The Superficial Circumflex Iliac Artery Perforator Flap for Devastating Hand Injuries in Obese Patients.

INTRODUCTION: Blast injuries to the hand, such as those from fireworks, are debilitating and life altering. Often, because of the nature of the injury, there is a need for soft tissue and skin coverage. However, in the increasingly obese American population, free flaps often are too bulky for functional hand coverage. In this study, we present a series of 7 patients who underwent the superficial circumflex iliac artery perforator (SCIP) flap for upper extremity reconstruction with improvement in cosmesis, including a primarily repaired donor site, as well as an overwhelmingly high return to work with minimal revision surgery necessary. METHODS: All patients who underwent a SCIP for hand injuries from a blast were included. Flaps were harvested based on previously described methods. A single attending surgeon performed all surgeries. All patients were followed for at least 6 months. Preoperative and postoperative characteristics were described. RESULTS: A total of 7 patients were included in this study. Ages ranged from 16 to 58 years and body mass index from 19 to 48 kg/m 2 . More than half of the patients had a body mass index greater than 30 kg/m 2 . All donor sites were primarily closed. Five patients returned to their preinjury work. Three patients had neurotized flaps with return of protective sensation. Three patients required revision surgery; all 3 had liposuction, and 1 had additional flap advancement surgery. CONCLUSION: The SCIP flap is a versatile flap that can be used in hand reconstruction in blast injuries with good functional outcome and improved cosmesis compared with other perforator flaps for the upper extremity.

Flexor Tenosynovitis Caused by Neisseria gonorrhea Infection: Case Series, Literature Review, and Treatment Recommendations.

Neisseria gonorrhoeae is the most common sexually transmitted disease in the world and is known to cause disseminated disease, most commonly tenosynovitis. Classically, gonorrhea-associated tenosynovitis presents with concomitant dermatitis and arthralgias, though this is not always the case. N. gonorrhoeae -related tenosynovitis has become more commonly seen by hand surgeons. To aid in management, we present three cases of gonorrhea-induced tenosynovitis spanning a range of presentations with variable treatments to demonstrate the variety of patients with this disease. Only one of our patients had a positive gonococcal screening test and no patient had purulent urethritis, the most common gonorrhea-related symptom. A separate patient had the classic triad of tenosynovitis, dermatitis, and arthralgias. Two patients underwent operative irrigation and debridement, and one was managed with anti-gonococcal antibiotics alone. Though gonorrhea is a rare cause of flexor tenosynovitis, it must always be on the differential for hand surgeons when they encounter this diagnosis. Taking an appropriate sexual history and performing routine screening tests can assist in the diagnosis, the prescription of appropriate antibiotics, and potentially avoiding an unnecessary operation.

Post-Mastectomy Patients in an Urban Safety-Net Hospital: How Do Safety-Net Hospital Breast Reconstruction Rates Compare to National Breast Reconstruction Rates?

BACKGROUND: Breast reconstruction (BR) has documented psychological benefits following mastectomy. Yet, racial/ethnic minority groups have lower reported rates of BR. We sought to evaluate the rate, type, and outcome of BR in a racially and ethnically diverse population within a safety-net hospital system. METHODS: All patients who underwent mastectomy between October 2015 and July 2019 at Harbor-UCLA Medical Center were retrospectively examined. Rates and type of BR were analyzed according to patient characteristics (race/ethnicity, age, and body mass index), smoking status, cancer stage, and presence of diabetes mellitus. Breast reconstruction outcomes were also assessed. RESULTS: Of the 259 patients that underwent mastectomy, 87 (33.6%) received BR. Immediate BR was performed in 79 (30.5%) patients and delayed BR in 8 (3.1%). Of the 79 patients with immediate BR, 58 (73.4%) received implant-based BR and 21 (26.5%) autologous tissue. The BR failure rate was 10%, all implant-based. Increasing age and smoking negatively impacted BR rates. Black (P =.331) and Hispanic (P =.132) ethnicity were not independent predictors of decreased breast reconstruction. CONCLUSION: This study demonstrated that the rate, type, and quality of BR in this integrated safety-net hospital within a diverse population are comparable to national rates. When made available, historically underrepresented minority patients of Black and Hispanic ethnicity utilize BR.

Squamous Cell Carcinoma Arising in Breast Implant Capsules.

ABSTRACT: Breast augmentation and reconstruction utilizing implants are among the most common plastic surgery procedures performed in the United States. A small proportion of these implants are removed each year. We report 2 cases where routine pathologic evaluation of capsulectomy specimens revealed squamous cell carcinoma associated with the breast implant capsule and discuss the possible pathogenesis of this unusual entity. Both patients had long-standing implants (>10 years) and presented with acute unilateral breast erythema and swelling. Intraoperatively, the capsules for both cases appeared thickened and calcified, containing extensive granulomatosis and keratinaceous debris invading into the chest wall. Extensive workup failed to find an occult primary. One patient died from a malignant pleural effusion secondary to tumor invasion during chemotherapy, and the second patient obtained stabilization of the mass after 5 weeks of chemotherapy but subsequently declined further surgical intervention. A thorough literature review was performed, and 5 similar reports were identified, involving 6 patients. All patients presented with similar clinical presentations as ours and had poor outcomes. The mean reporting age at diagnosis was 60 years, and the average time from initial implant to diagnosis was 25 years. Due to the small numbers of squamous cell carcinomas associated with breast implant capsules, the true association between the 2 is unknown. It is postulated that chronic inflammation/irritation from the breast implant and epithelialization of the capsule play a significant role in the disease process. This may represent a new entity of "chronic inflammatory capsular malignancies." Increased awareness of this entity may allow for earlier suspicion, diagnosis, and management.

Review of Outcomes in Prepectoral Prosthetic Breast Reconstruction with and without Surgical Mesh Assistance.

BACKGROUND: In the past decade, surgeons have increasingly advocated for a return to prepectoral breast reconstruction with claims that surgical mesh (including acellular dermal matrix) can reduce complication rates. However, numerous surgical and implant advancements have occurred in the decades since the initial prepectoral studies, and it is unclear whether mesh is solely responsible for the touted benefits. METHODS: The authors conducted a systematic review of all English language articles reporting original data for prepectoral implant-based breast reconstruction. Articles presenting duplicate data were excluded. Complications were recorded and calculated on a per-breast basis and separated as mesh-assisted, no-mesh prior to 2006, and no-mesh after 2006 (date of first silicone gel-filled breast implant approval). Capsular contracture comparisons were adjusted for duration of follow-up. RESULTS: A total of 58 articles were included encompassing 3120 patients from 1966 to 2019. The majority of the included studies were retrospective case series. Reported complication outcomes were variable, with no significant difference between groups in hematoma, infection, or explantation rates. Capsular contracture rates were higher in historical no-mesh cohorts, whereas seroma rates were higher in contemporary no-mesh cohorts. CONCLUSIONS: Limited data exist to understand the benefits of surgical mesh devices in prepectoral breast reconstruction. Level I studies with an appropriate control group are needed to better understand the specific role of mesh for these procedures. Existing data are inconclusive but suggest that prepectoral breast reconstruction can be safely performed without surgical mesh.

Bipedicled flaps in posttraumatic lower-extremity reconstruction.

BACKGROUND: Complex, lower-extremity, soft-tissue defects pose a significant challenge to the reconstructive surgeon and often require the use of free flaps, which puts significant demands on the patient, the surgeon and the health-care system. Bipedicled flaps are random but receive a blood supply from two pedicles, allowing the surgeon to use local tissue with an augmented nutrient blood flow. They are simple to elevate and economical in operating time. This study describes our experience with lower-extremity wound reconstruction using the bipedicled flap as an alternative to pedicled flaps and free flaps. METHODS: Ten patients with lower-extremity defects underwent bipedicled flap reconstruction. Operative times, length of stay following flap procedure and postoperative complications were documented. Data were collected in a prospective fashion. RESULTS: Two patients had minimal areas of flap necrosis, both of which resolved with conservative local wound care and one patient developed a postoperative wound infection remedied with a course of oral antibiotics. We experienced one major complication involving wound dehiscence requiring an additional flap. CONCLUSIONS: Bipedicled flaps provide a safe, fast and relatively easy alternative for coverage of certain complex open wounds in the lower extremities. Their use does not preclude the use of more traditional options of pedicled muscle or free flap coverage at a later time should they be required. CLINICAL QUESTIONS ADDRESSED/LEVEL OF EVIDENCE: What are alternative strategies for lower-extremity wound reconstruction. Level of Evidence V.

Matrix metalloproteinase-9 delays wound healing in a murine wound model.

BACKGROUND: Metalloproteinase-9 (MMP-9) is a type IV collagenase found at elevated levels in chronic wounds. As wounds heal, MMP-9 diminishes. In this study, we investigated whether MMP-9 directly contributes to chronic wound pathogenesis. METHODS: Recombinant proMMP-9 was prepared using immortalized keratinocytes transduced by a lentivirus. ProMMP-9 was purified from cell culture media and activated using 4-aminophenylmercuric acetate. Active MMP-9 was then suspended in xanthan gum to a concentration paralleling that found in human chronic wounds. Two parallel 6-mm punch biopsies were made on the backs of C57BL mice. Wounds were treated daily with MMP-9 or vehicle. Wound areas were measured and tissues examined by densitometry, real-time RT-PCR, histology, and immunohistochemistry at days 7, 10, and 12. RESULTS: Exogenous MMP-9, at the level found within chronic wounds, delayed wound healing in this animal model. By 7 days, wounds in the MMP-9-injected group were 12% larger than control wounds (P = .008). By day 12, wounds in the MMP-9-injected group were 25% larger than those of the control group (P = .03). Histologic examination shows that high levels of active MMP-9-impaired epithelial migrating tongues (P = .0008). Moreover, consistent with elevated MMP-9, the collagen IV in the leading edge of the epithelial tongue was diminished. CONCLUSION: MMP-9 appears to directly delay wound healing. Our data suggests that this may occur through interference with re-epithelialization. We propose that MMP-9 interferes with the basement membrane protein structure, which in turn impedes keratinocyte migration, attachment, and the reestablishment of the epidermis.

TNF-alpha suppresses alpha-smooth muscle actin expression in human dermal fibroblasts: an implication for abnormal wound healing.

Abnormal wound healing encompasses a wide spectrum, from chronic wounds to hypertrophic scars. Both conditions are associated with an abnormal cytokine profile in the wound bed. In this study, we sought to understand the dynamic relationships between myofibroblast differentiation and mechanical performance of the collagen matrix under tissue growth factor-beta (TGF-beta) and tumor necrosis factor-alpha (TNF-alpha) stimulation. We found TGF-beta increased alpha-smooth muscle actin (alpha-SMA) and TNF-alpha alone decreased the basal alpha-SMA expression. When TGF-beta1 and TNF-alpha were both added, the alpha-SMA expression was suppressed below the baseline. Real-time PCR showed that TNF-alpha suppresses TGF-beta1-induced myofibroblast (fibroproliferative) phenotypic genes, for example, alpha-SMA, collagen type 1A, and fibronectin at the mRNA level. TNF-alpha suppresses TGF-beta1-induced gene expression by affecting its mRNA stability. Our results further showed that TNF-alpha inhibits TGF-beta1-induced Smad-3 phosphorylation via Jun N-terminal kinase signaling. Mechanical testing showed that TNF-alpha decreases the stiffness and contraction of the lattices after 5 days in culture. We proposed that changes in alpha-SMA, collagen, and fibronectin expression result in decreased contraction and stiffness of collagen matrices. Therefore, the balance of cytokines in a wound defines the mechanical properties of the extracellular matrix and optimal wound healing.