception of limb-sparing surgery versus amputation for lower extremity sarcoma.

BACKGROUND: In lower extremity sarcoma treatment, limb salvage approaches present superior alternatives to amputation due to reduced postoperative morbidity and improved quality of life. This study provides a novel analysis of socioeconomic disparities that may affect reception of limb-sparing surgery. METHODS: Patients with lower extremity bone or soft tissue sarcoma who received either limb-sparing surgery or amputation from 2007 to 2021 were identified in the Surveillance, Epidemiology and End Results (SEER) database. Demographic, socioeconomic, and oncologic variables were collected for each patient. Multivariate binary logistic regression was conducted to assess preoperative demographic and oncologic risk factors for amputation (p < 0.05). RESULTS: A total of 6465 patients were identified in the final cohort, 586 (9.1%) of whom received amputation. After controlling for tumor size, stage, and neoadjuvant therapy administration, non-Hispanic American Indian/Alaskan Native race/ethnicity predicted the highest odds of amputation (OR: 1.78, 95% CI: 1.12-2.85, p = 0.015). Nonmetropolitan residence (OR: 1.69, 95% CI: 1.43-2.00, p < 0.001) also conferred higher risk of amputation compared with residence in a large metropolitan area. Overall, amputation was associated with a higher risk of ten-year cancer-specific mortality (p < 0.001) even when controlled by sociodemographic and clinical characteristics. CONCLUSIONS: There are significant disparities in limb-sparing surgery and amputation rates in lower extremity sarcoma management, even when accounting for differences in baseline oncologic characteristics. Further study into socioeconomic drivers of these trends will allow the development of initiatives that improve disparities in reconstructive outcomes.

A Systematic Review of the Orthoplastic Approach in Adult Lower Extremity Soft Tissue Sarcoma Flap Reconstruction.

BACKGROUND: The orthoplastic approach to patient care has changed the way patients with a wide variety of lower extremity pathology are treated. Through a systematic review, we aim to analyze outcomes in adult patients with lower extremity soft tissue sarcomas who undergo an orthoplastic flap management approach to their care. METHODS: A systematic review of adult lower extremity soft tissue sarcoma excision with plastic surgery flap reconstruction was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines searching the Pubmed, Embase, and Web of Science databases from inception to April 2023. RESULTS: After removal of duplicates, title and abstract screening, and full-text review, 26 articles were accepted for inclusion. The total mean follow-up duration was 32.0 ± 24.3 months. Reconstruction used microvascular free flaps in 65.5% (487/743), while 34.5% (256/743) were local flaps. 85.8% (307/358) of patients ambulated postoperatively. Revision surgery was required in 21% of patients during their respective follow-up periods. The limb salvage rate was 93.4% (958/1,026). Among pooled surgical outcomes, 22.2% (225/1,012) of patients experienced a perioperative complication. DISCUSSION: Our study demonstrates that although complication rates in lower extremity soft tissue sarcoma reconstruction may be further optimized, a multidisciplinary flap reconstructive approach provides high rates of limb salvage and functional postoperative ambulation.

Antecubital Burn Resulting From Antenna Coupling: A Case Report.

CASE: We present the case of a 54-year-old man who underwent elective hip disarticulation complicated by third-degree burn of the left antecubital fossa requiring skin graft. After careful review, it was determined that "antenna coupling" as a result of electrosurgery was the likely cause. We present an experiment demonstrating this phenomenon. CONCLUSION: Antenna coupling is a real but rare cause of intraoperative burns not previously described in the orthopaedic literature. Care should be taken to avoid coiling or running bovie or other electrosurgical device cords with other metallic cords or corded devices.

Trends in orthoplastic operative exposure for plastic surgery residents in the United States.

BACKGROUND: Recent trials have demonstrated clinical benefits to a combined orthoplastic approach for complex reconstructive surgery of the hand, upper and lower extremity. PURPOSE: We sought to assess recent trends in exposure to orthoplastic-type procedures among plastic surgery residents training in the United States. METHODS: Independent plastic surgery residents' case logs were extracted from the Accreditation Council for Graduate Medical Education (2011-2022). Select reconstructive procedure were taken as proxies for orthoplastic-type cases and analyzed by descriptive statistical analysis. RESULTS: The average number of orthoplastic-type cases completed per resident per year increased from 168.2 to 189.2 (12.5% increase) between 2011-2022. The greatest increase was in exposure to peripheral nerve injury repair of the hand and upper extremity (22.6 to 39.1, 73% increase). As a proportion of total procedures during the study period, orthoplastic-type procedures remained relatively unchanged (range 9.5-10.4%). CONCLUSIONS: Our findings suggest that plastic surgery residents may be increasingly well-prepared to contribute to orthoplastic care during and following their training. The steady proportion of cases that orthoplastic-type procedures represented over the study period suggests the increase in relevant orthoplastic case volume may be incidental and secondary to an overall rise among all procedures. Given evidence of the benefits of an orthoplastic approach, we recommend consideration of explicit benchmarks for orthoplastic training among plastic surgery residents.

The Emerging Role of Three-dimensional Technologies in Orthoplastic Surgery.

Three-dimensional (3D) planning and manufacturing technologies have become integral to head and neck reconstruction following tumor resection. These technologies facilitate the prototyping of patient-specific solutions in both digital and physical form. Three-dimensional tumor models and cutting guides help conceptualize and verify the surgical approach, as well as serve as a blueprint for reconstruction. Computer-aided renderings have been shown to add precision to bony contouring to achieve functional and aesthetic goals following tumor resection, such as in mastication, oral competence, speech, and symmetric facial aesthetics. Three-dimensional technologies have also been introduced in orthopedic oncology, making limb-salvage surgery the mainstay of treatment in cases where amputation was historically required. The advent of customized 3D cutting guides and plates allows surgeons to spare surrounding healthy tissue, markedly enhancing postoperative quality of life and significantly reducing associated morbidities. Borrowing from these applications of 3D planning and modeling, our institution has recently implemented these technologies for the reconstructive planning of soft tissue defects following sarcoma resection. Here we present a series of cases that demonstrate the workflow and clinical outcomes associated with the utilization of 3D planning techniques in orthoplastic surgery.

Explantation in Tissue Expander and Direct-to-Implant Reconstruction with Acellular Dermal Matrix: How to Avoid Early Reconstructive Failures.

BACKGROUND: In the United States, approximately 57,000 tissue expander/implant-based breast reconstructions are performed each year. Complete submuscular tissue expander coverage affords the best protection against implant exposure but can restrict lower pole expansion. The benefits of using acellular dermal matrix are enticing, but questions remain as to whether or not its presence increases reconstructive failures. The purpose of this study was to investigate predictors of explantation in those patients with acellular dermal matrix reconstructions and to discuss salvage techniques. METHODS: An approved retrospective review was conducted of 137 patients undergoing 234 individual breast reconstructions over 4 years performed by a single plastic surgeon (J.D.) at a single institution. Patients who underwent implant-based reconstruction with either immediate placement of a tissue expander that was subsequently exchanged for a permanent implant at a second operation or immediate placement of a permanent implant when indicated were included. RESULTS: One hundred thirty-seven patients who underwent 234 implant-based breast reconstructions using acellular dermal matrix met criteria. There was an overall 23 percent complication rate, including any cellulitis, seroma, skin necrosis, and hematoma formation. Significant preoperative risk factors for any postoperative complication included body mass index greater than 25 kg/m2 and a history of radiation therapy before acellular dermal matrix placement. Radiation therapy was found to be a significant risk factor for postoperative skin necrosis. Of explantations, many fluid cultures grew Gram-negative bacteria. CONCLUSIONS: Skin necrosis is a serious risk factor for explantation in implant-based reconstruction with acellular dermal matrix. The reconstructive surgeon should consider early excision of any skin necrosis as soon as it is identified. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Jewelry Ring-Associated Electrothermal Burn Injuries: A Nine-Patient Case Series.

Ring-associated burns are infrequent, comprising only a small fraction of burn consults and admissions. However, because of the location of these burns and the propensity for circumferential wounds, small burn size may belie the severity of resultant injuries. Herein, the authors present their experience with this potentially severe type of burn. Records from a regional burn center were retrospectively analyzed during a 36-month period. All patients who sustained ring burns were included. Data points included demographics, burn location, need for surgical intervention, grafted area, hospital days (length of stay), percent graft take, complications, and time to re-epithelialization. Nine patients sustained ring-associated burns during the study period, accounting for 1.4% of all patients with burns seen during the same period. Average age was 41 years (range: 29-52 years). Seven (77%) ring-associated burns involved contact with a battery. All injuries were circumferential. Average burn TBSA was 0.07%. Two patients (22%) had third-degree injuries, both of which received split-thickness skin grafts. Grafted area was 4 and 5 cm, respectively. Average length of stay was 2.8 days. Mean graft take was 99.5 ± 1.5%. Average time to complete re-epithelialization was 12 days. One patient suffered temporary disability. No patients suffered from compartment syndrome. Ring-associated burns are an uncommon source of injury in the burn population. Despite small burn TBSA, these patients are more likely to require split-thickness skin grafts and suffer dysfunction compared with similarly-sized burns in other body regions. Expedient treatment and coordination with occupational therapy should be undertaken to achieve optimal outcomes.

Use of a home vacuum-assisted closure device in the burn population is both cost-effective and efficacious.

INTRODUCTION: The vacuum assisted closure device (VAC) improves wound-healing when utilized as a bolster to secure split thickness skin grafts (STSG). Patients typically remain hospitalized for VAC therapy; however, home VACs (hVAC) are now available. Limited studies examine burns treated with hVAC as a STSG bolster. METHOD: A retrospective study of records from an ABA verified regional burn center was conducted over 23 months. Patients included STSGs for burn. Data points included demographics, burn mechanism and location, graft characteristics, hospital length of stay (LOS), and time to heal. RESULTS AND DISCUSSION: Fifty patients were included, with average age of 39 years (range <1-83years). Average burn TBSA was 1.27±1.42 (range 0.05-8.18). Grafted area average was 102.9±128.1cm2. The most commonly treated areas were the leg/foot, thigh, and torso (53%, 16%, and 16%, respectively). Average LOS was 1.1±1.2 days. Mean graft-take was 99.2±2.8% with one patient undergoing repeat STSG. Average post-operative time to heal was 16±6 days. A 5-day inpatient stay with a VAC costs an average of $34,635, compared to $9134 for an hVAC over the same period. CONCLUSIONS: The hVAC is a cost-effective STSG bolster in the burn population for appropriate candidates. Excellent graft-take and low morbidity rates imply that this is an efficacious alternative for STSG bolster.

ITC analysis of ligand binding to preQ1 riboswitches.

Riboswitches regulate genes by binding to small-molecule effectors. Isothermal titration calorimetry (ITC) provides a label-free method to quantify the equilibrium association constant, K(A), of a riboswitch interaction with its cognate ligand. In addition to probing affinity and specific chemical contributions that contribute to binding, ITC can be used to measure the thermodynamic parameters of an interaction (ΔG, ΔH, and ΔS), in addition to the binding stoichiometry (N). Here, we describe methods developed to measure the binding affinity of various preQ1 riboswitch classes for the pyrrolopyrimidine effector, preQ1. Example isotherms are provided along with a review of various preQ1-II (class 2) riboswitch mutants that were interrogated by ITC to quantify the energetic contributions of specific interactions visualized in the crystal structure. Protocols for ITC are provided in sufficient detail that the reader can reproduce experiments independently, or develop derivative methods suitable for analyzing novel riboswitch-ligand binding interactions.