The First Successful Combined Full Face and Bilateral Hand Transplant.

BACKGROUND: Vascularized composite allotransplantation has redefined the frontiers of plastic and reconstructive surgery. At the cutting edge of this evolving paradigm, the authors present the first successful combined full face and bilateral hand transplant. METHODS: A 21-year-old man presented for evaluation with sequelae of an 80 percent total body surface area burn injury sustained after a motor vehicle accident. The injury included full face and bilateral upper extremity composite tissue defects, resulting in reduced quality of life and loss of independence. Multidisciplinary evaluation confirmed eligibility for combined face and bilateral hand transplantation. The operative approach was validated through 11 cadaveric rehearsals utilizing computerized surgical planning. Institutional review board and organ procurement organization approvals were obtained. The recipient, his caregiver, and the donor family consented to the procedure. RESULTS: Combined full face (i.e., eyelids, ears, nose, lips, and skeletal subunits) and bilateral hand transplantation (i.e., forearm level) was performed over 23 hours on August 12 to 13, 2020. Triple induction and maintenance immunosuppressive therapy and infection prophylaxis were administered. Plasmapheresis was necessary postoperatively. Minor revisions were performed over seven subsequent operations, including five left upper extremity, seven right upper extremity, and seven facial secondary procedures. At 8 months, the patient was approaching functional independence and remained free of acute rejection. He had significantly improved range of motion, motor power, and sensation of the face and hand allografts. CONCLUSIONS: Combined face and bilateral hand transplantation is feasible. This was the most comprehensive vascularized composite allotransplantation procedure successfully performed to date, marking a new milestone in plastic and reconstructive surgery for patients with otherwise irremediable injuries.

Impact of Diabetes on 30-Day Complications in Mastectomy and Implant-Based Breast Reconstruction.

BACKGROUND: Diabetic patients are known to be at increased risk of postoperative complications after multiple types of surgery. However, conflicting evidence exists regarding the association between diabetes and wound complications in mastectomy and breast reconstruction. This study evaluates the impact of diabetes on surgical outcomes after mastectomy procedures and implant-based breast reconstruction. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database review from 2010 to 2015 identified patients undergoing total, partial, or subcutaneous mastectomy, as well as immediate or delayed implant reconstruction. Primary outcomes included postoperative wound complications and implant failure. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Multivariate regression was used to control for confounders. RESULTS: The following groups were identified: partial (n = 52,583), total (n = 41,540), and subcutaneous mastectomy (n = 3145), as well as immediate (n = 4663) and delayed (n = 4279) implant reconstruction. Diabetes was associated with higher rates of superficial incisional surgical site infection (SSI) in partial mastectomy (odds ratio [OR] = 8.66; P = 0.03). Diabetes was also associated with higher rates of deep incisional SSI (OR = 1.61; P = 0.01) in subcutaneous mastectomy and both superficial (OR = 1.56; P = 0.04) and deep incisional SSI (OR = 2.07; P = 0.04) in total mastectomy. Diabetes was not associated with any wound complications in immediate reconstruction but was associated with higher rates of superficial incisional SSI (OR = 17.46; P < 0.001) in the delayed reconstruction group. There was no association with implant failure in either group. CONCLUSIONS: Evaluation of the largest national cohort of mastectomy and implant reconstructive procedures suggests that diabetic patients are at significantly increased risk of 30-d postoperative infectious wound complications but present no difference in rates of early implant failure.

Diabetes is not associated with increased rates of free flap failure: Analysis of outcomes in 6030 patients from the ACS-NSQIP database.

BACKGROUND: Diabetes affects a significant proportion of the population in the United States. Microsurgical procedures are common in this patient population, and despite many conflicting reports in the literature, there are no large studies evaluating the direct association between diabetes and outcomes, specifically failure, following free flap reconstruction. In this study, we sought to determine the impact of diabetes on postoperative outcomes following free flap reconstruction using a national multi-institutional database. METHODS: We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients undergoing free flap reconstruction from 2010 to 2015. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Univariate and multivariate analyses were performed to control for confounders. RESULTS: We identified 6030 eligible patients. No significant difference in flap failure rates was observed. However, diabetic patients presented significantly higher rates of wound complications, including deep incisional surgical site infection (SSI) (OR = 1.35; P = .01) and wound dehiscence (OR = 1.17; P = .03). Diabetic patients also presented a significantly longer hospital length of stay (LOS) (ß = .62; P < .001). CONCLUSIONS: Our study evaluated the largest national cohort of free flap procedures. These results suggest that diabetes is not associated with increased rates of flap failure. However, diabetic patients are at significantly higher risk of postoperative deep incisional SSI, wound dehiscence, and longer LOS. Our findings provide the most concrete evidence to date in support of free flap reconstruction in diabetic patients, but highlight the need for heightened clinical vigilance and wound care for optimal outcomes.

Abdominal Panniculectomy: Determining the Impact of Diabetes on Complications and Risk Factors for Adverse Events.

BACKGROUND: The prevalence of obesity along with bariatric surgery and massive weight loss requiring panniculectomy is increasing in the United States. The effect of diabetes mellitus on outcomes following panniculectomy remains poorly defined despite its prevalence. This study aims to evaluate the impact of diabetes mellitus on complications following panniculectomy and determine risk factors for adverse events. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients undergoing panniculectomy between 2010 and 2015. Patients were stratified based on diabetes status. RESULTS: Review of the database identified 7035 eligible patients who underwent panniculectomy, of which 770 (10.9 percent) were diabetic. Multivariate regression showed that diabetes mellitus was a significant risk factor for wound dehiscence (OR, 1.92; 95 percent CI, 1.41 to 3.15; p = 0.02). Obesity was a significant risk factor for superficial (OR, 2.78; 95 percent CI, 1.53 to 3.69; p < 0.001) and deep (OR, 1.52; 95 percent CI, 1.38 to 3.97; p = 0.01) incisional surgical-site infection. Smokers were also at an increased risk for superficial (OR, 1.42; 95 percent CI, 1.19 to 1.75; p = 0.03) and deep (OR, 1.63; 95 percent CI, 1.31 to 2.22; p = 0.02) incisional surgical-site infection. CONCLUSIONS: Diabetes mellitus is an independent risk factor for wound dehiscence following panniculectomy. Obesity and smoking were significant risk factors for superficial and deep incisional surgical-site infection. These results underscore the importance of preoperative risk factor evaluation in patients undergoing panniculectomy for safe outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Carpal Tunnel Syndrome Following Corrective Osteotomy for Distal Radius Malunion: A Rare Case Report and Review of the Literature.

BACKGROUND: Although median nerve neuropathy and carpal tunnel syndrome (CTS) are known complications of both untreated and acutely treated distal radius fracture, median neuropathy after correction of distal radius malunion is not commonly reported in hand surgery literature. We describe a patient with severe CTS after corrective osteotomy, open reduction internal fixation (ORIF) with a volar locking plate (VLP), and bone grafting for distal radius malunion. METHODS: We report a case of severe acute CTS as a complication of corrective osteotomy with bone grafting for distal radius malunion. RESULTS: The patient was treated with surgical exploration of the median nerve and carpal tunnel release. CONCLUSION: The authors report a case of acute CTS after ORIF with VLP for a distal radius malunion warranting surgical exploration and carpal tunnel release. Treatment teams must be aware of this potential complication so that the threshold for reoperation is low and irreversible damage to the median nerve is prevented.

Aberrant Lower Extremity Arterial Anatomy in Microvascular Free Fibula Flap Candidates: Management Algorithm and Case Presentations.

An accurate and comprehensive understanding of lower extremity arterial anatomy is essential for the successful harvest and transfer of a free fibula osteoseptocutaneous flap (FFF). Minimum preoperative evaluation includes detailed history and physical including lower extremity pulse examination. Controversy exists regarding whether preoperative angiographic imaging should be performed for all patients. Elevation of an FFF necessitates division of the peroneal artery in the proximal lower leg and eradicates its downstream flow. For patients in whom the peroneal artery comprises the dominant arterial supply to the foot, FFF elevation is contraindicated. Detailed preoperative knowledge of patient-specific lower extremity arterial anatomy can help to avoid ischemia or limb loss resulting from FFF harvest. If preoperative angiographic imaging is omitted, careful attention must be paid to intraoperative anatomy. Should pedal perfusion rely on the peroneal artery, reconstructive options other than an FFF must be pursued. Given the complexity of surgical decision making, the authors propose an algorithm to guide the surgeon from the preoperative evaluation of the potential free fibula flap patient to the final execution of the surgical plan. The authors also provide 3 clinical patients in whom aberrant lower extremity anatomy was encountered and describe each patient's surgical course.

Management of Stenosing Flexor Tenosynovitis: Maximizing Nonoperative Success without Increasing Morbidity.

BACKGROUND: Traditional nonoperative management of stenosing tenosynovitis is limited to one corticosteroid injection, followed by surgery in the case of failure. Recently, nonoperative strategies have been extended to include two or three injections despite the absence of large prospective studies supporting this practice. METHODS: A prospective study was performed of all patients presenting with stenosing tenosynovitis to a single surgeon (R.S.R.) over a 22-year period. Patients with potentially confounding comorbidities were excluded. All digits received one to three injections of triamcinolone acetonide plus local anesthetic into the tendon sheath. Data were analyzed by digit. RESULTS: Five hundred seventy-one digits (401 patients) were included. Digits that were symptomatic for 3 months or less were more likely to resolve after one injection than those that were symptomatic for more than 3 months (OR, 2.6; 95 percent CI, 1.67 to 4.0; p < 0.01). For the digits that failed to resolve after the first injection, those that were symptomatic for 5 months or less before one injection were more likely to respond to a second injection than those that were symptomatic for more than 5 months (OR, 9.4; 95 percent CI, 3.0 to 29.7; p < 0.01). Eight digits received three injections, after which six (75 percent) achieved remission. There were no instances of tendon/pulley rupture, infection, or soft-tissue atrophy. CONCLUSIONS: Stenosing tenosynovitis is more likely to respond to nonoperative therapy when treated before 3 months. It is safe and effective to administer more than one corticosteroid injection, as second and third doses increase the overall remission rate without increasing morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Use of an Anastomotic Coupling Device for the Creation of Spliced Autogenous Grafts in Lower Extremity Revascularization.

INTRODUCTION: Despite a recent rise in popularity of endovascular techniques, open bypass surgery is still required for treating many lower extremity vascular lesions. Greater saphenous vein (GSV) of adequate length and caliber for successful infrainguinal lower extremity bypass is unavailable in 15% to 45% of patients. To overcome limitations imposed by absent vein due to prior use, short vessel length, or sclerotic segments, both alternate (ie, basilic and cephalic) and GSV conduits may be "spliced" together in series via venovenostomy. Although vascular surgeons typically perform a hand-sewn venovenostomy, device-based venous coupling has been performed by plastic surgeons for many years. We therefore sought to review our experience with venous coupling for segmental lower extremity bypass graft assembly. METHODS: A retrospective review was performed in all patients who underwent lower extremity revascularization using autogenous vein grafts spliced together with the Synovis (Birmingham, Alabama) anastomotic coupler at a single institution over a 5-year period. RESULTS: The anastomotic coupler device was used on 5 patients for 7 venovenostomies. The mean age of patients was 66 years, and the mean follow-up period was 751 days. Two patients were lost to follow-up, while 2 other patients died of causes unrelated to their lower extremity bypass. The average time to perform venovenostomy was 3 minutes. Three patients developed stenosis of their composite graft at a site other than the venovenostomy, who were successfully treated with either angioplasty or bypass revision. One-year primary and primary-assisted patency rates were 50% and 75%, respectively. CONCLUSIONS: Given the known benefits of the anastomotic coupling device when used for venous anastomoses in microsurgical reconstruction, transition of this device to the vascular surgery realm represents a logical progression. Although small, our series demonstrates that the anastomotic coupler can successfully be used for the formation of spliced autogenous grafts for lower extremity revascularization in the absence of adequate GSV.

Reduction of suture associated inflammation after 28 days using novel biocompatible pseudoprotein poly(ester amide) biomaterials.

Sutures elicit an inflammatory response, which may impede the healing process and result in wound complications. We recently reported a novel family of biocompatible, biodegradable polymers, amino acid-based poly(ester amide)s (AA-PEA), which we have shown to significantly attenuate the foreign body inflammatory response in vitro. Two types of AA-PEA (Phe-PEA and Arg-Phe-PEA) were used to coat silk or plain-gut sutures, which were implanted in the gluteus muscle of C57BL/6 mice, while the uncoated control sutures were implanted in the contralateral side. After 3, 7, 14, and 28 days the mean area of inflammation surrounding the sutures was compared. Phe-PEA coating of silk sutures significantly decreased inflammation compared with noncoated controls (67.8 ± 17.4% after 3d [p = 0.0014], 51.6 ± 7.2% after 7d [p < 0.001], and 37.3 ± 8.3% after 28d [p = 0.0001]) when assessed via analysis of photomicrographs using digital image software. Phe-PEA coated plain-gut sutures were similarly assessed and demonstrated a significant decrease in the mean area of inflammation across all time points (54.1 ± 8.3% after 3 d, 41.4 ± 3.9% after 7 d, 71.5 ± 8.1% after 14 d, 78.4 ± 8.5%, and after 28 d [all p < 0.0001]). Arg-Phe-PEA coated silk demonstrated significantly less inflammation compared to noncoated controls (61.3 ± 9.4% after 3 d, 44.7 ± 4.7% after 7 d, 19.6 ± 8%, and 38.3 ± 6.8% after 28 d [all p < 0.0001]), as did coated plain-gut (37.4 ± 8.3% after 3 d [p = 0.0004], 55.0 ± 7.8% after 7 d [p < 0.0001], 46.0 ± 4.6% after 14 d [p < 0.0001], and 59.0 ± 7.9% after 28 d [p < 0.0001]). Both Phe-PEA and Arg-Phe-PEA coatings significantly decrease the inflammatory response to sutures in vivo for up to 28 days.

Fabrication and in vivo microanastomosis of vascularized tissue-engineered constructs.

Tissue engineering endeavors to create replacement tissues and restore function that may be lost through infection, trauma, and cancer. However, wide clinical application of engineered scaffolds has yet to come to fruition due to inadequate vascularization. Here, we fabricate hydrogel constructs using Pluronic(®) F127 as a sacrificial microfiber, creating microchannels within biocompatible, biodegradable type I collagen matrices. Microchannels were seeded with human umbilical vein endothelial cells (HUVEC) or HUVEC and human aortic smooth muscle cells (HASMC) in co-culture, generating constructs with an internal endothelialized microchannel. Histological analysis demonstrated HASMC/HUVEC-seeded constructs with a confluent lining after 7 days with preservation and further maturation of the lining after 14 days. Immunohistochemical staining demonstrated von Willebrand factor and CD31(+) endothelial cells along the luminal surface (neointima) and alpha-smooth muscle actin expressing smooth muscle cells in the subendothelial plane (neomedia). Additionally, the deposition of extracellular matrix (ECM) components, heparan sulfate and basal lamina collagen IV were detected after 14 days of culture. HUVEC-only- and HASMC/HUVEC-seeded microchannel-containing constructs were microsurgically anastomosed to rat femoral artery and vein and perfused, in vivo. Both HUVEC only and HUVEC/HAMSC-seeded constructs withstood physiologic perfusion pressures while their channels maintained their internal infrastructure. In conclusion, we have synthesized and performed microvascular anastomosis of tissue-engineered hydrogel constructs. This represents a significant advancement toward the generation of vascularized tissues and brings us closer to the fabrication of more complex tissues and solid organs for clinical application.