The Influence of Closing the Abdominal Donor-Site Superficial Fascial System in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: The superficial fascial system is routinely closed to alleviate tension at the abdominal donor site after harvest of the deep inferior epigastric artery perforator flap (DIEP) for breast reconstruction. This is thought to decrease rates of wound dehiscence and improve contour postoperatively. There has been no comparative analysis on closure of the superficial fascial system and its effect on donor-site outcomes. METHODS: The authors retrospectively evaluated outcomes of DIEP flap breast reconstructions performed between 2017 and 2019. After May of 2018, the surgeons collectively agreed to stop closure of the superficial fascial system. All subsequent patients underwent closure of rectus abdominis fascia followed by skin closure. Patient demographic data and abdominal donor-site comorbidities were recorded between the superficial fascial system closure and no-superficial fascial system closure groups. Representative photographs of patients from the two groups were blindly assessed for scar appearance and contour using previously published grading scales. The results were compared. RESULTS: DIEP flap breast reconstruction was performed in 103 consecutive women. Among patients with abdominal donor-site reconstruction, 66 had superficial fascial system closure and 37 did not. There was not a significant difference in fat necrosis or wound dehiscence between the two groups (p = 0.29 and p = 0.39, respectively). Postoperative abdominal scar and contour were evaluated by 10 independent raters and showed no significant difference between the two groups. CONCLUSION: Omission of superficial fascial system closure resulted in no difference in wound dehiscence or fat necrosis rates and aesthetic appearance of the abdominal scar and contour. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Frequency and implications of occipital and posterior auricular sentinel lymph nodes in scalp melanoma.

BACKGROUND: Patients with scalp melanoma have poor oncologic outcomes compared with those with other cutaneous sites. Sentinel lymph node (SLN) biopsy provides prognostic information but is challenging in the head and neck. We explore the anatomic distribution of scalp melanoma and describe the most common sites of SLN drainage and of SLN metastatic disease. METHODS: Retrospective review of scalp melanoma patients who underwent SLN biopsy. Melanoma location was classified as frontal, coronal apex, coronal temporal, or posterior scalp. SLN location was classified by lymph node level and region. RESULTS: We identified 128 patients with scalp melanoma. The most common primary tumor location was the posterior scalp (43%) and the most frequent SLN drainage site was the level 2 lymph node basin (48%). Total 31 patients (24%) had metastatic disease in an SLN. Scalp SLNs, classified as being in the posterior auricular or occipital region, were localized in 26% of patients. For patients in which a scalp SLN was identified, 30% had a positive scalp SLN (n = 10). CONCLUSIONS: Scalp SLNs are frequent drainage sites for scalp melanoma and, when found, have a 30% chance of harboring metastatic disease. Surgeons, radiologists, and pathologists should be vigilant in identifying, removing, and analyzing scalp SLNs.

A near miss: Autonomic dysfunction in a 2% total burn surface area burn patient with ventilator-dependent amyotrophic lateral sclerosis.

While minor burns in the general population do not have significant cardiovascular effects, in amyotrophic lateral sclerosis patients they can precipitate fatal autonomic dysfunction. Our case serves as an important example in which a small 2% total burn surface area burn resulted in cardiovascular derangements that could have precipitated a serious cardiac event and death.

Postbiopsy Pigmentation is Prognostic in Head and Neck Melanoma.

PURPOSE: To assess postbiopsy pigmentation (PBP) as a prognostic feature in patients with cutaneous head and neck (H&N) melanoma. METHODS: Retrospective review of patients undergoing sentinel lymph node biopsy (SLNB) for H&N melanoma (1998-2018). PBP was defined as visible remaining pigment at the scar or biopsy site that was documented on physical exam by both a medical oncologist and a surgeon at initial consultation. Variables associated with disease-free survival (DFS) and overall survival (OS) were analyzed using multivariable Cox proportional hazards models. RESULTS: Among 300 patients, 34.3% (n = 103) had PBP and 44.7% (n = 134) had microscopic residual disease on final pathology after wide local excision. Prognostic factors associated with DFS included advanced age, tumor depth, ulceration, PBP, and positive SLNB (p < 0.05). Patients with PBP fared worse than their counterparts without PBP in 5-year DFS [44.1% (31.1-56.3%) vs. 73.0% (64.1-80.0%); p < 0.001] and 5-year OS [65.0% (50.0-76.6%) vs. 83.6% (75.7-89.2%); p = 0.005]. After multivariable adjustment, PBP remained associated with shorter DFS [hazard ratio (HR) 1.72, 95% confidence interval (CI) 1.01-2.93; p = 0.047], but was not prognostic of OS. CONCLUSIONS: In patients with H&N melanoma, PBP is associated with significantly shorter DFS. Patients with PBP may warrant greater consideration for SLNB and closer postoperative surveillance.

Indications and Outcomes of Single-Pedicle vs 2-Pedicle Thigh Free Flaps in Head and Neck Reconstruction.

IMPORTANCE: Flap choice and design are crucial to the success of free flap reconstruction of the head and neck. These are dependent on donor and recipient site characteristics. OBJECTIVE: To demonstrate indications and outcomes of a single-pedicle anterolateral thigh flap (standard ALT flap) vs a thigh free flap with 2 pedicles in head and neck reconstruction. DESIGN, SETTING, AND PARTICIPANTS: A retrospective case series of consecutive patients treated in a tertiary academic care center between October 2011 and June 2017 by a single reconstructive microsurgeon was carried out. Eighty-one patients underwent reconstruction of a cutaneous and/or mucosal defect of the head and neck. Patients with a composite mandibular defect who received both a fibular flap and a thigh flap were excluded. Those with less than 6 months of follow-up were excluded. MAIN OUTCOMES AND MEASURES: Patient characteristics and clinical variables, including age, sex, primary diagnosis/indication for reconstruction, type of flap, dimensions of flap, and number of perforators in the flap, were collected. Optimal cutoff values to quantitate the differences in length and width between the standard ALT and 2-pedicle thigh flaps were determined using receiver operating characteristic (ROC) curve analysis and the Youden Index. The types of flap were compared to determine any difference in flap complications including flap loss, venous congestion, and poor wound healing. RESULTS: Of the 81 patients (mean [SD] age, 58.2 [15.9] years; 62 [76.5%] men), 57 and 18 patients were reconstructed with a standard ALT flap and a thigh flap with 2 pedicles, respectively. Six patients underwent multiple simultaneous thigh (MST) flaps. Defect size (width ≥12 cm, standard ALT: 95% CI, 7.6-9.7; thigh flap with 2 pedicles: 95% CI, 7.0-17.4; P = .02; length ≥17 cm, standard ALT: 95% CI, 11.9-15.2; thigh flap with 2 pedicles: 95% CI, 13.6-30.0; P = .001), the presence of divergent mucosal defects, and through-and-through oral cavity/pharyngeal defects were associated with the use of 2 pedicles. Within groups of thigh flaps with 2 pedicles and MST flaps, there were no flap complications (ie, partial loss, venous congestion, or wound healing issues from poor perfusion). CONCLUSIONS AND RELEVANCE: Harvesting a thigh flap with 2 pedicles has the potential to reduce flap complications and should be considered for divergent and wide or long defects. Width and length measurements respectively of 12 cm and 17 cm are reasonable numbers to initially consider when deciding whether to include a second pedicle. LEVEL OF EVIDENCE: 3.