Characterizing Outcomes of Medial and Lateral Perforators in Deep Inferior Epigastric Perforator Flaps.

BACKGROUND: Perforators are typically found in rows in the deep inferior epigastric perforator (DIEP) flap. As methods to assess flap perfusion continue to improve, surgeons may be more likely to select perforators traditionally avoided. The purpose of this article is to describe clinical outcomes based on row and number of perforators to reevaluate flap and abdominal donor site morbidity. METHODS: A retrospective analysis was performed on patients who underwent breast reconstruction with DIEP flaps by four microsurgeons from 2013 to 2020. The row and number of perforators were determined from operative reports. Chi-square and t-test or nonparametric Fisher's exact test and Wilcoxon two-sample test were used for discrete and continuous variable, respectively, as applicable. Logistic regression was used for multivariable analyses. RESULTS: Of 628 flaps, 305 were medial row (58.7%), 159 were lateral row (30.6%), and 55 had both rows (10.6%). Partial flap loss was higher in both rows (p = 0.003). Fat necrosis was higher with medial (p = 0.03) and both rows (p = 0.01) when compared with lateral using multivariable analysis. Hernia or bulge was higher in lateral row flaps (lateral: 8/157, 5.1%; medial, 5/299, 1.7%; both, 0/55; p = 0.05); however, mesh was more commonly used in both row flaps (p = 0.05). There was no difference in fat necrosis or abdominal morbidity between single and multiple perforators. CONCLUSION: There was no difference in fat necrosis based on the number or row of perforators. The lateral row provides adequate perfusion but may be associated with an elevated risk of hernia or bulge. Patients may benefit from mesh, especially when both rows are dissected.

Salve and Burdock: A Safe, Effective Amish Remedy for Treatment of Traumatic Wounds?

BACKGROUND: Amish patients show a demonstrated preference for traditional, herbal remedies over modern medical interventions such as skin grafting. One such remedy is a mixture of Burn & Wound Ointment (B & W Ointment; Holistic Acres, LLC; Newcomerstown, Ohio) and steeped burdock leaves. Although both have demonstrated some antimicrobial and wound healing properties, burdock and/or the combination of B & W Ointment and burdock has never been studied to determine its purported ability to reduce pain, prevent infection, and accelerate wound healing. METHODS: A retrospective chart review was performed on 6 Amish patients treated with salve and burdock leaves instead of skin grafting following complex traumatic wounds to determine whether the traditional treatment incurred any patient harm. RESULTS: The time of wound epithelialization and healing complications were noted, among other data points. Time to full epithelialization ranged from 1 to 7 months. Time to full wound healing was proportional to wound size. CONCLUSIONS: Although the treatment presented here is unconventional, it did not cause harm to the patients studied.

Nurse training with simulation: an innovative approach to teach complex microsurgery patient care.

Simulation has become an integral part of education at all levels within the medical field. The ability to allow personnel to practice and learn in a safe and controlled environment makes it a valuable tool for initial training and continued competence verification. An area of specific interest to the reconstructive microsurgeon is assurance that the nursing staff has adequate training and experience to provide optimum care for microsurgery patients. Plastic surgeons in institutions where few microsurgeries are performed face challenges teaching nurses how to care for these complex patients. Because no standard exists to educate microsurgery nurses, learning often happens by chance on-the-job encounters. Outcomes, therefore, may be affected by poor handoffs between inexperienced personnel. Our objective is to create a course that augments such random clinical experience and teaches the knowledge and skills necessary for successful microsurgery through simulated patient scenarios. Quality care reviews at our institution served as the foundation to develop an accredited nursing course providing clinical training for the care of microsurgery patients. The course combined lectures on microsurgery, pharmacology, and flap monitoring as well as simulated operating room, surgical intensive care unit, postanesthesia care unit, Trauma Bay, and Floor scenarios. Evaluation of participants included precourse examination, postcourse examination, and a 6-month follow-up. Average test scores were 72% precourse and 92% postcourse. Educational value, effectiveness of lectures and simulation, and overall course quality was rated very high or high by 86% of respondents; 0% respondents rated it as low. Six-month follow-up test score average was 88%. Learning to care for microsurgery patients should not be left to chance patient encounters on the job. Simulation provides a safe, reproducible, and controlled clinical experience. Our results show that simulation is a highly rated and effective way to teach nurses microsurgery patient care. Simulated patient care training should be considered to augment the clinical experience in hospitals where microsurgery is performed.

Pedicled rectus femoris flap for coverage of complex open pelvic fractures.

Complex open pelvic fractures are highly morbid injuries. Distant soft tissue transfer is often necessary for reconstruction. We report two cases of traumatic open pelvic fractures in which a pedicled rectus femoris flap was used for soft tissue coverage. Two patients presented with complex open pelvic fractures resulting from blunt trauma. In both patients a pedicled rectus femoris flap was used to reconstruct the full thickness soft tissue defect. Both patients had complete soft tissue coverage of the anterior pelvic defect allowing definitive pelvic fracture fixation. No significant donor site morbidity was associated with either patient post operatively. The well described pedicled rectus femoris flap's reliable anatomy, ease of harvest, and versatility as well as acceptable donor site morbidity makes this flap ideal for the reconstruction of complex open anterior pelvic fractures with full thickness soft tissue defects when other local flaps or free tissue transfer is not an option.

Composite forearm free fillet flaps to preserve stump length following traumatic amputations of the upper extremity.

BACKGROUND: Replantation of traumatic upper arm amputations are usually contraindicated due to patient age, comorbid diseases, ischemia time, and/or avulsion of proximal structures. Stable soft tissue coverage preserving proximal stump length and critical joints is required to prevent loss of limb function and aid in prosthetic fitting and comfort. The use of free fillet flaps from the amputated limb is well documented for lower-extremity amputations but has only recently been reported for upper-arm amputations involving distal humeral or elbow wounds or following radical upper-arm tumor resections. Furthermore, these described free fillet flaps were fasciocutaneous rather than composite flaps. Composite free fillet flaps from the amputated upper arm utilizing the flexor muscles adjacent to the vascular pedicles is not well described or documented. METHODS: Eight upper-extremity, composite, free fillet flaps were performed to cover proximal humeral and shoulder defects secondary to upper-arm traumatic amputation from July 1995 to May 2005 on 7 males and 1 female. A retrospective chart review was completed, and information collected included the age of patient, gender, date of injury and surgery, amputation site, mechanism of injury, ischemia time, type of fillet flap, donor and recipient vessels, flap sensation, flap survival, and number of complications. RESULTS: All upper-arm amputations were trauma related (100%) and secondary to industrial accidents (4), motor vehicle and motorcycle accidents (2), fall (1), and train (1). Patient age ranged from 16 to 62 years and polytrauma was noted in 50%. Procedures included 6 composite free fillet flaps and 2 radial forearm free fillet flaps, with 4 (50%) sensate. Sensory nerves included the medial (3) and lateral (2) antebrachial cutaneous nerves attached to median proximal nerve stumps. Ischemia time ranged from 280 to 630 minutes. All flaps survived and 2 (25%) complications occurred in 1 patient. Subjective and protective sensation was observed in each neurorrhaphy; however, no confirmatory tested was used. CONCLUSION: Immediate soft tissue coverage using composite free fillet flaps from amputated limbs can be successful, with few complications, and preserves limb length while maximizing available tissue. Furthermore, including flexor muscle belly adjacent to the vascular pedicles provides additional coverage and a well-vascularized composite flap to aid in prosthetic fitting and comfort.