A rare case of angioinvasive aspergillosis aortic graft infection causing peripheral thromboembolism.

Angioinvasive aspergillosis is a fungal infection that rarely involves vascular grafts. This case illustrates a patient with a history of aortic arch Dacron graft reconstruction presenting with acute bilateral lower extremity ischemia. The patient underwent emergent open thromboembolectomy. The intraluminal contents had an atypical appearance for thromboembolism, and histologic examination was consistent with aspergillosis. Cardiac computed tomography and transesophageal echocardiography showed an aortic arch graft vegetation. Aortic graft excision and reconstruction were performed for control of the fungal source. Investigation into the etiology of thromboembolism should include consideration for septic emboli in patients with indwelling vascular grafts. When suspected, graft excision should be considered for definitive management.

Using Black Bone Magnetic Resonance Imaging for Fibula Free Flap Surgical Planning: A Means to Reduce Radiation Exposure with Accurate Surgical Outcomes.

SUMMARY: Advances in virtual surgical planning and three-dimensionally-printed guides have enabled increased precision in vascularized free fibula flap reconstruction of the mandible and valuable preoperative planning. However, virtual surgical planning currently requires high-resolution computed tomographic scans, exposing patients to ionizing radiation. The aim of this study was to determine whether black bone magnetic resonance imaging can be used for accurate surgical planning and three-dimensionally-printed guide creation, thus reducing patient radiation exposure. This study included 10 cadaver heads and 10 cadaver lower extremities. A mock fibula free flap for mandible reconstruction was performed. Five operations were planned with guides created using black bone magnetic resonance imaging, whereas the other five were planned and performed using guides created with computed tomographic scan data. All specimens underwent a postoperative computed tomographic scan, and three-dimensional reconstruction of scans was performed and surgical accuracy to the planned surgery was assessed. Guides created from black bone magnetic resonance imaging demonstrated high accuracy to the surgical plan. There was no statistically significant difference in postoperative deviation from the plan when black bone magnetic resonance imaging versus computed tomographic scanning was used for virtual surgical planning and guide creation. Both modalities led to a postoperative positive or negative deviation from the virtual plan within 0.8 mm. This study demonstrates that virtual surgical planning and three-dimensionally-printed guide creation for free fibula flaps for mandible reconstruction can be performed using black bone magnetic resonance imaging with comparable accuracy to computed tomographic scanning. This could reduce radiation exposure for patients and enable a more streamlined imaging process for head and neck cancer patients.

Complex Microsurgical Reconstruction After Tumor Resection in the Trunk and Extremities.

Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.

The Turkey Digit: A New Training Model for Digit Replantation.

PURPOSE: Replant survival rates have reportedly declined over the past decade. Although this problem is multifactorial, 1 potential solution may include the development of a relevant teaching model. The development of an in vivo animal model that can be used for surgical training could enhance surgeon and resident experience and potentially improve outcomes. Here, we present a novel training model for digit replantation using turkey digits. METHODS: Six mature male Bourbon Red turkeys were included in this study. With the animal under general anesthesia, the third digit on either the left or the right foot was randomly selected and amputated. The medial and lateral digital neurovascular bundles were dissected on both sides and the digit was replanted. Perfusion was confirmed prior to skin closure. The foot was casted prior to extubating the turkeys. Turkeys were then placed in a non-weight-bearing sling. Digit status was evaluated twice daily. RESULTS: All 6 replanted digits were viable immediately after surgery and for at least 24 hours after surgery. The average digit survival was 6 days with a maximum survival of 15 days. All digits were eventually lost owing to a variety of reasons including infection and arterial thrombosis. CONCLUSIONS: The turkey digit proved to be a successful short-term animal training model for digit replantation. Future studies are needed to determine optimum standard surgical procedure and postoperative care to maximize the educational benefits of this training model. CLINICAL RELEVANCE: To establish an animal model that can simulate digital replantation.

Postoperative Management After Total Pharyngolaryngectomy Using the Free Ileocolon Flap: A 5-Year Surgical Intensive Care Unit Experience.

INTRODUCTION: Management after total pharyngolaryngectomy with free ileocolon flaps can be challenging. Adequate postoperative surgical guidelines are essential to avoid complications. Factors, such as agitation, hypotension, or prolonged mechanical ventilation, might compromise final outcomes. Herein, we describe our experience in the early postoperative care of patients after total pharyngolaryngectomy with immediate reconstruction using the free ileocolon flap. METHODS: This is a retrospective review of all patients who underwent total pharyngolaryngectomy and immediate reconstruction using the free Ileocolon flap. Demographics, etiology of resection, neoadjuvant therapy, surgical time, method of sedation, postoperative use of vasopressors, length of intensive care unit (ICU) stay, time of discontinuation of mechanical ventilation, and complications were recorded and analyzed. RESULTS: Between 2010 and 2015, a total of 34 patients underwent total pharyngolaryngectomy and immediate reconstruction using the free Ileocolon flap. The most common cause of total pharyngolaryngectomy was cancer. Twenty-eight patients had neoadjuvant therapy (radiation). The average surgical time was 11.5 hours (range, 8-14.5 hours), average length of ICU stay was 3 days (range, 2-15 days) with an average time for mechanical ventilation cessation of 3 days (range, 1-20 days). Midazolam and dexmedetomidine were the most common sedatives used during surgery and in the ICU period. Three patients required vasopressors due to hypotension, 2 had unplanned self-extubation from the tracheostomy site, 2 experienced postoperative bleeding, 1 had pneumonia, 4 required unplanned return to the operating room, 2 had partial flap loss, and 1 had complete flap loss. CONCLUSIONS: Overall, a majority of patients recovered well postoperatively with minimal complications and low rate of reoperation. Our research provides a foundation to develop a risk-stratified approach to determine the need for an ICU admission or early transfer to floor care.

A Quick and Reliable Method to Decellularize a Gracilis Flap: A Crucial Step Toward Building a Muscle.

INTRODUCTION: Tissue loss as a consequence of congenital anomalies, trauma, malignancy, or gangrene represents a major health care problem in the United States. Because younger individuals are disproportionately affected, the costs are magnified over time and the resultant individual and societal effects are tremendous. The currently available options to restore soft tissue defects are associated with donor site morbidities. Vascularized composite allotransplantation may provide form, function, and esthetics without a donor site; however, it comes with the significant risk associated with toxic immunosuppression (Biomaterials. 2015;61:246-256, Ann Plast Surg. 2015;75(1):112-116, Transplantation. 2009;88(2):203-210). Engineered tissues offer promise in finding viable alternatives to allograft and autologous tissues. In this study, we present our simple and quick method to decellularize a muscle without disrupting the vascular network integrity or the extracellular matrix. Optimizing the decellularization process is a crucial step toward creating an "off-the-shelf" flap that can be used for soft tissue reconstruction. METHODS: The superficial gracilis muscle of 20 rats were harvested on their circulation and decellularized using perfusion with Krebs-Henseleit buffer and sodium dodecyl sulfate for 6 hours. These flaps were evaluated by gross morphology, histology, DNA quantification, integrity of the vascular network, scanning electron microscopy, and transmission electron microscopy. RESULTS: All samples were decellularized successfully as determined by DNA content and histological analysis for cellular content. The vascular network was preserved in all samples. CONCLUSIONS: We present a quick, simple, and affordable method to decellularize a muscle flap through the vascular network. Our proposed method is efficient and can be completed in a significantly shorter time when compared with other methods. It is also safe and does not affect integrity of tissue, and this is essential for a reliable recellularization.

Infections following Immediate Implant-Based Breast Reconstruction: A Case-Control Study over 11 Years.

BACKGROUND: Surgical-site infection after implant-based breast reconstruction adversely affects surgical outcomes and increases health care costs. This 11-year case-control study examines risk factors specific for surgical-site infection after immediate tissue expander/implant-based breast reconstruction. METHODS: The authors performed a retrospective review to identify all consecutive patients with breast implant infections between 2006 and 2016. Patients who developed surgical-site infection after immediate tissue expander/implant-based breast reconstruction were included. Surgical-site infection was defined using the Centers for Disease Control and Prevention criteria; specifically, infections requiring hospital admission, intravenous antibiotics, or surgical intervention were included. The authors matched a control patient to each infection case by patient age and date of surgery. Patient demographics, medical comorbidities, and perioperative surgical variables were examined. Univariate and multivariable conditional logistic regression models were constructed. RESULTS: A total of 270 breasts in 252 patients were evaluated. On multivariate analysis, patients with a higher body mass index (OR, 1.1 per 1 body mass index point increase; 95 percent CI, 1.0 to 1.2; p = 0.02), hypertension (OR, 6.5; 95 percent CI, 1.9 to 22.3; p = 0.002), neoadjuvant chemotherapy (OR, 2.6; 95 percent CI, 1.0 to 6.3; p = 0.04), axillary lymph node dissection (OR, 7.1; 95 percent CI, 1.7 to 29.2; p = 0.006), seroma formation (OR, 15.34; 95 percent CI, 3.7 to 62.5; p = 0.0001), and wound healing complications (OR, 23.91; 95 percent CI, 6.1 to 93.4; p < 0.0001) were significantly associated with surgical-site infection. CONCLUSIONS: Women with obesity, women with hypertension, and those treated with neoadjuvant chemotherapy are at increased risk of surgical-site infection. Further risks are also associated with postoperative seroma and wound complications. This may help patient selection and counseling, adjusted based on risk factors regarding complications of immediate implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Vascular Anatomy of the Scaphoid: New Discoveries Using Micro-Computed Tomography Imaging.

PURPOSE: The purpose of this study was to investigate the intraosseous vascular anatomy of the scaphoid using recent advances in micro-computed tomography (micro-CT) imaging and 3-dimensional reconstruction. We also studied the effect of scaphoid shape and screw position on the intraosseous vascular structure. METHODS: Thirteen upper extremities were injected with a contrast agent. The scaphoid bones were extracted and scanned using a micro-CT scanner. The vascular impact of screw insertion at various axes through the scaphoid was calculated and compared using the generated 3-dimensional models. The specimens were 3-dimensionally-printed and the morphology was assessed according to bone dimensions. A relationship between the internal vascular patterns and these morphological features was determined. RESULTS: All specimens received vascular inflow from the dorsal ridge forming a vascular network that supplied an average of 83% of the bone's volume. This network was supplemented in 4 specimens with volar vessels entering at the waist. Another network was identified, created by vessels entering volarly at the tubercle, which supplied the remainder of the scaphoid. One specimen did not receive any vessels at the tubercle. With regards to screw placement, screws placed in the central axis were the least disruptive to the internal vascularity, followed by the antegrade (dorsal) insertion axis. Two morphological bone types were identified: type I or full scaphoids and type II or slender scaphoids. Type I possessed a more robust internal vascular network than type II scaphoids. CONCLUSIONS: This study identifies 2 distinct types of scaphoid morphology with 1 of them having a less robust blood supply, which may prove to be related to development of nonunion, avascular necrosis, or Preiser disease. Central axis and antegrade (dorsal) screw fixation may be least disruptive to the internal blood supply. CLINICAL RELEVANCE: Safer fixation of the scaphoid bone may be achieved by knowledge of intraosseous vascular patterns.

Surgical Management of Lower Extremity Lymphedema: A Comprehensive Review.

Lymphedema refers to the accumulation of protein-rich fluid in the interstitial spaces. This can occur secondary to congenital malformation of the lymphatic channels or nodes or as a result of an insult that damages appropriately formed channels and nodes. Stagnant, protein-rich lymph initiates an inflammatory response that leads to adipocyte proliferation, fibrous tissue deposition, and increased susceptibility to infections. The end result is permanent disfigurement and dermal changes. Early and accurate diagnosis is essential, since lymphedema is a chronic and progressive problem. When lymphedema affects the lower extremity, it is important to manage it in a way that preserves function and mobility. Early diagnosis also allows for a proactive rather than reactive approach to treatment and utilization of novel physiologic procedures, such as lymphovenous anastomosis and vascularized lymph node transfer. Such interventions slow down disease progression and reduce morbidity by allowing the surgeon to salvage the remaining functional lymphatic channels. When physiologic procedures fail or when faced with a delayed presentation, the addition of excisional procedures can provide a more comprehensive treatment of this debilitating disease. The aim of this article is to review the most current concepts in the surgical management of lower extremity lymphedema.

The vascularized medial femoral condyle free flap for reconstruction of segmental recalcitrant nonunion of the clavicle.

BACKGROUND: Recalcitrant clavicular nonunion is a rare but complicated problem of clavicular fracture fixation. Nonunion is most often treated with clavicular shortening or in extreme cases vascularized bone grafting. Herein we describe our experience using the vascularized medial femoral condyle (MFC) free flap for the reconstruction of segmental defects in cases of recalcitrant clavicular nonunion. METHODS: A retrospective chart review was conducted of patients with symptomatic recalcitrant nonunion of the clavicle who underwent reconstruction with the vascularized MFC free flap from June 2003 to January 2018. Patients' demographics, time to union, and postoperative complications were collected. RESULTS: A total of 7 patients (6 women; 39.8 ± 9.01 years old) underwent clavicular reconstruction after an average of 3.7 ± 1.3 previous surgical procedures. Average preoperative visual analog scale score for pain was 4.1. The graft size ranged from 2 to 5 cm in length with approximately 1 cm in width and depth. The average time of total nonunion was 66 ± 48.2 months before surgery. All flaps survived and all clavicles healed with an average time to radiographic union of 15 ± 6.7 months. Patients regained full shoulder motion, and average postoperative visual analog scale score was 1.6 ± 1.8. All patients returned to their preoperative employment status. Donor site morbidity from the knee was minimal. CONCLUSION: The MFC free flap is a good option for recalcitrant bone nonunion of the clavicle where larger vascularized flaps are not warranted. It is effective and offers minimal donor site morbidity.

Diagnosis and Management of Acute Scaphoid Fractures.

The scaphoid is the most commonly fractured carpal bone; despite its frequent injury, the diagnosis of fracture can be complicated by the presence of normal radiographs at the time of presentation. Clinical intuition can be increased by physical examination and immediately available modalities such as ultrasound within the emergency department. Definitive diagnosis should be made with computed tomography and magnetic resonance to verify the presence of displacement. This article provides an overview of the incidence and presentation of acute scaphoid fractures with a surgical focus on percutaneous dorsal screw fixation.

Vascularity of the Proximal Fibula and Its Implications in Vascularized Epiphyseal Transfer: An Anatomical and High-Resolution Computed Tomographic Angiography Study.

BACKGROUND: Various vascular pedicles have been used to supply the proximal fibula for vascularized epiphyseal transfer. The optimal pedicle has, however, not been agreed on. This study aimed to describe the detailed vascular anatomy of the proximal fibula to assist the surgeon in choosing the optimal pedicle. METHODS: Twenty-eight lower extremities were injected with latex or a mixture of latex and barium sulfate. Vessels supplying the proximal fibula were identified and dissected, and the course, diameter, anatomical relations, length, and branches were documented. In the barium group, high-resolution computed tomographic scanning was conducted before dissection. In seven specimens, branches of the deep peroneal nerve to the tibialis anterior muscle were carefully preserved, and their relation to the proximal fibular vascularity was noted. RESULTS: An anastomotic vascular network supplied the proximal fibula. This was formed superiorly by branches of the inferior lateral genicular artery, and inferiorly by branches of the anterior tibial artery, the most important of which were the first and second recurrent epiphyseal arteries. One or more deep peroneal nerve branches passed deep to the first recurrent epiphyseal artery in all specimens examined. In five specimens, all of the branches were superficial to the second recurrent epiphyseal artery, whereas two had branches deep to it. CONCLUSIONS: The proximal fibula can be transferred using the inferior lateral genicular or anterior tibial artery because of the existing anastomosis. Factors including length of pedicle, potential for nerve injury, and diaphyseal portion to be harvested should be considered in the pedicle choice.

Staged inset of free flaps for complex microsurgical head and neck reconstruction to ensure total flap survival.

INTRODUCTION: Microsurgical reconstruction of complex head and neck defects often requires reliable tissue in multiple spatial configurations to achieve good functional and aesthetic outcomes. In addition to robust perforators, flap inset and wound closure require great caution to minimize complications especially in the presence of trismus with limited space for inset. This report describes the technique and results of our staged approach to flap inset which increases the chance of total flap survival in complex head and neck reconstructions. METHODS: From February 2010 to August 2016, a total of 53 patients were identified via a retrospective chart review. Patients who were suspected to have a high risk of vascular compromise and subsequently underwent complex head and neck reconstruction with staged inset of anterolateral thigh (ALT) flaps were included. The flap was inset only partially at the recipient site initially with fewer sutures. At a second stage, after neovascularization from surrounding tissue was established, the flap was partially elevated, divided and mobilized on its own pedicle for definitive inset. RESULTS: Fifty-one patients had complete survival of flaps and had uneventful postoperative course. Six cases required immediate re-exploration to release wound tension or reposition the pedicle. Of these, 4 flaps were salvaged, 2 failed due to small perforators despite anastomosis revision. The flap survival rate was 96.2% and the average time between 2 stages was 24 days (range, 21-28). CONCLUSION: Staged flap inset can improve free flap survival in complex head and neck reconstructions.

Donor-Site Morbidity and Functional Status following Medial Femoral Condyle Flap Harvest.

BACKGROUND: The medial femoral condyle free vascularized bone flap is a valuable alternative to other types of vascularized bone grafts. The donor-site morbidity and functional outcomes after flap harvest have not been fully appreciated. The authors report the postoperative outcomes and analyze the impact of increasing the size of the flap on knee donor-site morbidity. METHODS: A retrospective chart review of patients who underwent medial femoral condyle flap surgery between 2001 and 2012 at their institution was performed. The size of the flap was stratified, based on the largest dimension, into three groups. Demographics, outcomes, and complications related to the flap donor site were recorded and analyzed. Subsequently, functional status was assessed by administering a validated condition-specific measure. A univariate logistic regression analysis was performed, and results were analyzed. RESULTS: A total of 75 patients were identified. Average age was 29.5 ± 15.2 years. Average follow-up time was 13 months. The overall complication rate was 18.6 percent. Paresthesia in the saphenous nerve distribution was the most common complication. Increasing the size of the flap resulted in a significant elevation in complication risk (p < 0.05). A total of 47 patients completed the Lower Extremity Functional Scale questionnaire. The average Lower Extremity Functional Scale score was 72.12 ± 14.18. Fifty-one percent (n = 24) scored 80 points, indicating a normal level of function on average. CONCLUSIONS: The medial femoral condyle flap has overall acceptable donor-site morbidity, with a good level of function postoperatively. Larger flaps are associated with a greater number of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Virtual surgical planning and three-dimensional printing in multidisciplinary oncologic chest wall resection and reconstruction: A case report.

INTRODUCTION: Primary sarcomas of the sternum are extremely rare and present the surgical teams involved with unique challenges. Historically, local muscle flaps have been utilized to reconstruct the resulting defect. However, when the resulting oncologic defect is larger than anticipated, local tissues have been radiated, or when preservation of chest wall muscles is necessary to optimize function, local reconstructive options are unsuitable. PRESENTATION OF CASE: Virtual surgical planning (VSP) and in house three-dimensional (3D) printing provides the platform for improved understanding of the anatomy of complex tumours, communication amongst surgeons, and meticulous pre-operative planning. We present the novel use of this technology in the multidisciplinary surgical care of a 35 year old male with primary sarcoma of the sternum. Emphasis on minimizing morbidity, maintaining function of chest wall muscles, and preservation of the internal mammary vessels for microvascular anastomosis are discussed. DISCUSSION: While the majority of patients at our institution receive local or regional flaps for reconstruction of thoracic defects, advances in microvascular surgery allow the reconstructive surgeon the latitude to choose other flap options if necessary. VSP and 3D printing allowed the surgical team involved to utilize free tissue transfer to reconstruct the defect with free tissue transfer from the thigh. Perseveration of the internal mammary vessels was paramount during tumor extirpation. CONCLUSION: Virtual surgical planning and rapid prototyping is a useful adjunct to standard imaging in complex chest wall resection and reconstruction.

Gender-Confirmation Surgery Using the Pedicle Transverse Colon Flap for Vaginal Reconstruction: A Clinical Outcome and Sexual Function Evaluation Study.

Vaginal reconstruction and vaginoplasty are indicated in vaginal agenesis, following pelvic tumor resection, trauma, and for gender-confirmation surgery. In this article, the authors present the clinical outcomes and sexual function evaluation when using the pedicle transverse colon flap for gender-confirmation surgery in transgender women. This is a retrospective chart review of all transgender women who underwent gender-confirmation surgery using the pedicle transverse colon flap. Demographics, procedure specifics, and surgical outcomes were recorded and analyzed. Sexual function was measured using the Female Sexual Function Index and the Female Genital Self-Image Scale 1 year after surgery. Fifteen patients underwent gender-confirmation surgery using the aforementioned technique. The average age of the patients was 20 years (range, 18 to 32 years), and the average operating room time was 10.1 hours (range, 8 to 12.5 hours). The average length and width of the flaps were 15 and 2.8 cm, respectively. During a 12-year follow-up, two complications were reported: one patient had pain caused by narrowing at the introitus, which required intervention, and one patient had an excessive amount of secretions in the first month, which subsided 3 months after surgery. The mean Female Sexual Function Index score was 28.6 (range, 24 to 31). All patients achieved normal sexual function as indicated by a Female Sexual Function Index score of 25 or more. For the Female Genital Self-Image Scale, the mean total score was 20.0 ± 4.5 (range, 7 to 28). The pedicle transverse colon flap is another valuable alternative method for vaginoplasty with promising results and minor complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Does Low-Dose Heparin Have a Significant Role in Free Flap Surgery?

BACKGROUND: It is controversial issue that heparin decreases thrombosis for microsurgical anastomosis, and its effective role is under discussion. This study is for proving whether low-dose heparin is preventing thrombosis in free flap reconstruction. METHODS: Through chart reviews of 134 patients, using low-dose heparin for free tissue transfer from 2011 to 2016, retrospective analysis was performed. 33 patients received low-dose heparin therapy after surgery. And 101 patients received no-heparin therapy. Complications included flap necrosis, hematoma formation, dehiscence and infection. RESULTS: In no-heparin therapy group, comparing the flap necrosis revealed 16 cases (15.84%). And, flap necrosis was 6 cases (18.18%) in low-dose heparin therapy group. The statistical analysis of flap necrosis rate showed no significant difference (p=0.75). The results showed that there was no significant difference of flap necrosis rate between two groups. CONCLUSION: In this study, patients in the low-dose heparin group had no significantly lower rates of flap failure compared with no-heparin group. This suggests that low-dose heparin may not prevent thrombosis and subsequent flap failure to a significant extent.