A multi-disciplinary review of the potential association between closed-suction drains and surgical site infection.

BACKGROUND: Despite the putative advantages conferred by closed-suction drains (CSDs), the widespread utilization of post-operative drains has been questioned due to concerns regarding both efficacy and safety, particularly with respect to the risk of surgical site infection (SSI). Although discipline-specific reports exist delineating risk factors associated with SSI as they relate to the presence of CSDs, there are no broad summary studies to examine this issue in depth. METHODS: The pertinent medical literature exploring the relationship between CSDs and SSI across multiple surgical disciplines was reviewed. RESULTS: Across most surgical disciplines, studies to evaluate the risk of SSI associated with routine post-operative CSD have yielded conflicting results. A few studies do suggest an increased risk of SSI associated with drain placement, but are usually associated with open drainage and not the use of CSDs. No studies whatsoever attribute a decrease in the incidence of SSI (including organ/space SSI) to drain placement. CONCLUSIONS: Until additional, rigorous randomized trials are available to address the issue definitively, we recommend judicious use and prompt, timely removal of CSDs. Given that the evidence is scant and weak to suggest that CSD use is associated with increased risk of SSI, there is no justification for the prolongation of antibiotic prophylaxis to "cover" an indwelling drain.

Hydrogen sulfide reduces neutrophil recruitment in hind-limb ischemia-reperfusion injury in an L-selectin and ADAM-17-dependent manner.

BACKGROUND: Reperfusion following ischemia leads to neutrophil recruitment into injured tissue. Selectins and ß2-integrins regulate neutrophil interaction with the endothelium during neutrophil rolling and firm adhesion. Excessive neutrophil infiltration into tissue is thought to contribute to ischemia-reperfusion injury damage. Hydrogen sulfide mitigates the damage caused by ischemia-reperfusion injury. This study's objective was to determine the effect of hydrogen sulfide on neutrophil adhesion receptor expression. METHODS: Human neutrophils were either left untreated or incubated in 20 µM hydrogen sulfide and/or 50 µg/ml pharmacologic ADAM-17 inhibitor TAPI-0; activated by interleukin-8, fMLP, or TNF-α; and labeled against P-selectin glycoprotein ligand-1, leukocyte function associated antigen-1, Mac-1 α, L-selectin, and ß2-integrin epitopes CBRM1/5 or KIM127 for flow cytometry. Cohorts of three C57BL/6 mice received an intravenous dose of saline vehicle or 20 µM hydrogen sulfide with or without 50 µg/ml TAPI-0 before unilateral tourniquet-induced hind-limb ischemia for 3 hours followed by 3 hours of reperfusion. Bilateral gastrocnemius muscles were processed for histology before neutrophil infiltration quantification. RESULTS: Hydrogen sulfide treatment significantly increased L-selectin shedding from human neutrophils following activation by fMLP and interleukin-8 in an ADAM-17-dependent manner. Mice treated with hydrogen sulfide to raise bloodstream concentration by 20 µM before ischemia or reperfusion showed a significant reduction in neutrophil recruitment into skeletal muscle tissue following tourniquet-induced hind-limb ischemia-reperfusion injury. CONCLUSIONS: Hydrogen sulfide administration results in the down-regulation of L-selectin expression in activated human neutrophils. This leads to a reduction in neutrophil extravasation and tissue infiltration and may partially account for the protective effects of hydrogen sulfide seen in the setting of ischemia-reperfusion injury.

High-fidelity tissue engineering of patient-specific auricles for reconstruction of pediatric microtia and other auricular deformities.

INTRODUCTION: Autologous techniques for the reconstruction of pediatric microtia often result in suboptimal aesthetic outcomes and morbidity at the costal cartilage donor site. We therefore sought to combine digital photogrammetry with CAD/CAM techniques to develop collagen type I hydrogel scaffolds and their respective molds that would precisely mimic the normal anatomy of the patient-specific external ear as well as recapitulate the complex biomechanical properties of native auricular elastic cartilage while avoiding the morbidity of traditional autologous reconstructions. METHODS: Three-dimensional structures of normal pediatric ears were digitized and converted to virtual solids for mold design. Image-based synthetic reconstructions of these ears were fabricated from collagen type I hydrogels. Half were seeded with bovine auricular chondrocytes. Cellular and acellular constructs were implanted subcutaneously in the dorsa of nude rats and harvested after 1 and 3 months. RESULTS: Gross inspection revealed that acellular implants had significantly decreased in size by 1 month. Cellular constructs retained their contour/projection from the animals' dorsa, even after 3 months. Post-harvest weight of cellular constructs was significantly greater than that of acellular constructs after 1 and 3 months. Safranin O-staining revealed that cellular constructs demonstrated evidence of a self-assembled perichondrial layer and copious neocartilage deposition. Verhoeff staining of 1 month cellular constructs revealed de novo elastic cartilage deposition, which was even more extensive and robust after 3 months. The equilibrium modulus and hydraulic permeability of cellular constructs were not significantly different from native bovine auricular cartilage after 3 months. CONCLUSIONS: We have developed high-fidelity, biocompatible, patient-specific tissue-engineered constructs for auricular reconstruction which largely mimic the native auricle both biomechanically and histologically, even after an extended period of implantation. This strategy holds immense potential for durable patient-specific tissue-engineered anatomically proper auricular reconstructions in the future.

Body contouring after bariatric surgery: how much is really being done?

The proportion of postbariatric surgery patients who undergo body contouring (BC) procedures is unknown. We designed a study to explore demographic features and patient education regarding BC in the bariatric surgery (BS) population. A survey was mailed to 1158 patients who underwent BS by 2 surgeons between 2003 and 2011. A total of 284 (24.5%) patients responded. Seventy-two patients (25.4%) reported discussing BC surgery with their bariatric surgeon perioperatively. Forty patients (14.1%) were referred for plastic surgery consultation. Thirty-three patients (11.6%) underwent BC procedures. The most frequent reasons cited for not undergoing BC were expense (29.2%) and lack of awareness regarding options (23.6%). Thirty-nine percent of respondents reported that they might have chosen differently, had they received more information. As a result of insufficient perioperative counseling, the majority of BS patients are unaware of the multitude of BC procedures available. Additional efforts toward improving patient (and surgeon) education regarding postbariatric BC options are warranted.

A prospective analysis of the association between indwelling surgical drains and surgical site infection in plastic surgery.

INTRODUCTION: Many surgeons fear that closed-suction drains serve as a portal for bacterial entry into surgical spaces. Despite a lack of supporting evidence, postoperative antibiotics are often prolonged while drains remain in place. METHODS: Medical records of all patients who underwent intraoperative Jackson-Pratt drain placement and sterile removal over a 12-month period were prospectively analyzed. RESULTS: Fifty-four patients with 101 drains were included. Drains were in place for 5 to 43 days [mean (SD), 13.5 (6.3) days]. Sixty-three percent of drains had positive cultures. All patients received perioperative antibiotics. Thirty-nine patients received postoperative antibiotics [mean (SD), 13.8 (13.8) days]. There were 2 cases of cellulitis. One patient required reoperation. CONCLUSIONS: Sixty-six drains (65.3%) were placed in the presence of prosthetic material. Although nearly two thirds of drains were colonized with bacteria, our wound infection rate was extremely low (5.6%). Thus, closed-suction drains may be left in place for an extended period without increasing the risk of infection, even in the presence of prosthetic material.

Use of Integra and interval brachytherapy in a 2-stage auricular reconstruction after excision of a recurrent keloid.

Keloids present a formidable clinical challenge. Surgical excision in conjunction with radiation therapy may decrease the chance of keloid recurrence. Split-thickness skin grafts, however, are more prone to failure in the setting of radiation. In this report, we present a patient with a recurrent auricular keloid who underwent excision and immediate Integra (Integra LifeSciences, Plainsboro, NJ) application, followed by high-dose rate brachytherapy and interval split-thickness skin graft placement. A 23-year-old woman with a history of a recurrent auricular keloid after previous surgical excision, corticosteroid injection, and radiation underwent reexcision of her keloid. Integra was used to cover the resultant exposed auricular perichondrium. The patient then received high-dose rate brachytherapy (1500 cGy) on postoperative days 1 and 2, followed by definitive split-thickness skin graft placement 3 weeks after her initial surgery. The patient recovered from all interventions without complication. There was no evidence of keloid formation 27 months after the interval split-thickness skin graft placement at either the auricular recipient or thigh donor sites. We report the first case of a 2-stage reconstruction of a recurrent auricular keloid (composed of keloid excision and placement of Integra in conjunction with high-dose rate brachytherapy, followed by interval split-thickness skin grafting), resulting in an acceptable cosmetic result without evidence of recurrence at long-term follow-up.

Sequential second free fibula flap for the reconstruction of metachronous osteoradionecrosis of the mandible.

Osteoradionecrosis (ORN) of the mandible is a potentially catastrophic complication of external beam radiation therapy for head and neck malignancies. A 55-year-old man treated with chemoradiation for base-of-tongue cancer presented with a necrotic left mandibular body and underwent left mandibulectomy with right free fibula osteocutaneous flap reconstruction. Two and a half years later, he presented with right mandibular body ORN and underwent a second mandibular resection and subsequent reconstruction with a left fibula osteocutaneous free flap fixed in the midline to the previously placed contralateral fibula. He recovered well from all procedures. To the best of our knowledge, we report the first case of a patient with metachronous ORN of the mandible requiring resection and subsequent reconstruction with sequential free fibula flaps. Even in the presence of prior microvascular reconstructions, patients can successfully undergo additional reconstructive procedures to restore their function, appearance, and quality of life.

Mathematical modeling and frequency gradient analysis of cellular and vascular invasion into integra and strattice: toward optimal design of tissue regeneration scaffolds.

BACKGROUND: Rapid, effective host cell invasion and vascularization is essential for durable incorporation of avascular tissue-replacement scaffolds. In this study, the authors sought to qualitatively and quantitatively determine which of two commercially available products (i.e., Strattice and Integra) facilitates more rapid cellular and vascular invasion in a murine model of graft incorporation. METHODS: Integra and Strattice were implanted subcutaneously into the dorsa of C57BL/6 mice; harvested after 3, 7, or 14 days; and stained with hematoxylin and eosin, 4',6-diamidino-2-phenylindole, and immunohistochemical stains for CD31 and α-smooth muscle actin. Exponential decay equations describing cellular invasion through each layer were fit to each material/time point. Mean cell density and cell frequency maps were created denoting extent of invasion by location within the scaffold. RESULTS: Qualitative analysis demonstrated extensive cellular infiltration into Integra by 3 days and increasing over the remaining 14 days. Invasion of Strattice was sparse, even after 14 days. α-Smooth muscle actin immunohistochemistry revealed blood vessel formation within Integra by 14 days but no analogous neovascularization in Strattice. Mean decay equations for Integra and Strattice were y = 76.3(0.59) and y = 75.5(0.33), respectively. Both cell density measurements and frequency mapping demonstrated that, at all time points, Integra manifested a greater density/depth of cellular invasion when compared with Strattice. CONCLUSIONS: These data confirm empiric clinical observations that Integra is more rapidly invaded than Strattice when placed in a suitable host bed. A remnant microvasculature template is not sufficient for effective cellular ingrowth into an artificial tissue construct. These findings provide insight into means for improving future dermal replacement products.

An interdisciplinary approach to the prevention and treatment of groin wound complications after lower extremity revascularization.

BACKGROUND: If not effectively treated, groin wound infections following lower extremity revascularization (LER) may result in graft or limb loss. METHODS: A retrospective review was performed of all patients who underwent muscle flap transposition by a single surgeon after LER between 2006 and 2010. RESULTS: Twenty-nine muscle transposition flaps were performed in 24 patients (21 sartorius, 6 rectus femoris, and 2 gracilis). Nineteen were for treatment of groin wound infections, two for treatment of lymphocele, one for coverage of exposed graft in the setting of pyoderma gangrenosum, and seven for infection prophylaxis. Two graft losses followed flap placement. The limb loss rate was 4%. When performed for therapeutic purposes, graft salvage rates were 100% for autogenous and 92% for synthetic grafts. CONCLUSIONS: Muscle transposition flaps are an effective means of graft salvage in the setting of groin wound complications following LER and should be considered for infection prophylaxis in high-risk patients.

The length-control suture: a new method for prevention of hypertrophic scars and dog-ears.

Surgical and traumatic wounds develop hypertrophic scarring when exposed to lengthwise stress. The length-control suture (LCS) technique, in which a suture is passed in a closed-loop beneath the wound and anchored to the underside of the dermis, thereby pulling the apices inward, protects wounds from these forces and also limits the formation of dog-ears. Between 2006 and 2009, a retrospective review was performed in 230 consecutive patients who underwent wound closure with the LCS technique by a single surgeon. Wounds were evaluated at 6 weeks and 6 months. In 223 cases (97%), the technique resulted in a scar that was thin, soft, and flat. There were 6 cases of spitting and 1 case of hypertrophy. The LCS technique is useful for a wide variety of surgical and traumatic wounds across all anatomic regions. This technique if used results in scars that are reliably flat, thin, and supple within 6 months.

Browpexy through the upper lid (BUL): a new technique of lifting the brow with a standard blepharoplasty incision.

BACKGROUND: Browpexy returns the brow to an anatomical, aesthetically-appealing location on the upper face. Recently, browlifting techniques have evolved from aggressive, open approaches toward less invasive, limited-incision techniques. Browpexy through the upper lid (BUL), an innovative technique based on earlier practices, anchors the underlying brow soft tissue to the bone, allowing for stabilization. Furthermore, this procedure can be performed concomitantly with an upper eyelid blepharoplasty through the same access incision. OBJECTIVE: The authors evaluate the efficacy of BUL in patients with ptotic eyebrows requiring stabilization and/or elevation and in patients with prominent brow fat pads. METHODS: The charts of 21 patients who were treated with BUL by the senior author (HMS) between February 2007 and October 2008 were retrospectively reviewed. RESULTS: The age range of the 21 patients in this study was 54 to 70 years. Twelve patients were men; nine were women. Each patient presented with complaints of tired-appearing or "weighed-down" upper eyelids. All patients were uniformly happy with their postoperative aesthetic results. There were no major immediate or long-term complications (including, but not limited to, uneven postoperative brow position, loss of suspension, frontal nerve injury, hematoma, infection, or wound dehiscence). No patients required reoperation for recurrent brow ptosis or upper lid deformity. CONCLUSIONS: BUL is ideal for patients with ptotic eyebrows who need brow stabilization and/or elevation, as well as for patients with prominent brow fat pads who require stabilization. BUL achieves excellent results through a standard upper eyelid blepharoplasty incision, and allows the surgeon to perform a concomitant upper eyelid blepharoplasty and browpexy without a traditional coronal, scalp, or forehead incision.

Therapeutic delivery of hydrogen sulfide for salvage of ischemic skeletal muscle after the onset of critical ischemia.

BACKGROUND: Recent evidence suggests that hydrogen sulfide is capable of mitigating the degree of cellular damage associated with ischemia-reperfusion injury (IRI). METHODS: This study evaluated the potential utility of hydrogen sulfide in preventing IRI in skeletal muscle by using in vitro (cultured myotubes subjected to sequential hypoxia and normoxia) and in vivo (mouse hind limb ischemia, followed by reperfusion) models to determine whether intravenous hydrogen sulfide delivered after the ischemic event had occurred (pharmacologic postconditioning) conferred protection against IRI. Injury score and apoptotic index were determined by analysis of specimens stained with hematoxylin and eosin and terminal deoxynucleotide transferase-mediated deoxy-uridine triphosphate nick-end labeling, respectively. RESULTS: In vitro, hydrogen sulfide reduced the apoptotic index after 1, 3, or 5 hours of hypoxia by as much as 75% (P = .002), 80% (P = .006), and 83% (P < .001), respectively. In vivo, hydrogen sulfide delivered after the onset of hind limb ischemia and before reperfusion resulted in protection against IRI-induced cellular changes, which was validated by significant decreases in the injury score and apoptotic index. The timing of hydrogen sulfide delivery was crucial: when delivered 20 minutes before reperfusion, hydrogen sulfide conferred significant cytoprotection (P < .001), but treatment 1 minute before reperfusion did not provide protection (P = NS). CONCLUSIONS: These findings confirm that hydrogen sulfide limits IRI-induced cellular damage in myotubes and skeletal muscle, even when delivered after the onset of ischemia in this murine model. These data suggest that when given in the appropriate dose and within the proper time frame, hydrogen sulfide may have significant therapeutic applications in multiple clinical scenarios.

Nasal spreader grafts: a comparison of medpor to autologous tissue reconstruction.

Reconstruction of the damaged nasal vault is challenging. Limited available autologous tissue has lead surgeons to pursue alloplastic alternatives. A retrospective review comparing 18 patients who underwent secondary rhinoplasty with internal nasal valve reconstruction with spreader graft (SG) implants using either autologous tissue or high-density porous polyethylene (Medpor) was performed. All underwent bilateral SG reconstruction of the internal nasal valve with Medpor (10 cases) or autologous cartilage (8 cases). Mean follow-up was 26 months for the autologous group and 29 months for the Medpor group. Functional performance and aesthetic results were identical. Complications were few: 1 case of unilateral infection in the Medpor group treated with partial excision, and 1 case of erythema at the auricular donor site for the autologous tissue group. For patients who have exhausted autologous tissue options or are unwilling to tolerate potential donor-site morbidity, the Medpor SG is an appropriate option that allows for excellent aesthetic and functional results that remains stable over time.

Perioperative antibiotics in the setting of microvascular free tissue transfer: current practices.

Microvascular free tissue transfer is a ubiquitous and routine method of restoring anatomic defects. There is a paucity of data regarding the role of perioperative antibiotics in free tissue transfer. We designed a survey to explore usage patterns among microvascular surgeons and thereby define a standard of care. A 24-question survey regarding the perioperative antibiotic use in microvascular head and neck, breast, and lower extremity reconstruction was sent to all those members of the American Society for Reconstructive Microsurgery who had registered e-mail addresses ( N = 450). Ninety-nine members responded. A first-generation cephalosporin is the most frequent choice of perioperative antibiotics across most categories: 93.5% for breast, 59.2% for head and neck, 91.1% for nontraumatic lower extremity, and 84.9% for traumatic noninfected lower extremity reconstruction. In penicillin-allergic patients, clindamycin is the most common choice. For traumatic lower extremity reconstruction in the presence of soft tissue infection or osteomyelitis, culture and sensitivity results determine the selection of perioperative antibiotics in 74%. A first-generation cephalosporin is the standard of care for perioperative antibiotic use in microvascular breast, head and neck, nontraumatic lower extremity, and traumatic noninfected lower extremity reconstruction. No consensus exists regarding the appropriate duration of coverage. These data may serve as a guide until a large controlled prospective trial is performed and a standard of care is established.

Pyoderma gangrenosum after lower extremity bypass.

A 66-year-old male with lower extremity ischemia underwent femoral-posterior tibial bypass with composite vein graft from the arm. Ten days later, he presented to the emergency department with pain, wound erythema, and drainage. Despite a prolonged course of intravenous antibiotics and serial operative debridements, the wound edges repeatedly necrosed after each procedure. The vein graft remained viable. Punch biopsies of wound edges were consistent with pyoderma gangrenosum (PG). The patient's condition improved on immunosuppressive therapy. Although a rare clinical entity, postsurgical PG is a well-described phenomenon whose diagnosis is often delayed. Clinical suspicion is imperative to ensure timely treatment and minimize morbidity.

QT Prolongation Following Ectopic Beats: Initial Data Regarding The Upper Limit Of Normal With Possible Implications For Antiarrhythmic Therapy And Concealed (Unexpressed) Long QT.

Background: Ectopic beats are frequently associated with morphologic repolarization alterations of ensuing sinus beats. Less is known about repolarization duration alterations of post-ectopic sinus beats. In one patient who developed long QT and torsades de pointes upon exposure to a class III antiarrhythmic drug, and was later genotyped as being a carrier for long QT syndrome (LQTS) type 1, review of a pre-drug Holter monitor study revealed marked QT prolongation of post-ectopic sinus beats. In wondering whether this might be a common clue to "concealed" unexpressed LQTS, we realized that we must first characterize the range of post-ectopic QT prolongation present in normals. Prolongation beyond the upper limit of this range might then raise suspicion of possible LQTS and alter the antiarrhythmic drug selection process for the suppression of atrial fibrillation or other arrhythmias. Methods: Accordingly, we assessed the presence/degree of repolarization prolongation following premature ectopic impulses in 166 subjects with normal conduction intervals and normal repolarization on their resting 12-lead ECG, 75 of whom had no known associated cardiovascular disorder of any kind. That is, in our subjects, the maximal prolongation of the QT interval of the sinus beat following isolated ventricular and atrial premature complexes was characterized. Results: QT prolongation is common in post ectopic sinus beats. However, in our subjects the uncorrected QT interval of post-ectopic sinus beats never exceeded 480 ms in duration [which was much shorter than that seen (510-590 ms) in our gene carrier]. CONCLUSIONS: The QT interval in normal subjects may prolong following premature complexes but not to a value in excess of 480 ms.