Surgical Management of Hidradenitis Suppurativa: Outcomes of 590 Consecutive Patients.

BACKGROUND: Hidradenitis suppurativa is a progressive, recurrent inflammatory disease. Surgical management is potentially curative with limited efficacy data. OBJECTIVE: To evaluate hidradenitis surgical patients. METHODS: Retrospective review of outcomes of 590 consecutive surgically treated patients. RESULTS: Most patients were white (91.0% [435/478]), men (337 [57.1%]), smokers (57.7% [297/515]) with Hurley Stage III disease (476 [80.7%]). Procedure types were excision (405 [68.6%]), unroofing (168 [28.5%]), and drainage (17 [2.9%]) treating disease of perianal/perineum (294 [49.8%]), axilla (124 [21.0%]), gluteal cleft (76 [12.9%]), inframammary (12 [2.0%]), and multiple surgical sites (84 [14.2%]). Postoperative complications occurred in 15 patients (2.5%) and one-fourth (144 [24.4%]) suffered postoperative recurrence, which necessitated reoperation in one-tenth (69 [11.7%]) of patients. Recurrence risk was increased by younger age (hazard ratio [HR], 0.8; 95% confidence interval [CI], 0.7-0.9), multiple surgical sites (HR, 1.6; 95% CI, 1.1-2.5), and drainage-type procedures (HR, 3.5; 95% CI, 1.2-10.7). Operative location, disease severity, gender, and operative extent did not influence recurrence rate. CONCLUSION: Excision and unroofing procedures were effective treatments with infrequent complications and low recurrence rates. Well-planned surgical treatment aiming to remove or unroof the area of intractable hidradenitis suppurativa was highly effective in the management of this challenging disease.

Management of perioperative microvascular thrombotic complications - The use of multiagent anticoagulation algorithm in 395 consecutive free flaps.

BACKGROUND: Thrombotic complications remain a major barrier to successful microsurgical reconstruction, but their effective management remains controversial. METHODS: A retrospective review of 395 consecutive microvascular transfers was performed with the focus on treatment of thrombotic complications utilizing an algorithm, which employed multiagent anticoagulation. RESULTS: Three-hundred-ninety-five free flaps were performed in 255 patients for breast (n = 316), head and neck (n = 57), extremity (n = 16), trunk (n = 3), and pelvis (n = 3) defects that were oncologic in 95.2% and irradiated in 33.4% of cases. Patients with a hypercoagulable history (8 of 9) and intraoperative thrombosis (16 of 16) were anticoagulated without developing postoperative thrombotic events. The hematoma exploration rate among the patients anticoagulated during the initial free flap procedure was 27%. Twenty four (9.4%) patient were returned to the operating room postoperatively for threatened free flaps: 6 had non-microvascular issues and 18 (7.1%) patients underwent microsurgical explorations. Fourteen (5.5%) patients had 15 postoperative free flap thrombotic events in 14 free flaps, of which 12 flaps were successfully salvaged with a combination of flap intra-arterial (n = 15), subcutaneous/intramuscular (n = 6), and intravenous (n = 3) tissue plasminogen activator (tPA), microvascular explorations (n = 20), and therapeutic multiagent anticoagulation/antiplatelet therapy (n = 17); none had a hematoma of the reconstructed site. Two free flaps were lost to arterial thrombosis, with an overall microvascular salvage rate of 89% and a free flap success rate of 99.5%. CONCLUSIONS: Thrombophilia uncovered by microvascular procedures can be effectively treated with anticoagulation upon discovery and prevent postoperative free flap thrombotic events. High free flap salvage can be achieved with the early intervention combined with thrombolysis and multiagent anticoagulation and antiplatelet therapy.

Combination of a fillet flap, free tissue transfer, and autologous tissue grafts in pelvic reconstruction following retroperitoneal sarcoma: a case report.

The resection of large pelvic tumors is challenging due to their infiltrative nature into multiple structures and organ systems. In this report, we describe the use of multiple vascularized and nonvascularized spare parts to reconstruct a pelvic defect in a patient with a uniquely large pelvic sarcoma invading the spinal canal. A 39-year-old Caucasian female who presented with a large retroperitoneal sarcoma where the tumor encased the left ureter, kidney, colon, and external iliac vessels and invaded the L3-S1 vertebral bodies. An extensive hemipelvectomy and reconstruction was performed over two days. A free thigh and leg fillet flap together with ipsilateral fibula flap, based on the superficial femoral artery and venae comitantes, was used for spinal reinforcement as well as abdominal and pelvic wall reconstruction. The postoperative course was uneventful without complications, no flap compromise or wound healing problems. After a follow-up period of 4 months, the patient had no complications and returned to activities of daily living with mild limitations. The success of this flap procedure shows the practicality and usefulness of using the full spectrum of tissue transfer for the purposes of a large pelvic reconstruction.

Angioembolization of a leaking radial artery pseudoaneurysm in a radial forearm free flap.

BACKGROUND: A radial forearm free flap (RFFF) is used frequently in oral and pharyngeal reconstruction. Pseudoaneurysms within RFFFs and their management have not been previously reported. METHODS AND RESULTS: In the present case, a patient with chemoradiation failure of the right base of the tongue clear cell carcinoma underwent salvage resection and failed reconstruction with pectoralis major muscle flap. He subsequently underwent RFFF reconstruction with delayed development of a radial artery pseudoaneurysm at the site of a previous arterial line within the RFFF, which was not present perioperatively. A rupture of this pseudoaneurysm manifested with recurrent bleeding. Angiography with embolization successfully arrested the bleeding without compromising the flap. CONCLUSION: Ruptured pseudoaneurysm of the radial artery within the RFFF is a rare and life-threatening complication, which in the posterior oral cavity and pharynx can be effectively managed with angioembolization.

Management of anterolateral thigh free flap donor site defects with a continuous external tissue expander.

Anterolateral thigh (ALT) free flaps can result in donor site wounds that cannot be closed directly, requiring immediate or delayed split-thickness skin grafting. The use of skin grafts for such wounds can impose postoperative activity restrictions and additional wound morbidity. The purpose of the study was to investigate the efficacy of continuous external tissue expander (CETE) in achieving staged direct closure of these wounds. Outcomes of 20 ALT free flap cases with flap widths up to 15 cm treated with CETE were retrospectively reviewed. Closure of the thigh wounds was achieved in 19 cases with an average expansion time of 9.6 days. The use of a CETE device was effective in achieving staged direct (tertiary) closure and avoiding skin grafting, which further decreased donor site morbidity of large ALT free flap reconstructions.

Microvascular salvage of a thrombosed total ear replant.

Microvascular replantation, when possible, is the treatment of choice for total ear amputations. Both arterial and venous reconstruction should be attempted. The present case report describes a successful total ear replantation in a 45-year-old woman whose ear was amputated due to a horse accident. Venous thrombosis subsequently occurred and was managed with anticoagulation and leech therapy. Eighty hours after the replantation, arterial thrombosis took place. The posterior auricular artery thrombosed anastomosis was resected and reconstructed with an interposition vein graft. This report illustrates the feasibility of the successful microvascular salvage of a thrombosed total ear replant. It suggests the need for close clinical monitoring of the replanted ear and prompt microvascular reexploration in an event of the loss of arterial flow.

Merkel cell carcinoma: diagnosis, management, and outcomes.

Merkel cell carcinoma is a rare, aggressive cutaneous malignancy with high rates of recurrence, metastases, and mortality. Its nonspecific clinical presentation often delays the diagnosis, and its treatment is still controversial because of the infrequent nature of the tumor. The authors provide an overview of the current literature on epidemiology, cause, pathogenesis, staging, management, and outcomes of this disease. Effective diagnostic and treatment modalities such as wide local excision of the primary tumor, importance of sentinel node biopsy for staging, evidence for the use of adjuvant radiation therapy, and emphasis on a multidisciplinary treatment approach of Merkel cell carcinoma as it pertains to surgical practice are reviewed.

The use of ovarian vessels for microvascular tissue transfer in lower extremity limb salvage.

Limb salvage procedures in previously operated, radiated, and vessel-depleted fields rely heavily on the use of microvascular tissue transfer. This report illustrates the feasibility of the use of ovarian vessels for the revascularization of a free flap. We have achieved success with the use of rectus abdominis muscle free flap for coverage of exposed vascular reconstruction in the 75-year-old soft tissue sarcoma patient with twice chemoradiated femoral and hypogastric defect, preventing external hemipelvectomy.

Soft-tissue reconstruction of external hemipelvectomy defects.

BACKGROUND: External hemipelvectomy is the ultimate salvage procedure for locally advanced pelvic tumors, infections, and failed revascularizations. It is associated with high wound morbidity requiring surgical management. In this study, the authors analyzed their experience with primary and secondary reconstruction of hemipelvectomy wounds. METHODS: The records of 160 consecutive hemipelvectomy patients from the authors' institution were reviewed to identify the incidence of soft-tissue coverage problems and approaches to their management. RESULTS: At the time of hemipelvectomy, a musculocutaneous hemipelvectomy flap was sufficient for closure in 159 patients, one patient needed a free lower leg fillet flap, and none required pedicle flaps. No hemipelvectomy hernias were observed, although abdominal wall reconstruction was performed in three patients. Wound complications were encountered in 62 patients (39 percent), and 51 patients required operative débridement. Thirty-three patients healed by secondary intention, and 25 underwent delayed reconstruction with local tissue rearrangements (n = 15), split-thickness skin grafting (n = 6), and pedicled flaps (n = 6). All pedicled flaps were contralateral inferiorly based rectus abdominis muscle (n = 2) and musculocutaneous (n = 4) flaps. CONCLUSIONS: Hemipelvectomy is associated with high wound morbidity. When the hemipelvectomy flap has a musculocutaneous design, hernias are exceedingly rare. Although immediate reconstruction is accomplished with a hemipelvectomy flap in the vast majority of cases, secondary reconstructions are often required for management of wound complications. For large defects, a contralateral inferiorly based rectus abdominis muscle or musculocutaneous flap is the reconstruction of choice. The rectus abdominis muscle should therefore always be preserved in hemipelvectomy patients by careful preoperative planning, especially when creation of an ostomy is considered.

Predictors of complications and outcomes of external hemipelvectomy wounds: account of 160 consecutive cases.

BACKGROUND: Hemipelvectomy has high wound complication rates. This study aimed to determine variables that may influence hemipelvectomy wound morbidity. METHODS: The records of 160 consecutive hemipelvectomy patients were reviewed with a focus on demographics, treatment, and surgical techniques. Multivariate analysis was used to determine risk factors for postoperative hemipelvectomy wound infection and flap necrosis. RESULTS: There were 31 standard, 62 modified, and 67 extended hemipelvectomy patients in whom 19 contiguous visceral, 62 spinal, 4 contralateral pelvic resections, and 1 contralateral hemipelvectomy were performed. Hospital mortality rate was 5%, and overall morbidity was 54%. Wound complications such as infection (39%) and flap necrosis (26%) were the most common. For modified, standard, and extended hemipelvectomies, rates of wound infection were 29%, 34%, and 51% (P = .036) and rates of flap necrosis were 16%, 25%, and 35% (P = .046), respectively. Longer operative time and increased complexity were associated with higher wound infection and flap necrosis rates. The hemipelvectomy flap design did not influence the frequency of wound infection (P = .173) or flap necrosis (P = .098). Common iliac vessel ligation was the most statistically significant predictor of flap necrosis and was associated with the 2.7-fold increase in flap necrosis rate (P = .001) in patients undergoing posterior flap hemipelvectomy. CONCLUSIONS: External hemipelvectomy has low mortality but high morbidity. Postoperative wound infection and flap necrosis are multifactorial events related to length and extent of operation. Level of vascular ligation strongly influenced flap necrosis rate for posterior flap hemipelvectomy.

Outcomes of skin graft reconstructions with the use of Vacuum Assisted Closure (VAC(R)) dressing for irradiated extremity sarcoma defects.

BACKGROUND: Flaps are currently the predominant method of reconstruction for irradiated wounds. The usefulness of split-thickness skin grafts (STSG) in this setting remains controversial. The purpose of this study is to examine the outcomes of STSGs in conjunction with VAC therapy used in the treatment of irradiated extremity wounds. METHODS: The records of 17 preoperatively radiated patients with extremity sarcomas reconstructed with STSGs in conjunction with VAC(R) therapy were reviewed regarding details of radiation treatment, wound closure, and outcomes. RESULTS: STSGs healed without complications (>95% of the graft take) in 12 (71%). Minor loss (6% - 20% surface) was noted in 3 patients (17.6%) and complete loss in 2 (11.7%). Two patients (11.7%) required flap reconstructions and 12 (88%) healed without further operative procedures. CONCLUSION: Although flap coverage is an established treatment for radiated wounds, STSG in conjunction with liberal utilization of VAC therapy is an alternative for selected patients where acceptable soft tissue bed is preserved. Healing of the preoperatively radiated wounds can be achieved in the vast majority of such patients with minimal need for additional reconstructive operations.

Predictors of survival and recurrence in the surgical treatment of merkel cell carcinoma of the extremities.

PURPOSE: Merkel cell carcinoma (MCC) is a rare and aggressive malignancy that originates within the extremities in about 40% of cases. Treatment approaches to this tumor have not been standardized. The purpose of this study was to examine treatment approaches to extremity MCC and to determine predictors of recurrence and patient survival. METHODS: A retrospective review of 38 consecutive patients with surgically treated extremity MCC was performed. Patient demographics, histologic tumor stage and location and pre-existing malignancies were recorded. Patients were treated by wide-local excision (WLE) or Mohs' technique. Clinically negative regional lymph nodes were either observed (n = 16) or staged with elective lymphadenectomy or sentinel lymph node dissection (SLND) (n = 17), and clinically positive nodes underwent therapeutic node dissection (n = 5). Adjuvant radiotherapy (n = 21) and chemotherapy (n = 6) were noted, as well as time to tumor recurrence and overall patient survival. Predictors of recurrence and survival were analyzed using Kaplan-Meier method and log rank test. RESULTS: There was no difference in local recurrence rates when comparing Mohs' technique to WLE for the treatment of primary tumors. Although there was no survival advantage to lymph node dissection, lymph node status was effective in predicting the risk of regional recurrence. Radiation reduced the local recurrence rate (HR = 0.29, 95% CI [0.10, 0.85]), but did not lead to improved overall survival. CONCLUSION: Margin-negative excision of the MCC remains the mainstay of treatment. Surgical staging, preferably with SLND, identifies patients that may develop regional recurrence. This study further supports the important role of adjuvant radiation therapy in improving locoregional tumor control in the patients with MCC.

Application of vacuum-assisted closure dressing in penile skin graft reconstruction.

INTRODUCTION: Skin grafting of penile defects is difficult because of the flexibility of the underlying recipient bed. This leads to disruption of the vascular ingrowth into the skin graft and compromises the results of the reconstruction. TECHNICAL CONSIDERATIONS: We successfully used a vacuum-assisted closure dressing with an incorporated wooden framework to secure penile skin grafts in place during the early postoperative period. CONCLUSIONS: A vacuum-assisted closure dressing can be used successfully to secure large and circumferential skin grafts, as well as skin grafts on concealed penises.

Endoscopic removal of dermoid cysts of the eyebrow in pediatric patients.

Direct excision of dermoid cysts of the brow may lead to a prominent facial scar. These scars can be completely avoided with an endoscopic temporal approach that places the incisions in the hair-bearing portion of the scalp. Over the past 10 years, this approach was offered to every pediatric patient with a cyst in the area of the brow, and outcomes were favorable. The operative technique and results in 8 consecutive patients are reviewed.