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BACKGROUND: Operative microscopes are traditionally draped in single-use plastic to prevent infection theoretically. The necessity of this routine in breast free flap surgery is unclear. Alternatively, sterile wrapping of microscope handles would reduce operating room waste and provide a more cost-effective and environmentally sustainable approach to sterility. This study aimed to determine whether the draping technique used during abdominally based free flaps (Ab-FF) influenced the rate of surgical site infections. METHODS: We conducted a retrospective review of Ab-FF performed consecutively between March 2017 and August 2022. Patient demographics, comorbidities, perioperative data, and postoperative complications were collected. The primary outcomes included postoperative surgical site infections and environmental impact. RESULTS: Of the 281 identified breasts reconstructed with Ab-FF, operating microscopes were sterilely covered with microscope drapes (n = 215) or handle covers (n = 66) composed of polyethylene-based plastic. Overall, postoperative infections occurred in 9.3% of cases (n = 26) in either the recipient breast (n = 11, 3.9%) or abdominal donor site (n = 15, 5.3%), primarily due to S. aureus and Streptococcus species. The handle (n = 6, 9.1%) and drape (n = 20, 9.3%) cohorts had similar infection rates with no sequelae of operative complications. In multivariate analysis, radiation was the only independent predictor of postoperative infection, while bilateral reconstructions were independently protective. Replacing a microscope drape with a handle reduces carbon emissions by 1276 grams of CO2 and direct costs by $7.84 per item. CONCLUSIONS: The principles of "Lean and Green" surgery prioritize reducing operating room generated waste to achieve financial and environmental sustainability. This cohort study of 281 breast free flaps demonstrates that switching from whole microscope draping to handle wrapping was not associated with an increased rate or odds of infection. Adopting a microscope handle wrapping protocol decreased the carbon footprint and operative costs. The results of this study offer evidence to support adoption and further exploration of pragmatic, cost-effective, and sustainable approaches to microsurgical breast reconstruction.
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The 5-factor modified Frailty Index (mFI-5) is a risk-stratification tool utilized to predict complications and mortality following major lower extremity (LE) amputation. However, its prognostic value for long-term mortality is unknown. The study aim was to assess whether a high mFI-5 score relates to long-term mortality following major LE amputation for chronic wounds. Patients ≥60 years who underwent major LE amputation from 2017 to 2021 were retrospectively reviewed. Data regarding demographics, comorbidities, perioperative factors, amputation type, and postoperative complications was collected and mFI-5 was calculated. Survival analysis was performed with Kaplan-Meier curves and differences were assessed with Log-Rank test. A total of 172 patients were identified. Mean age was 70.7 ± 8.0 years. Median time to ambulation was 3.7 months (IQR 4.0). By final follow-up of 17.5 ± 15.9 months, ambulatory rate was 51.7% (n = 89), overall mortality 36.0% (n = 62), 1-year mortality 14.0% (n = 24), and 3-year mortality 27.9% (n = 48). Patients with an mFI-5 of ≥4 (26.7%, n = 46) compared with patients with mFI-5 <4 (73.3%, n = 126) had a higher rate of prolonged postoperative LOS (34.8% vs 19.8%, p = .042), overall mortality (52.2% vs 30.2%, p = .008), 1-year mortality (23.9% vs 10.3%, p = .023), and 3-year mortality (45.7% vs 21.4%, p = .002). Multivariate analysis demonstrated mFI-5 was an independent predictor of 3-year mortality (OR 2.35, p = .043). At a threshold ≥4, the mFI-5 demonstrated utility in predicting long-term mortality. The value of this prognostic indicator is in its preoperative application of assessing risk of mortality, which should be utilized in conjunction with other measures.
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Amputación Quirúrgica , Fragilidad , Extremidad Inferior , Humanos , Masculino , Femenino , Amputación Quirúrgica/mortalidad , Anciano , Estudios Retrospectivos , Fragilidad/mortalidad , Fragilidad/complicaciones , Extremidad Inferior/cirugía , Medición de Riesgo , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Pronóstico , Anciano de 80 o más Años , Estimación de Kaplan-MeierRESUMEN
BACKGROUND: Reconstructive surgery has experienced a paradigm shift in favor of free flaps. Yet, local flaps may be of particular use in foot and ankle reconstruction among comorbid patient populations. Thus, we sought to better characterize long-term outcomes in this setting. METHODS: A single-center, retrospective cohort study of patients undergoing local muscle and fasciocutaneous flaps of the foot and ankle from January 2010-November 2022 was performed. Flap were performed on wounds measuring 3x6cm or smaller, and flap selection depended on preoperative vascular assessment, Doppler findings, comorbidity profile, and wound location, depth, and geometry. RESULTS: Two-hundred and six patients met inclusion criteria. Median age was 61.0 years (IQR 16.8), and comorbidities included diabetes mellitus (DM; n=149/206, 72.3%) and peripheral arterial disease (PAD; n=105/206, 51.0%). Presentations included chronic, non-healing wounds (n=77/206, 39.1%) or osteomyelitis (n=45/206, 22.8%), and most frequently extended to the bone (n=128/206, 62.1%). Eighty-seven patients (n=87/206, 42.2%) received muscle flaps, while 119 received fasciocutaneous flaps (n=119/206, 57.8%). Six patients (n=6/206, 2.9%) necessitated return to the operating room, with thrombosis occurring in two cases (n=2/206, 1.0%). Flap success rate was 98.1%. By a median follow-up duration of 21.7 months (IQR 39.0), 45 patients (n=45/206, 21.8%) necessitated ipsilateral amputation, 73% (n=145/199) were ambulatory, and two deaths were related to the operated wound (n=2/49, 4.1%). Multivariate analysis revealed positive predictors of complications included DM, end-stage renal disease, and prior histories of venous thromboembolism or smoking. CONCLUSION: Local flaps remain a reliable option to reconstruct smaller defects of the foot and ankle in a highly comorbid population.
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Background: The aim of this study was to compare the use of pedicled local (PFs) versus random pattern flaps (RpFs) in foot and ankle reconstruction in patients with chronic, nonhealing wounds. Methods: A single-center, retrospective review of 204 patients with 118 PFs and 86 RpFs was performed. The primary outcome included rates of limb salvage. Results: PFs were used more often in the hindfoot (44.1% versus 30.2%, P = 0.045), lateral and medial surface (39.8% versus 18.6%, P = 0.001), and wounds containing exposed bone and hardware (78.8% versus 62.8%, P = 0.018). RpFs were used more for forefoot (19.8% versus 10.2%, P = 0.053) and plantar defects (58.1% versus 30.3%, P = 0.000). RpFs had a higher rate of immediate success (100% versus 95.8%, P = 0.053), with no significant differences in rate of long-term limb salvage (77.1% versus 69.8%, P = 0.237). PFs had higher rates of ischemia requiring intervention (11.0% versus 3.5%, P = 0.048). RpFs had a higher rate of minor amputations (15.12% versus 6.8%, P = 0.053) but similar rates of major amputation (15.1% versus 16.1%, P = 0.848). There were no significant differences in rates of mortality or ambulatory status. Conclusions: Both RpFs and PFs remain reliable options to reconstruct defects of the foot and ankle. Optimizing the use of each flap type should consider wound characteristics. RpFs are preferred for dorsal and plantar defects, whereas PFs are protective for minor infections and preferred for deeper wounds despite a higher rate of partial necrosis.
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BACKGROUND: This study aims to compare perfusion dynamics using indocyanine green videoangiography before and after the creation of a second venous anastomosis between the superficial inferior epigastric vein and the retrograde internal mammary vein (IMV) in deep inferior epigastric perforator (DIEP) flap breast reconstructions. METHODS: Indocyanine green videoangiography performed during DIEP flap reconstructions was analyzed prospectively. The areas of interest were above the perforators with the highest intensity (complete perfusion), the most distal lateral edge of the flap (partial perfusion), and the next lowest intensity (ischemic). We compared the zone intensities before and after the second venous anastomosis, assessing venous drainage patency and functionality. Patient characteristics, operative details, and complications were collected. RESULTS: Seven patients (10 breasts) underwent DIEP reconstruction. Mean age was 54.5 ± 12.4 years. Mean operative duration was 575.5 ± 172.6 minutes. Donors included DIEV (n = 10, 100.0%), superficial inferior epigastric vein (n = 9, 90.0%), and superficial circumflex epigastric vein (n = 1, 10.0%). All DIEVs were anastomosed to the antegrade IMV (n = 10, 100.0%). Superficial inferior epigastric veins were anastomosed to the retrograde IMV (n = 10, 100.0%). Mean peak intensities of the complete perfusion zone before and after the second venous anastomosis were 160.7 ± 42.1 and 188 ± 42.1, respectively ( P = 0.163). Mean peak intensities of the partial perfusion zone were 100.8 ± 21.5 and 152 ± 31.5, respectively ( P < 0.001). Mean peak intensities of the ischemic zone were 90.4 ± 37.4 and 143.4 ± 45.3, respectively ( P = 0.012). CONCLUSION: These findings highlight the potential benefits of the super drainage technique in enhancing perfusion and reducing complications, emphasizing the need for further investigation and consideration of this technique in clinical practice.
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Verde de Indocianina , Mamoplastia , Colgajo Perforante , Humanos , Mamoplastia/métodos , Persona de Mediana Edad , Femenino , Colgajo Perforante/irrigación sanguínea , Colgajo Perforante/trasplante , Adulto , Estudios Prospectivos , Angiografía/métodos , Anciano , Arterias Epigástricas/trasplante , Anastomosis Quirúrgica/métodos , Colorantes , Venas/cirugía , Venas/diagnóstico por imagen , Neoplasias de la Mama/cirugíaRESUMEN
BACKGROUND: Acellular dermal matrices (ADMs) are frequently employed in immediate prosthesis-based breast reconstruction (iPBR) to provide structural support. Despite differences in ADM derivatives, few studies directly compare their outcomes in the setting of iPBR. We sought to conduct a large head-to-head study comparing 3 ADMs used across our institution. METHODS: A multicenter retrospective review of patients undergoing iPBR with SurgiMend PRS (fetal bovine-derived; Integra Lifesciences, Princeton, NJ), AlloDerm (human-derived; LifeCell Corp, Bridgewater, NJ), or DermACELL (human-derived; Stryker Corp, Kalamazoo, MI) between January 2014 to July 2022 was performed. Primary outcomes included rates of unplanned explantation and total reconstructive failure. Secondary outcomes included 90-day postoperative complications and long-term rates of capsular contracture development. RESULTS: A total of 738 patients (1228 breasts) underwent iPBR during the study period; 405 patients received DermACELL (54.9%), 231 received AlloDerm (31.3%), and 102 received SurgiMend PRS (13.8%). Rates of short-term complications, total reconstruction failure, reoperation within 90 days, capsular contracture, and unplanned explantation were comparable. These findings remained true upon multivariate analysis accounting for baseline differences between cohorts, whereby ADM type was not an independent predictor of any outcome of interest. Conversely, factors such as body mass index, diabetes mellitus, smoking history, neoadjuvant and adjuvant chemotherapy, adjuvant radiation, skin-sparing mastectomy, Wise pattern and periareolar incisions, use of tissue expanders, and a subpectoral plane of insertion were significant predictors of postoperative complications. CONCLUSION: Low rates of complications support the equivalency of fetal bovine and human-derived ADMs in iPBR. Patient characteristics and operative approach are likely more predictive of postoperative outcomes than ADM derivative alone.
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Dermis Acelular , Neoplasias de la Mama , Colágeno , Humanos , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Adulto , Colágeno/uso terapéutico , Neoplasias de la Mama/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Implantes de Mama , Implantación de Mama/métodos , Mamoplastia/métodos , Mastectomía/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Double-incision mastectomy (DIM) with free nipple grafts (FNG) is a common technique employed in gender-affirming mastectomy (GAM), but is associated with a high scar burden. Intraoperatively, the surgeon may opt for a single-incision mastectomy (SIM) along the inframammary folds (IMF) to optimize aesthetic outcomes. This study sought to identify factors predictive of intraoperative conversion. METHODS: From February 2018 to November 2022, TGNB patients who underwent GAM at a single institution were retrospectively reviewed. Data regarding patient characteristics, perioperative details, postoperative complications, and aesthetic satisfaction were collected. RESULTS: A total of 352 patients were identified. Median age and body mass index (BMI) were 25.0 years (IQR: 9.0) and 28.5 kg/m2 (IQR: 8.5), respectively. Most patients received IMF incisions (n = 331, 94.0%); of whom, 66 (19.9%) underwent intraoperative conversion from DIM to SIM with FNG. Larger breast cup-size (p < 0.001) and a greater degree of ptosis (p = 0.002) preoperatively were significantly associated with intraoperative conversion to SIM. There was no significant association between intraoperative conversion and the ratio of intermammary distance to the width of the chest wall (p = 0.086). Overall complication rates were significantly higher among patients with diabetes mellitus (p = 0.015) and a greater degree of ptosis (p = 0.018). 77.8% (n = 274) of patients were satisfied with their aesthetic outcome. NPWT usage was associated with higher rates of aesthetic satisfaction (83.6% vs. 77.8%; p = 0.005). CONCLUSION: Patients with larger breast cup size and greater degree of ptosis should be counseled preoperatively that they may be at a higher risk of conversion to a singular incision.
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Pezones , Humanos , Femenino , Adulto , Estudios Retrospectivos , Pezones/cirugía , Satisfacción del Paciente , Masculino , Mamoplastia/métodos , Mastectomía/métodos , Estética , Cirugía de Reasignación de Sexo/métodos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Personas Transgénero , Persona de Mediana EdadRESUMEN
BACKGROUND: Complex surgical back wounds represent significant morbidity in patients who have undergone spinal procedures requiring closure or revision by plastic surgeons. This study aimed to assess the utility of bacterial wound culture data for predicting surgical outcomes of wound management. METHODS: This study is a single-institution retrospective review of consecutive patients who required plastic surgery intervention for wound infection following spinal procedures between the years 2010 and 2021 (n = 70). Statistical analysis was performed for demographics, comorbidities, perioperative laboratory studies, and treatment methods. The primary outcomes of interest were rate of postoperative complications after soft tissue reconstruction and reconstructive failure. The secondary outcome of interest was time to healing in number of days. RESULTS: The overall complication rate after wound closure was 31.4%, with wound infection in 12.9%, seroma in 10%, dehiscence in 12.9%, and hematoma in 1.4%. Increasing number of debridements before wound closure increased the likelihood of a surgical complication of any kind (odds ratio [OR], 1.772; 95% confidence interval [CI], 1.045-3.002). Positive wound cultures before reconstruction were associated with development of seroma only (OR, 0.265; 95% CI, 0.078-0.893). Use of incisional vacuum-assisted closure devices significantly decreased the odds of postoperative wound dehiscence (OR, 0.179; 95% CI, 0.034-0.904) and increased odds of healing (hazard ratio, 3.638; 95% CI, 1.547-8.613). CONCLUSIONS: Positive wound cultures were not significantly associated with negative outcomes after complex closure or reconstruction of infected spinal surgical wounds. This finding emphasizes the importance of clinical judgment with a multidisciplinary approach to complex surgical back wounds over culture data for wound closure timing.
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Infección de la Herida Quirúrgica , Humanos , Estudios Retrospectivos , Femenino , Masculino , Persona de Mediana Edad , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/microbiología , Infección de la Herida Quirúrgica/etiología , Anciano , Adulto , Cicatrización de Heridas , Procedimientos de Cirugía Plástica/métodos , Procedimientos de Cirugía Plástica/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/microbiología , Técnicas de Cierre de Heridas , Resultado del Tratamiento , Valor Predictivo de las PruebasRESUMEN
BACKGROUND: Restrictive policies on termination of pregnancy (TOP) may lead to more infants with congenital abnormalities. This study aims to assess the association between state-wide enactment of TOP restriction and cleft lip and/or palate (CL/P) incidence and identify mediating demographic characteristics. METHODS: This study examines state-specific trends in CL/P incidence in infants before and after implementing laws restricting TOP in MI compared to NY, where no such laws were passed. The percent change of CL/P incidence per 1000 live births in post-policy years (2012-2015) compared to pre-policy years (2005-2011) was compared while adjusting for confounding factors in multivariate models. RESULTS: The incidence of CL/P changed significantly in MI (19.1%) versus NY (-7.31%). Adjusting for sex, race/ethnicity, median household income level, and expected payer revealed that the adjusted percent difference between MI and NY was 53.3% (p <0.001). Stratification by race/ethnicity and median household income demonstrated that changes were only significant amongst Black (139%, p<0.001) and Hispanic (125%, p=0.045) patients or of those from the lowest (50.3%, p<0.001) and second lowest (40.1%, p=0.01) income quartiles. CONCLUSIONS: Our research, combined with the recent Dobbs Supreme Court decision allowing states to place further restrictions on TOP, suggests that more infants in the future will be born in need of treatment for CL/P.
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Procedimientos de Cirugía Plástica , Cirugía Plástica , Anciano , Estados Unidos , Humanos , MedicareRESUMEN
BACKGROUND: Autologous breast reconstruction confers favorable patient reports of satisfaction and quality of life compared to implant-based reconstruction over a lifetime. The latissimus dorsi with immediate fat transfer (LIFT) is an alternative approach to abdominally based free flaps (Ab-FF), which expands fully autologous reconstruction to non-microsurgeons. This study aims to compare the two procedures concerning their clinical and patient-reported outcomes one year postoperatively. METHODS: We conducted a retrospective review of LIFTs and Ab-FFs performed between March 2017 and August 2022. The primary outcomes were postoperative complications, reoperations, and longitudinal BREAST-Q scores. BREAST-Q modules included Satisfaction with Breasts, Abdomen, Back, Psychosocial Well-being, Physical Well-being: Chest, Abdomen, Back, and Sexual Well-being. RESULTS: Of the 281 included patients (408 breasts), 211 received Ab-FF, and 70 received LIFT. One-year follow-up (median [IQR]: 12 [12] months) demonstrated that Ab-FF independently predicted dehiscence, reoperation procedures, and revisional surgery. LIFT independently increased the odds of seroma. In addition, obesity predicted dehiscence, while bilateral reconstructions predicted revisional fat grafting. BREAST-Q scores fluctuated over time but were similar across all measured domains by one year postoperatively. CONCLUSIONS: Although Ab-FF is the gold-standard approach for fully autologous reconstruction, LIFT procedures may be associated with a less complicated postoperative course while eliciting similar patient-reported outcomes. LIFT may subsequently be preferred to limit postoperative complications, particularly in patients with obesity. LIFT can also be utilized by more plastic surgeons who are either not microsurgically trained or do not have an environment that fosters Ab-FF.
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Thyroid chondroplasty (TC) in facial gender-affirming surgery (FGAS) is aimed at modifying the thyroid cartilage to achieve a more feminine laryngeal appearance. This study evaluated open versus endoscopic techniques to TC and associated outcomes and complications. A systematic review (SR) of articles pertaining to TC was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve articles representing 368 patients were included for analysis. Nine articles described open approaches, and three articles described endoscopic techniques. The rate of total complications was 4.3% (n = 12) in the open approach compared to 15% (n = 13) in the endoscopic approach. Positive esthetic results were reported in 92% of cases performed with the open approach and 90% with the endoscopic approach. In the open approach, seven (2.5%) patients requested additional removal of cartilage, and three (1.1%) requested scar revision. In the endoscopic approach, three (3.7%) patients requested additional cartilage removal. In addition, data of individuals who underwent "cervical tracheoplasty" for gender dysphoria from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed, and there was no incidence of wound or major complications among patients who underwent tracheoplasty alone. Although the advantage of the endoscopic approach is a scarless neck incision, the rate of complications is higher with the open approach. Endoscopic approaches are still not widely used, and continued investigations are warranted to improve familiarity with this approach and reduce postoperative complications.
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Cartílago Tiroides , Humanos , Cartílago Tiroides/cirugía , Endoscopía/métodos , Cirugía de Reasignación de Sexo/métodos , Cirugía de Reasignación de Sexo/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estética , Femenino , Masculino , Resultado del Tratamiento , Disforia de Género/cirugíaRESUMEN
BACKGROUND: Some surgeons use body mass index criteria within the patient selection processes before vaginoplasty, thereby limiting access to select obese patients. We sought to better characterize the effect of obesity on postoperative outcomes across multiple vaginoplasty techniques. METHODS: A single-center retrospective review of all transfeminine patients undergoing primary vaginoplasty procedures from December 2018 to July 2022 was conducted. Patients were stratified into cohorts according to the World Health Organization Obesity Class criteria. Data regarding demographics, comorbidities, operative details, postoperative complications, and all-cause revision were collected. RESULTS: A total of 237 patients met the inclusion criteria. Average follow-up duration was 9.1 ± 4.7 months. Multivariate regression revealed that patients with class I and class II/III obesity were associated with higher odds of developing vaginal stenosis (class I: odds ratio [OR], 7.1 [ P = 0.003]; class II/III: OR, 3.4 [ P = 0.018]) and all-cause revision (class I: OR, 3.7 [ P = 0.021]; class II/III: OR, 4.8 [ P = 0.027]). Undergoing either robotic peritoneal or robotic intestinal vaginoplasty was associated with lower odds of delayed wound healing (peritoneal: OR, 0.2 [ P < 0.001]; intestinal: OR, 0.2 [ P = 0.011]). Lastly, adherence to dilation regimen was negatively associated with development of vaginal stenosis (OR, 0.04; P < 0.001). CONCLUSIONS: Patients with obesity may be at a higher risk of developing vaginal stenosis after vaginoplasty, which may ultimately necessitate operative revision. Although patients with obesity may remain surgical candidates, proper preoperative counseling and adherence to postoperative vaginal dilation regimens are critical to optimizing outcomes.
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Transexualidad , Vagina , Humanos , Femenino , Vagina/cirugía , Constricción Patológica , Obesidad/complicaciones , Estudios Retrospectivos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
BACKGROUND: NF is a life-threatening soft tissue infection that most commonly occurs in the lower extremity. While presenting symptoms such as erythema, severe pain, sepsis, and wound crepitation are well documented, diagnosis of NF of the breast often is obscured by a low clinical index of suspicion due to its relative rarity as well as by the breast parenchyma that physically separates the underlying fascia and overlying skin. Several risk factors have previously been identified, such as underlying infection, diabetes, advanced age, and immunosuppression. However, the gross morbidity and high mortality associated with NF warrant continued surveillance of contributing factors across any anatomic location. Fifteen cases in the literature document the development of NF following breast surgery. CASE REPORT: The authors of this case report aim to expand on the current literature through the presentation of a unique case of NF of the breast following right breast lumpectomy and oncoplastic closure with left reduction mammaplasty in an immunocompromised patient found to have concurrent perforated sigmoid diverticulitis. CONCLUSION: This case exemplifies how frequent postoperative surveillance, a low threshold for intervention, and efficient coordination of care are vital to minimizing the morbidity and mortality risks associated with NF of the breast.
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Fascitis Necrotizante , Infecciones de los Tejidos Blandos , Femenino , Humanos , Fascitis Necrotizante/etiología , Fascitis Necrotizante/cirugía , Mastectomía Segmentaria/efectos adversos , Infecciones de los Tejidos Blandos/cirugía , Fascia , MastectomíaRESUMEN
BACKGROUND: While advanced age is often considered a risk factor for complications following abdominal surgery, its impact on outcomes after complex open ventral hernia repair (VHR) with component separation technique (CST) remains unclear. METHODS: A single-center retrospective review of patients who VHR with CST from November 2008 to January 2022 was performed and cohorts were stratified by presence of advanced age (≥60 years). RESULTS: Of 219 patients who underwent VHR with CST, 114 patients (52.1 â%) were aged ≥60 years. Multivariate analysis demonstrated BMI to be an independent predictor for any complication (OR 1.1, p â= â0.002) and COPD was positively associated with seroma development (OR 20.1, p â= â0.012). Advanced age did not independently predict postoperative outcomes, including hernia recurrence (OR 0.8, p â= â0.766). CONCLUSIONS: VHR with CST is generally safe to perform in patients of advanced age. Every patient's comorbidity profile should be thoroughly assessed preoperatively for risk stratification regardless of age.
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Hernia Ventral , Complicaciones Posoperatorias , Humanos , Complicaciones Posoperatorias/etiología , Hernia Ventral/cirugía , Hernia Ventral/complicaciones , Comorbilidad , Factores de Riesgo , Herniorrafia/efectos adversos , Herniorrafia/métodos , Estudios Retrospectivos , RecurrenciaRESUMEN
BACKGROUND: In patients with chronic lower extremity (LE) wounds, chronic osteomyelitis confers additional complexity to achieving adequate treatment. Previous reviews demonstrate increased rates of osteomyelitis recurrence in patients who receive muscle flaps compared with fasciocutaneous flaps for LE limb salvage; however, these studies were not limited to atraumatic populations who receive exclusively free flaps. Thus, this study compared rates of recurrence in chronic osteomyelitis patients undergoing LE reconstruction with fasciocutaneous versus muscle free flaps. METHODS: Patients undergoing free tissue transfer (FTT) between July 2011 and July 2021 were retrospectively reviewed. Patients were stratified into fasciocutaneous and muscle free flap groups. Primary outcomes included osteomyelitis recurrence, flap complications, limb salvage, and ambulatory status. RESULTS: Forty-eight patients with pathologic diagnosis of chronic osteomyelitis of the wound bed were identified, of which 58.3% received fasciocutaneous (n = 28) and 41.7% received muscle flaps (n = 20). The most common comorbidities included diabetes mellitus (n = 29, 60.4%), peripheral neuropathy (n = 27, 56.3%) and peripheral vascular disease (n = 24, 50.0%). Methicillin-resistant or methicillin -sensitive Staphylococcus aureus were the most common pathogen in 18.7% (n = 9) of procedures. The majority of patients underwent a median of three debridements followed by negative pressure wound therapy prior to receiving FTT. At a median follow-up of 16.6 months, the limb salvage and ambulatory rates were 79.2 (n = 38) and 83.3% (n = 40), respectively. The overall rate of microsurgical flap success was 93.8% (n = 45). Osteomyelitis recurred in 25% of patients (n = 12) at a median duration of 4.0 months. There were no significant differences in rates of osteomyelitis recurrence, flap complications, limb salvage, ambulation, and mortality. On multivariate analysis, flap composition remained a nonsignificant predictor of osteomyelitis recurrence (odds ratio: 0.975, p = 0.973). CONCLUSION: This study demonstrates that flap composition may not influence recurrence of osteomyelitis following free flap reconstruction of chronic LE wounds, suggesting that optimal flap selection should be based on wound characteristics and patient goals.
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Colgajos Tisulares Libres , Traumatismos de la Pierna , Osteomielitis , Procedimientos de Cirugía Plástica , Humanos , Estudios Retrospectivos , Colgajos Tisulares Libres/cirugía , Osteomielitis/cirugía , Músculos , Traumatismos de la Pierna/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Free tissue transfer (FTT) provides a versatile method to achieve successful lower limb salvage. Thrombocytosis in patients undergoing lower extremity (LE) FTT is associated with increased risk of complications. The aims of this study were to assess the feasibility of performing LE FTT in patients with preoperative thrombocytosis, and whether antiplatelet (AP) therapy on the day of surgery (DOS) affects outcomes. METHODS: A retrospective review of thrombocytotic patients who underwent LE FTT between 2011 and 2022 was performed. Patients were stratified into groups based on the receipt of AP therapy on the DOS. Patients were propensity score matched for comorbidity burden and postoperative risk stratification. Outcomes of interest included perioperative transfusion requirements, postoperative flap-related complications, rates of flap success, limb salvage, and ambulatory status. RESULTS: Of the 279 patients who underwent LE FTT, 65 (23.3%) were found to have preoperative thrombocytosis. Fifty-three patients remained following propensity score matching; of which, 32 (60.4%) received AP therapy on the DOS and 21 (39.6%) did not. Overall flap success rate was 96.2% (n = 51). The likelihoods of thrombosis and hematoma development were similar between cohorts (p = 0.949 and 0.574, respectively). Receipt of DOS AP therapy was associated an additional 2.77 units and 990.10 mL of transfused blood (p = 0.020 and 0.018, respectively). At a mean follow-up of 20.7 months, overall limb salvage and ambulatory rates were 81.1% (n = 43) and 79.2% (n = 42), respectively, with no differences between cohorts. CONCLUSION: Preoperative thrombocytosis is not an absolute contraindication to LE FTT. DOS AP therapy may be protective in comorbid patients with elevated platelet counts but must be weighed against possible short-term bleeding as suggested by significant increases in postoperative transfusion requirements.
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Colgajos Tisulares Libres , Trombocitosis , Humanos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Puntaje de Propensión , Resultado del Tratamiento , Extremidad Inferior/cirugía , Estudios Retrospectivos , Complicaciones PosoperatoriasRESUMEN
BACKGROUND: Breast cancer-related lymphedema is the most common cause of lymphedema in the United States and occurs in up to 50% of individuals receiving axillary lymph node dissection (ALND). Lymphovenous bypass (LVB) at the time of ALND may prevent lymphedema, but long-term results and anastomotic patency are unclear. This study evaluates the feasibility and outcomes of performing immediate lymphatic reconstruction via coupler-assisted bypass (CAB). METHODS: This is a retrospective review of all patients undergoing prophylactic LVB following ALND at two tertiary care centers between 2018 and 2022. Patients were divided into cohorts based on whether they received the "standard" end-to-end (E-E) suturing or CAB technique. The primary outcome of interest was development of lymphedema. Quantitative and qualitative assessments for lymphedema were performed preoperatively and at 3, 6, 12, and 24 months postoperatively. RESULTS: Overall, 63 LVBs were performed, of which 24 lymphatics underwent immediate reconstruction via "CAB" and 39 lymphatics via "standard" end-to-end suture. Patient characteristics, including body mass index, and treatment characteristics, including radiation therapy, did not significantly differ between groups. CAB was associated with a greater mean number of lymphatics bypassed per vein (standard 1.7 vs. CAB 2.6, p = 0.0001) and bypass to larger veins (standard 1.2 vs. CAB 2.2 mm, p < 0.0001). At a median follow-up of 14.7 months, 9.1% (1/11) of individuals receiving CAB developed lymphedema. These rates were similar to those seen following standard bypass at 4.8% (1/21), although within a significantly shorter follow-up duration (standard 7.8 vs. CAB 14.7 months, p = 0.0170). CONCLUSION: The CAB technique is a viable, effective technical alternative to the standard LVB technique. This comparative study of techniques in prophylactic LVB suggests that CABs maintain long-term patency, possibly due to the ease of anastomosing several lymphatics to single large caliber veins while reducing the technical demands of the procedure.