Regenerative vs flap-based limb salvage: a multi-centered, prospective, randomized controlled trial.

Aim: The goal of this study was to compare success rates of a regenerative limb salvage approach (rLS) using dehydrated human chorion amnion membrane (dHACM) to traditional flap-based limb salvage (fLS). Materials & methods: This prospective RTC enrolled patients presenting with complex extremity wounds over a 3-year period. Primary outcomes included success of primary reconstruction, persistence of exposed structures, time to definitive closure, and time to weight bearing. Results: Patients meeting inclusion criteria were randomized to fLS (n = 14) or rLS (n = 25). The primary reconstructive method was successful for 85.7% of fLS subjects and 80% of rLS subjects (p = 1.00). Conclusion: This trial provides strong evidence that rLS is an effective option in the setting of complex extremity wounds, with success rates comparable to traditional flaps. Clinical Trial Registration: NCT03521258 (ClinicalTrials.gov).

Chronic and traumatic wounds may result in loss of limb without appropriate medical treatment. Traditionally large wounds with exposed bone or other important structures require surgery to transfer healthy soft tissue (a tissue flap) from one area of the body to the defect created by the wound. Our study seeks to demonstrate an approach to similar wounds using a biologic dressing to avoid extensive surgery. We demonstrate that this biologic dressing made from human membranes has a similar success rate to flap surgery for achieving wound healing.

Modern Approaches to Abdominal-Based Breast Reconstruction.

Modern approaches to abdominal-based breast reconstruction have evolved since the introduction of the transverse musculocutaneous flap by Dr Carl Hartrampf in the 1980s. The natural evolution of this flap is the deep inferior epigastric perforator (DIEP) flap, as well as the superficial inferior epigastric artery flap. As breast reconstruction has advanced, so too has the utility and nuances of abdominal-based flaps, including the deep circumflex iliac artery flap, extended flaps, stacked flaps; neurotization; and perforator exchange techniques. Even the delay phenomenon has been successfully applied to DIEP and SIEA flaps to augment flap perfusion.

Use of the Vertical Profunda Artery Perforator Flap to Capture the Dominant Perforator: A Cadaver Dissection and Imaging Study.

BACKGROUND: While the originally described transverse profunda artery perforator (tPAP) flap is designed to capture the first profunda perforator, our group hypothesized the dominant perforator may not always be captured in this configuration. This study maps the location of dominant profunda perforators using imaging and cadaveric dissections to determine the probability of capturing dominant perforators with the transverse flap design versus the vertical PAP (vPAP) variant. METHODS: Fifty preoperative magnetic resonance angiogram or computed tomographic angiogram scans (100 total extremities) were examined from autologous breast reconstruction patients between 2015 and 2019. Profunda perforator characteristics that were examined included the distance from the pubic tubercle to the infragluteal fold (IGF), the distance of the perforators from the IGF, distance posterior to the gracilis, the diameter of the perforator at fascial exit, and total number of perforators present. Profunda perforator dissection was performed in 18 cadaveric extremities. Analysis included mean distance from pubic tubercle, distance posterior to the gracilis, diameter at fascial exit, and total number of perforators. RESULTS: In imaging analysis, the mean distance from the IGF to the fascial exit of all dominant perforators was 7.04 cm. The mean diameter of the dominant perforator at the fascial exit was 2.61 mm. Twenty-six thighs (26%) demonstrated dominant perforators that exited the fascia greater than 8 cm below the IGF. In cadaver dissections, the mean distance from the pubic tubercle to the fascial exit of all the dominant perforators was 10.17 cm. Nine cadaver specimens (50%) demonstrated perforators that exited the fascia greater than 8 cm below the estimated IGF. CONCLUSION: The dominant perforator can often be missed in the traditional tPAP design. The vPAP incorporates multiple perforators with a long pedicle, excellent vessel diameter, and favorable donor-site.

Reconsidering the "MR Unsafe" breast tissue expander with magnetic infusion port: A case report and literature review.

Breast tissue expanders (TEs) with magnetic infusion ports are labeled "MR Unsafe." Therefore, patients with these implants are typically prevented from undergoing magnetic resonance imaging (MRI). We report a patient with a total submuscular breast TE who inadvertently underwent an MRI exam. She subsequently developed expander exposure, requiring explantation and autologous reconstruction. The safety profile of TEs with magnetic ports and the use of MRI in patients with these implants is surprisingly controversial. Therefore, we present our case report, a systematic literature review, and propose procedural guidelines to help ensure the safety of patients with TEs with magnetic ports that need to undergo MRI exams.

Microsurgical Engineering: Bilateral Deep Inferior Epigastric Artery Perforator Flap with Flow-Through Intraflap Anastomosis.

Squamous cell carcinoma (SCC) of the head and neck affects a significant number of people around the world every year. Treatment generally entails surgical resection, radiotherapy, chemotherapy, or some combination of the three. Following resection, microsurgical reconstruction can provide definitive coverage, replace many tissue types simultaneously, and bring healthy tissue to irradiated wound beds. Microsurgical engineering, the manipulation and reorganization of native vascular tissue, can further augment the adaptability of free tissue transfer to complex, compromised wound beds. We present one such case. The patient described in the following report was treated for a recurrent SCC of the left face, which required extensive resection resulting in a complex, composite tissue defect with compromised vascular supply. Using the principals of microsurgical engineering, definitive coverage of the defect, with accept- able aesthetic result, was achieved via bipedicle, DIEP flap with flow-through intraflap anastomosis.

Outcomes Comparison for Microsurgical Breast Reconstruction in Specialty Surgery Hospitals Versus Tertiary Care Facilities.

BACKGROUND: Postoperative monitoring is crucial in the care of free flap breast reconstruction patients. Tertiary care facilities (TCFs) provide postoperative monitoring in an ICU after surgery. Specialty surgery hospitals (SSHs) do not have ICUs, but these facilities perform free flap breast reconstruction as well. Are outcomes comparable between the 2 facilities in terms of flap reexploration times and overall success? METHODS: Retrospective study including 163 SSH and 157 TCF patients. Primary predictor was facility in which the procedure was performed. Secondary predictors included operative, demographic, and comorbidity data. Primary outcomes were flap take back rate and flap failures. Secondary outcomes were total time from adverse event noticed in the flap to returning to the operating room (OR) and total time from decision made to return to the OR to returning to the OR (decision made). Tertiary outcomes were length of stay, operative times, and blood loss. RESULTS: Patients at the TCF were generally less healthy than SSH patients. Salvage rates and failure rates were similar between the 2 institutions. Adverse event noticed and decision made times did not differ between the 2 facilities. Overall flap success rate was 98.22% at SSH and 98.81% at TCF. No primary or secondary predictors had a significant correlation with increased odds for flap failure. CONCLUSION: SSHs can offer similar outcomes in free flap breast reconstruction with just as effective clinical response times to endangered flaps as found in a TCF. However, surgery at an SSH may best be reserved for healthier patients.

Avoiding Facial Incisions with Midface Free Tissue Transfer.

BACKGROUND: We have adopted an intraoral microsurgical anastomosis to the facial vessels to eliminate the need for any visible facial incisions. METHODS: Cadaveric dissection was used to demonstrate accessibility of the facial artery and vein through an intraoral approach. Additionally, 5 patients underwent free tissue transfer for reconstruction of major defects of the midface through an intraoral, transmucosal approach, obviating the need for visible skin incisions. RESULTS: The pathology included palatal defects due to mucoepidermoid carcinoma and ischemic necrosis from cocaine abuse, maxillary defects secondary to fibrous dysplasia and avascular necrosis from traumatic blast injury, and a residual posttraumatic bony deformity of the zygoma. Reconstructions were performed with a free ulnar forearm flap, a free vastus lateralis muscle flap, a deep circumflex iliac artery myoosseous flap, a free fibula flap, and a deep circumflex iliac artery osseous flap, respectively. The facial artery and vein were used as recipient vessels for microvascular anastomosis for all cases. Mean follow-up was 12.2 months. All free tissue transfers were successful, and each patient had a satisfactory aesthetic outcome with no associated facial scars. CONCLUSION: This technique can be employed during reconstruction of an array of bony or soft-tissue midface deficits with minimal morbidity. This small series effectively demonstrates the varied pathologies and tissue deficiencies that can be successfully reconstructed with free tissue transfer using an entirely intraoral approach to the recipient facial vessels, resulting in no visible scars on the face and an improvement in the overall aesthetic outcome.

The Impact of Chemotherapy on Complications Associated with Mastectomy and Immediate Autologous Tissue Reconstruction.

We performed this study to evaluate the impact of chemotherapy on the outcomes associated with immediate autologous tissue reconstruction (IATR) in the treatment of breast cancer. Patients were divided into two groups: Group 1 received chemotherapy before surgery and Group 2 did not receive chemotherapy. Records were reviewed to identify demographics, comorbidities, histology, and wound healing complications. Groups were compared using Kruskal-Wallis and Fisher exact tests as appropriate. A total of 128 patients were identified: 29 received chemotherapy before surgery (Group 1) and 99 did not receive chemotherapy (Group 2). Group 1 patients were more likely to have diabetes 27 per cent versus 6 per cent (P = 0.005) despite both groups having a mean body mass index of 30. Group 2 patients had less advanced stage disease as expected because they did not receive chemotherapy; 37 per cent of Group 2 patients had stage 0 breast cancer (P < 0.001). The incidence of wound complications was 17 per cent in Group 1 and 12 per cent in Group 2 (P = NS). Preoperative chemotherapy for breast cancer followed by IATR was associated with no increased risk of healing complications. IATR can be offered to patients who require preoperative chemotherapy, and their healing will not be impaired as a result of the chemotherapy.

Multilocular True Ulnar Artery Aneurysm in a Pediatric Patient.

Ulnar artery aneurysms are an exceedingly rare entity in the pediatric population and have no consistent etiologic mechanism. We present the case of a 15-year-old male with a multilocular ulnar artery aneurysm in the setting of no antecedent history of trauma, no identifiable connective tissue disorders, and no other apparent etiological factors. Furthermore, the patient's arterial palmar arch system was absent. The aneurysm was resected, and arterial reconstruction was successfully performed via open surgical approach with cephalic vein interposition graft. We believe this treatment modality should be considered as the primary approach in all of these pediatric cases in consideration of the possible pitfalls of less comprehensive measures.

Expanding the Applications of the Profunda Artery Perforator Flap.

BACKGROUND: The profunda artery perforator free flap has not gained traction for nonbreast reconstruction, likely because of the presence of a proven workhorse in the anterolateral thigh flap. The authors believe that the profunda artery perforator flap offers similar coverage characteristics with the benefits of a medial donor site, a more consistent anatomy, and relatively easy dissection. The authors review their indications, technique, and outcomes in seven patients requiring eight free flap reconstructions. METHODS: The authors applied the use of the vertically oriented profunda artery perforator flap to both lower extremity and head and neck reconstructions in which an anterolateral thigh flap would normally have been used. Details reviewed include soft-tissue defect, perforator location, flap size, recipient vessel, and complications. RESULTS: Eight soft-tissue defects were covered with a vertically oriented profunda artery perforator flap in seven patients. Six reconstructions were for distal lower extremity and two were for head and neck reconstruction, both trauma and oncologic reconstructions. Flap sizes ranged from 40 to 92 cm. The pedicle length ranged from 7 to 10 cm. There were no partial or complete flap losses. One complication of seroma at the donor site requiring washout and closure was encountered. CONCLUSIONS: The profunda artery perforator flap is a safe and effective option for perforator-based free flap reconstruction with relative ease of harvest and an inconspicuous donor site. This flap offers an excellent alternative to the anterolateral thigh flap. In certain patient demographics, the profunda artery perforator flap should be considered as a primary option. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Fetal surgery: the ochsner experience with in utero spina bifida repair.

BACKGROUND: Myelomeningocele is the most common form of congenital central nervous system defect that is compatible with life. Most patients with myelomeningocele have significant functional impairment of ambulation and bowel and bladder function, require permanent cerebrospinal fluid diversion with shunting, and have significant morbidity and mortality from hindbrain herniation (Chiari II malformation). The advent of intrauterine surgery has provided new opportunities to better address this lifelong debilitating disease. CASE REPORT: The patient was a 19-year-old gravida 2 para 1 at 22-6/7 weeks whose fetus was diagnosed with an open neural tube defect and further demonstrated to have ventriculomegaly and hindbrain herniation. Amniocentesis confirmed normal karyotype and the presence of acetylcholinesterase. After an intrauterine procedure, the patient underwent cesarean section at 35-5/7 weeks and delivered a male infant. His spinal incision was well healed at birth without any evidence of cerebrospinal fluid leakage, and his extremities were normal in appearance, range of motion, and movement. The infant also has maintained relatively normal, age-appropriate bowel and bladder function and has no obvious neurologic deficit. CONCLUSION: As the benefit of fetal surgery becomes more widely accepted, quality of care and patient safety must be at the forefront of any institution's effort to offer fetal surgery. Given the current prevalence of spina bifida and the amount of resources required to treat this disease effectively either in utero or postnatally, it is our opinion that the treatment of spina bifida should be regionalized to tertiary referral centers with the interdisciplinary expertise to offer comprehensive treatment for all aspects of the disease and all phases of care for the patients.

Localization of the dominant deep inferior epigastric artery perforator by computed tomography angiogram: does the standard deep inferior epigastric artery perforator flap design include the dominant perforator?

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) free flap is the optimal autogenous reconstructive technique in many patients undergoing postmastectomy. Our aim was to evaluate the standard DIEP free flap design in relation to the dominant perforating vessels using computed tomography angiography (CTA). METHODS: We retrospectively reviewed CTAs from 75 patients who had undergone perforator flap reconstruction within the past year. Locations of the largest perforator with a minimum diameter of 2.0 mm piercing the anterior rectus fascia were recorded. RESULTS: Of 150 hemiabdomens reviewed, 146 (97.3%) had a dominant perforator. The median location for the dominant perforator was 3.3 cm lateral and 0.9 cm below the umbilicus. One hundred twenty-one (83%) of the dominant perforators arose within 3 cm of the umbilicus. One hundred one (69%) arose at or below the level of the umbilicus. Forty-five (31%) arose above the level of the umbilicus. Thirteen (9%) arose more than 2 cm above the umbilicus. CONCLUSIONS: The standard DIEP flap design incorporates most of the dominant perforating vessels. However, a significant number of perforators arise at or above the umbilicus, which would be near the edge or out of the standard design of the DIEP. Our findings support the use of preoperative CTA in the evaluation of patients undergoing DIEP free flap reconstruction. Modification of flap design to include the dominant perforating vessels should be considered when the dominant vessel is outside the standard design of the DIEP.

Posterolateral skull base reconstruction using the supraclavicular artery island flap.

The supraclavicular artery island (SAI) flap is a viable fasciocutaneous option for the reconstruction of head and neck defects. Although authors have reported success using SAI flaps for various reconstructive indications, concerns of a tenuous blood supply and distal ischemia have previously limited its use in the posterolateral skull base. This case series reports the outcomes of 5 consecutive patients receiving SAI flaps for posterolateral skull base reconstruction. All flaps were harvested in less than 1 hour with primary closure of all donor sites. A single patient developed superficial necrosis of the distal flap, which was repaired with a full-thickness skin graft. There were no other complications, and no donor site morbidity was observed. The SAI flap is an excellent option for the reconstruction of posterolateral skull base defects. The close color match, easy harvest within 1 hour, lack of microsurgical anastomosis, and absence of donor site morbidity support its continued utilization.

Long-term culture of human gingival keratinocyte progenitor cells by down-regulation of 14-3-3 sigma.

Human gingival keratinocytes in culture stop proliferating after a limited number of passages. This limitation is associated with a gradual depletion of the stem cell compartment of the cell population. Human skin keratinocytes have a three- to five-fold higher proliferation capacity under similar culture conditions, and previous studies indicated that stable down-regulation of the 14-3-3 sigma protein in these cultures prevents stem cell differentiation and generates immortal cell lines without the effects of tumorigenic transformation, e.g., genotypic alterations. In this report, we demonstrate the creation of an immortalized human gingival keratinocyte stem cell line by stable down-regulation of the 14-3-3 sigma protein. Keratinocyte cultures were generated from human subjects ranging from 17 to 92 years of age and retrovirally transduced with a 14-3-3 sigma antisense RNA expression construct. In contrast to the control cultures, which propagated for only 2-5 passages and 25-35 cell doublings, the 14-3-3 sigma-transduced cultures propagated for 11 passages and 110 cell doublings so far. The percentage of stem cells measured by clonal analysis, which gradually decreased in the control cultures, increased to a steady level of over 90% in the 14-3-3 sigma down-regulated culture. This gingival keratinocyte stem cell line and others, which can be generated using the same procedure, have the potential to be useful for studies on stem cell differentiation, for developing gene therapy procedures that target the gingival epithelium, as well as a stable platform for testing oral hygiene products and as potential material for preprosthetic surgery.