Canadian Postoperative Dependency Protocols Following Lower Limb Microvascular Reconstruction: A National Survey and Literature Review.

INTRODUCTION: Microsurgical free tissue transfer for lower limb reconstruction presents unique challenges in the postoperative period where dependency promotes interstitial fluid diffusion and reduced tissue perfusion. Management of flap edema, venous congestion, and ischaemic conditioning is critical for flap survival. Little evidence exists to guide postoperative protocols in the initiation and progression of lower extremity dangle, monitoring, and anticoagulation. We aim to describe current trends for postoperative dependency protocols by surveying Canadian microsurgeons. METHODS: Plastic surgeons performing lower limb microvascular reconstruction at Fellow of The Royal College of Surgeons of Canada approved teaching institutions were administered a 17-question anonymous electronic survey. A literature review was conducted to identify protocols and consensus opinions in other jurisdictions. RESULTS: All respondents (n = 16) monitored flaps clinically, with conventional Doppler used by 13 respondents. Anticoagulation was employed by 15 of 16 respondents, and 9 of 16 used 2 or more agents. The most common agents were aspirin, followed by low-molecular-weight heparin. Significant variability existed in dangling protocols. Dependency was initiated at postoperative day (POD) 3 to 10 (mean POD: 6 ± 1.64 standard deviation), with intervals ranging from 5 to 20 minutes and frequencies ranging from 1 to 6 times per day. Nearly half allowed both increasing duration and frequency of dependency. Flap success rates were above 90%, and the median length of stay was 10 to 12 days. CONCLUSION: While flap success rates across the country are similar, no consensus exists for postoperative dependency protocols amongst Canadian microsurgeons. Prospective randomised controlled trials are warranted to evaluate early aggressive dependency protocols to reduce length of stay and cost.

INTRODUCTION: Le transfert microchirurgical de tissus libres pour la reconstruction des membres inférieurs comporte des défis particuliers pendant la période postopératoire, où la dépendance entraîne la diffusion de liquide interstitiel et une perfusion réduite des tissus. Il est essentiel de prendre en charge l'œdème du lambeau, la congestion veineuse et le conditionnement ischémique pour assurer la survie du lambeau. Il existe peu de données probantes pour orienter les protocoles postopératoires sur l'initiation et la progression du ballottement, la surveillance et l'anticoagulation des extrémités inférieures. Les chercheurs ont décrit les tendances actuelles des protocoles de dépendance postopératoire après avoir sondé les microchirurgiens canadiens. MÉTHODOLOGIE: Les plasticiens qui effectuent des reconstructions microvasculaires des membres inférieurs aux établissements universitaires approuvés par le CRMCC ont reçu un sondage électronique anonyme de 17 questions. Les chercheurs ont effectué une analyse bibliographique pour établir les protocoles et les opinions consensuelles des autres territoires de compétence. RÉSULTATS: Tous les répondants (n=16) surveillaient les lambeaux en clinique. Treize répondants utilisaient le Doppler classique, 15, l'anticoagulation et neuf, au moins deux agents. Les agents les plus utilisés étaient l'aspirine, suivie de l'héparine de bas poids moléculaire. Les protocoles de ballotement variaient considérablement. La dépendance postopératoire se manifestait entre trois et dix jours après l'opération (dépendance postopératoire moyenne de 6 ± 1,64 d'écart-type), les intervalles se situant entre cinq et 20 minutes et la fréquence, entre une et six fois par jour. Près de la moitié favorisait à la fois une plus longue durée et une plus grande fréquence de dépendance. Le taux de réussite des lambeaux dépassait les 90%, et l'hospitalisation médiane était de dix à 12 jours. CONCLUSION: Le taux de succès des lambeaux est semblable partout au pays, mais il n'y a pas de consensus sur les protocoles de dépendance postopératoire chez les microchirurgiens canadiens. Il faudra procéder à des essais aléatoires et contrôlés prospectifs pour évaluer des protocoles énergiques précoces qui réduiront la durée de l'hospitalisation et le coût.

Surgical outcomes of VRAM versus gracilis flaps for the reconstruction of pelvic defects following oncologic resection✰.

PURPOSE: Pelvic reconstruction following abdominoperineal resection or pelvic exenteration is associated with signification surgical site morbidity. Immediate pelvic reconstruction with a muscle flap is now the gold standard, associated with reduced perineal morbidity compared to primary closure alone.2,3 The purpose of the present study was to directly compare outcomes of VRAM and gracilis flap pelvic reconstruction following oncologic resection. METHODS: A multicenter retrospective review was performed of 88 patients who underwent abdominoperineal resection or pelvic exenteration and immediate pelvic reconstruction, either with a VRAM (N = 61) or Gracilis flap (N = 27). Electronic medical records were analyzed for patient demographics, intraoperative data, and postoperative outcomes. Mortality, minor complication rate, major complication rate and time to complete wound healing was compared between groups. RESULTS: Overall, there was no significant difference in the minor complication rate (44% gracilis vs 48% VRAM, p = 0.8), major complication rate (19% gracilis vs 13% of VRAM, p = 0.53), 30-day mortality (0% VRAM vs 0% gracilis, p = 1.0) and median time to complete wound healing (68 days vs 67 days, p = 0.19) between the gracilis and VRAM groups. Muscle-only gracilis flaps had a significantly reduced healing time compared to musculocutaneous gracilis flaps (48 days vs 85 days, p = 0.007). CONCLUSIONS: The workhorse flap in pelvic reconstruction remains the VRAM. While previous studies have alluded to the inferiority of thigh based flaps compared to the VRAM, we demonstrate here that pelvic reconstruction with the gracilis flap can be performed with comparable donor and recipient complication rates and similar time to complete wound healing as the VRAM.

The Use of Neuronavigation as an Adjunct in Facial Reconstructive Surgery.

Neuronavigation, a ubiquitous tool used in neurosurgery, is rarely used in maxillofacial reconstructive surgery despite it offering many advantages without any disadvantage to the patient. The present report describes one patient with complex gun-shot wound facial injury and one patient with a rare malignant peripheral nerve sheath tumor involving the skull base, in which neuronavigation was used to improve the accuracy of bony reduction and minimize surgical invasiveness. Although neuronavigation is not necessary for all maxillofacial surgery, it can be a useful adjunct in complex maxillofacial reconstruction and maxillofacial tumor resection.

Long-term outcomes and patient satisfaction following wrist ganglion aspiration.

BACKGROUND: There is a strong body of evidence addressing short-term outcomes following wrist ganglion aspiration; however, few studies have investigated long-term outcomes and patient satisfaction. OBJECTIVE: To evaluate patient satisfaction and the long-term rate of recurrence following wrist ganglion aspiration. METHODS: Charts of all patients with a wrist ganglion treated by a single surgeon from 2001 to 2011 were reviewed. Demographic and clinical data were retrieved from patient charts. Patients were contacted by telephone and asked to complete a questionnaire addressing recurrence, satisfaction and symptom improvement. Improvement was assessed using a Likert scale, with 1 indicating 'significantly worse' and 5 indicating 'significantly improved'. Statistical analysis was performed using Pearson χ(2), Mann-Whitney-Wilcoxon and Fisher's exact tests. RESULTS: Forty-one consecutive patients were identified using hospital records; 21 (51%) consented to the telephone questionnaire. There were no differences in demographic or clinical data between patients who completed the telephone questionnaire and those who did not. The mean age at treatment was 45.3 years, mean time to follow-up was 6.3 years and 52.4% of ganglions recurred. Overall, 95% (20 of 21) of patients were satisfied with their treatment and would proceed again given the option; satisfaction was independent of recurrence. Following treatment, there was improvement in pain, function, range of motion and appearance; improvement in symptoms was independent of recurrence. CONCLUSIONS: Long-term recurrence of ganglions treated with aspiration appeared to be similar to the short-term rates reported in the literature. Independent of recurrence, patients remained satisfied with aspiration and reported improvement in symptoms.

HISTORIQUE: Les résultats à court terme de l'aspiration de ganglions sont bien étayés, mais peu d'études traitent des résultats à long terme et de la satisfaction des patients. OBJECTIF: Évaluer la satisfaction des patients et le taux de récurrence à long terme après l'aspiration de ganglions du poignet. MÉTHODOLOGIE: Les chercheurs ont examiné le dossier de tous les patients qui avaient un ganglion du poignet et avaient été traités par un même chirurgien entre 2001 et 2011. Ils ont extrait les données démographiques et cliniques de leur dossier. Ils les ont appelés et leur ont demandé de répondre à un questionnaire sur la récurrence, la satisfaction et la diminution des symptômes. Ils ont évalué cette diminution d'après l'échelle de Likert, 1 signifiant « bien pire ¼ et 5 « bien mieux ¼. Ils ont procédé à l'analyse statistique à l'aide du test du chi carré de Pearson, du test de Mann-Whitney-Wilcoxon et de la méthode exacte de Fisher. RÉSULTATS: Les chercheurs ont repéré 41 patients consécutifs dans les dossiers hospitaliers, dont 21 (51 %) ont consenti au questionnaire téléphonique. Ils n'ont relevé aucune différence démographique ou clinique entre les patients qui avaient rempli le questionnaire téléphonique et ceux qui ne l'avaient pas rempli. Les patients avaient un âge moyen de 45,3 ans au traitement, ont été suivis en moyenne 6,3 ans, et 52,4 % des ganglions ont récidivé. Dans l'ensemble, 95 % des patients (20 sur 21) étaient satisfaits de leur traitement et se seraient fait réopérer si on le leur avait proposé. Leur satisfaction était indépendante des récurrences. Après le traitement, la douleur diminuait et la fonction, l'amplitude de mouvements et l'apparence s'amélioraient. Cette diminution des symptômes était indépendante des récurrences. CONCLUSIONS: La récurrence à long terme des ganglions traités par aspiration semblait similaire aux taux à court terme publiés. Qu'ils présentent ou non une récurrence, les patients étaient satisfaits de l'aspiration et signalaient une diminution des symptômes.

Wrist ganglion treatment: systematic review and meta-analysis.

PURPOSE: To review the clinical outcomes of treatment for adult wrist ganglions and to conduct a meta-analysis comparing the 2 most common options: open surgical excision and aspiration. METHODS: The review methodology was registered with PROSPERO. We performed a systematic search of MEDLINE and EMBASE for articles published between 1990 and 2013. Included studies reported treatment outcomes of adult wrist ganglions. Two independent reviewers performed screening and data extraction. We evaluated the methodological quality of randomized controlled trials (RCT) and cohort studies using the Cochrane Handbook for Systematic Reviews and the Newcastle-Ottawa Scale, respectively; Grading of Recommendations, Assessment, Development, and Evaluation was used to evaluate the quality of evidence. RESULTS: A total of 753 abstracts were identified and screened; 112 full-text articles were reviewed and 35 studies (including 2,239 ganglions) met inclusion criteria for data extraction and qualitative synthesis. Six studies met criteria for meta-analysis, including 2 RCTs and 4 cohort studies. In RCTs surgical excision was associated with a 76% reduction in recurrence compared with aspiration. Randomized controlled trial quality was moderate. In cohort studies surgical excision was associated with a 58% reduction in recurrence compared with aspiration. Cohort study quality was very low. In cohort studies aspiration was not associated with a significant reduction in recurrence compared with reassurance. Across all studies mean recurrence for arthroscopic surgical excision (studies, 11; ganglions, 512), open surgical excision (studies, 14; ganglions, 809), and aspiration (studies, 12; ganglions, 489) was 6%, 21%, and 59%, respectively. Mean complication rate for arthroscopic surgical excision (studies, 6; ganglions, 221), open surgical excision (studies, 6; ganglions, 341), and aspiration (studies, 3; ganglions, 134) was 4%, 14%, and 3%, respectively. CONCLUSIONS: Open surgical excision offers significantly lower chance of recurrence compared with aspiration in the treatment of wrist ganglions. Arthroscopic excision has yielded promising outcomes but data from comparative trials are limited and have not demonstrated its superiority. Further RCTs are needed to increase confidence in the estimate of effect and to compare complications and recovery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Management of the radial forearm free flap donor site using a topically applied tissue expansion device.

BACKGROUND: The purpose of this study was to prospectively assess clinical outcomes in patients undergoing a new method of donor site management for radial forearm free flaps. METHODS: 177 patients underwent reconstruction of ablative defects of the head and neck using a radial forearm free-flap. All patients had topical tissue expansion tapes applied to their forearms preoperatively. Closure rates, healing time and complications associated with the technique were assessed. RESULTS: Ninety-five percent of patients had their donor sites closed primarily with a locally harvested full thickness skin graft. Complications related to the tissue expansion device included a loss of device adhesion (19.3%) requiring reapplication and minor pruritic reactions (4.1%). CONCLUSIONS: This system of donor site management has resulted in a significant reduction in the requirement of a split thickness skin graft for coverage of the donor site in a radial forearm free flap without any significant economic cost or patient morbidity.

Healing time of radial forearm free flap donor sites after preoperative tissue expansion: randomized controlled trial.

OBJECTIVE: The objective of this study is to test the hypothesis that using a simple and inexpensive preoperative tissue expansion device for radial forearm free flap donor sites will result in a significant reduction in healing time and reduced postoperative pain compared to unexpanded radial forearm free flap donor site skin. METHODS: Twenty-nine patients were enrolled and randomized to either the treatment (tissue pre-expansion) or the control group. An intention-to-treat analysis was used. Healing time was recorded for all patients. The Short Form McGill Pain Questionnaire was used to record arm pain and overall surgical pain 1 week postsurgery. RESULTS: The mean (95% CI) healing time was 5.7 (3.9-7.6) days for the treatment group and 32.5 (12.2-53.0) days for the control group (p < .001). Overall surgical pain (p < .001) was significantly lower in the treatment group. There was no significant difference in donor site arm pain (p < .2). CONCLUSION: Using a simple, noninvasive method of preoperative tissue expansion results in both clinically and statistically significant reductions in healing time and postoperative pain.

Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.

BACKGROUND: Over 70% of Canadian carpal tunnel syndrome (CTS) operations are performed outside of the main operating room (OR) with field sterility and surgeon-administered pure local anesthesia [LeBlanc et al., Hand 2(4):173-8, 14]. Is main OR sterility necessary to avoid infection for this operation? This study evaluates the infection rate in carpal tunnel release (CTR) using minor procedure room field sterility. METHODS: This is a multicenter prospective study reporting the rate of infection in CTR performed in minor procedure room setting using field sterility. Field sterility means prepping of the hand with iodine or chlorhexidine, equivalent of a single drape, and a sterile tray with modest instruments. Sterile gloves and masks are used, but surgeons are not gowned. No prophylactic antibiotics are given. RESULTS: One thousand five hundred four consecutive CTS cases were collected from January 2008 to January 2010. Six superficial infections were reported and four of those patients received oral antibiotics. No deep postoperative wound infection was encountered, and no patient required admission to hospital, incision and drainage, or intravenous antibiotics. CONCLUSIONS: A superficial infection rate of 0.4% and a deep infection rate of 0% following CTR using field sterility confirm the low incidence of postoperative wound infection using field sterility. This supports the safety and low incidence of postoperative wound infection in CTR using minor procedure field sterility without prophylactic antibiotics. The higher monetary and environmental costs of main OR sterility are not justified on the basis of infection for CTR cases.

Cosmetic and functional outcomes after preoperative tissue expansion of radial forearm free flap donor sites: a cohort study.

INTRODUCTION: The use of the DynaClose topical tissue expansion device for closure of radial forearm free flap (RFFF) donor sites has been demonstrated to significantly reduce healing time and postoperative pain compared to the traditional use of a split-thickness skin graft. However, long-term cosmetic and functional outcomes are not known. OBJECTIVE: The objective of this study was to test the hypothesis that using a new method of donor site management will result in improved cosmesis of RFFF donor sites as assessed by both patients and expert observers without resulting in a reduction in the function of the patients' forearm. METHODS: A cohort of 25 patients previously randomized to either the treatment (tissue expansion) or the control group were assessed at 10 months. The Patient and Observer Scar Assessment Scale (PAOSAS) was used to assess forearm scars, whereas the Michigan Hand Outcomes Questionnaire assessed hand function. RESULTS: Expert observers noted improved scar cosmesis in the treatment group (p  =  .013), with primary closure having the best cosmetic outcome, followed by local full-thickness skin graft closure (p < .001). There was no statistically significant improvement in cosmesis as assessed by patients (p  =  .03) or differences in Michigan Hand Outcomes Questionnaire scores between treatment groups (p  =  .57). CONCLUSION: Using an inexpensive, noninvasive preoperative tissue expansion device safely results in improved cosmetic outcomes as assessed by expert observers, without any significant functional forearm and hand deficits.

Reduction of donor site morbidity in the radial forearm free flap by use of topical tissue expanders.

OBJECTIVE: The objective of this study was to significantly reduce the donor site morbidity associated with use of the radial forearm free flap (RFFF). DESIGN: A pilot study to test the feasibility of topical tissue expanders to close the RFFF donor site. SETTING: The setting was a tertiary care teaching hospital. METHODS: This pilot study consisted of a series of 21 cases that used topical tissue expanders to preoperatively expand the forearm skin. This allowed primary closure of the donor site and, in some cases, closure with a full-thickness skin graft. MAIN OUTCOME MEASURE: The main outcome measure was the ability to close the RFFF donor site without the use of a partial-thickness skin graft from the lateral thigh. Secondary outcome measures were the postoperative appearance of the donor site wound and function of the forearm. RESULTS: Twenty-one cases were treated with the preoperative tissue expanders. It was possible to close the donor site without a partial-thickness skin graft from the thigh in 17 of these patients (81%). None of these patients experienced prolonged functional disability or serious complications. CONCLUSIONS: The use of preoperative topical tissue expanders has the potential to significantly improve donor site morbidity in the RFFF.

Management of open abdominal wounds with a dynamic fascial closure system.

BACKGROUND: In damage-control surgery, definitive abdominal closure may not be possible for several days or weeks after laparotomy until the patient has stabilized. METHODS: We present 23 patients treated with the Canica ABRA dynamic wound closure system that re-approximated open abdomens with silicone elastomers placed transfascially across the wound. This study aimed to assess the results of using this system and to identify risk factors for unsuccessful closure. The system maintains a medially directed force across the wound. A traditional regimen of wound dressing changes was performed. RESULTS: The dynamic closure system remained in place an average of 48 days and was applied an average of 18 days after the beginning of treatment for the open abdominal wound. Delayed primary fascial closure was achieved in 14 of 23 patients (61%) without further surgery. Six patients (26%) healed with ventral hernias but with a smaller abdominal defect. Two patients (9%) developed enterocutaneous fistulae through the wound that required further surgery. An overall reduction in wound area of 95% was achieved. CONCLUSION: This dynamic wound closure technique permitted the delayed primary closure of open abdomens in 61% of cases when treatment was instituted an average of 18 days after initial laparotomy.

Adipogenic and antiapoptotic protein levels in human adipose stromal cells after weight loss.

OBJECTIVE: Obesity is a major risk factor for type 2 diabetes and cardiovascular disease. However, current strategies to achieve sustained weight loss are often unsuccessful. Fat reaccumulation might be favored by enhanced adipose cell differentiation or survival in the postreduced state. RESEARCH METHODS AND PROCEDURES: We measured adipogenic and apoptotic protein expression in subcutaneous abdominal adipose stromal-vascular cells from 10 obese patients (7 women and 3 men) that were obtained before and after a 16% weight loss in a medically supervised weight loss program. RESULTS: After weight loss, protein expression was 2.4-fold higher (p < 0.005) for p42 C/CAAT enhancer binding protein alpha, but there was no change for peroxisome proliferator-activated receptor gamma1; both of these are adipogenic regulators. For neuronal apoptosis inhibitory protein, a protein associated with adipose cell apoptotic resistance, there was a rise of 1.7-fold (p < 0.02). DISCUSSION: Alterations in C/CAAT enhancer binding protein alpha and neuronal apoptosis inhibitory protein expression occurred in human adipose stromal-vascular cells after weight loss in a pilot study of 10 patients. It will be important for future studies to directly examine whether the adipogenic and antiapoptotic capacity of these cells is changed after weight loss.