APPLICATIONS OF VISCOELASTIC TESTING IN MICROSURGERY: A SYSTEMIC REVIEW AND META-ANALYSIS.

Viscoelastic testing including thromboelastography (TEG) and rotational thromboelastometry (ROTEM) has gained increasing popularity across many medical fields in recent years. As TEG/ROTEM testing uses whole blood sample and evaluates interactions between cellular components i.e., platelets, red blood cells and the clotting factors, these evaluations are uniquely capable of assessing coagulation in an in-vitro environment, resembling native conditions unlike those of conventual clotting tests (CCTs). While viscoelastic based protocols and applications are more commonplace in hepatic and cardiac surgery and trauma scenarios, results have attracted the attention of additional disciplines including microsurgery. TEG/ROTEM tests, with their ability to assess real-time risk of excessive bleeding or thrombosis, may be useful in the monitoring of microsurgery patients who may be at an increased risk for flap failure. The following review of TEG/ROTEM testing focuses on the most common applications of these coagulation tests and the evidence that does or does not support such uses. A systematic review and meta-analysis of the current application of TEG/ROTEM in microsurgery is reported along with an emphasis on the future that it might hold for the field.

Selecting a free flap for soft tissue coverage in lower extremity reconstruction.

BACKGROUND: Goals of lower extremity microvascular reconstruction (LEMR) include the restoration of function, prevention of infection, and optimal cosmesis. Indications for LEMR include large defects that are not amenable to pedicled options, a large zone of injury, and large complex defects. The novice microsurgeon should first master a handful of free flaps to develop an armamentarium of options for addressing such defects. The scope of this review is to provide free flap options for LEMR in any of the thirds of the lower leg. After reading this article, the reader will understand variations, advantages, disadvantages, indications, and tips for raising each of these flaps. METHODS: Six most commonly used free flaps for LEMR are described in this paper, including the anterolateral thigh flap (ALT) and its variations, the radial forearm flap (RFFF), the lateral arm flap (LAF), the gracilis muscle flap, the rectus abdominis flap (RAF) and the latissimus dorsi flap and its variations. Indications, advantages, disadvantages and technique tips are discussed for each flap. Moreover, selection of the recipient vessels, preoperative management along with an algorithm are also provided. CONCLUSIONS: The ALT flap is a workhorse in covering defects of the leg, foot, and ankle. It's the flap of choice at our institution, especially given the number of traumatic wounds seen as a result of motor vehicles, all-terrain vehicles (ATV), lawnmowers, and gunshot wounds (GSW). At times, the lower extremity zone of injury requires a distant donor site. The RAF can also provide coverage for large soft tissue defects but donor-site morbidity remains its main drawback. The LAF and RFFF provide two pliable options, one that provides pliable soft tissue with minimal donor site morbidity and another that provides a long pedicle. The free gracilis flap is an excellent choice for crossing the ankle joint. Lastly, the free latissimus dorsi is indicated for large defects of the lower extremity independently of the location.

Microvascular reconstruction of pediatric lower extremity trauma using free tissue transfer.

While free tissue transfer has long been established as a reliable microsurgical technique in the adult population, its application in pediatric reconstruction is a relatively recent phenomenon. Despite initial concerns regarding minute vessel diameters, increased propensity for vasospasm, and limited tissue availability, pediatric free tissue transfer is now a widely used technique that has demonstrated an acceptable level of donor and recipient site morbidity in children. Five flaps commonly used in the reconstruction of lower extremity trauma are discussed in this paper: the latissimus dorsi, rectus abdominis, anterolateral thigh, gracilis, and the subscapular and parascapular flaps. The indications, blood supply, advantages, and disadvantages of each are detailed. Incredible progress has been made in the application of microsurgical techniques to the pediatric population over the last several decades. With a healthy understanding of the anatomy and functionality of the donor site, the reconstructive surgeon can repair a variety of complex injuries with an acceptable morbidity and mortality rate.

Nasal Reconstruction: A Simplified Approach Based on 419 Operated Cases.

BACKGROUND: The purpose of this review is to examine a single surgeon's 10-year experience with nose defects and offer a simplified approach for nasal reconstruction to close most nasal defects following Mohs micrographic surgery (MMS). PATIENTS AND METHODS: A retrospective chart review was performed on patients undergoing repair of MMS defects of the nose over a 10-year period. Data collected included patients' age and sex, anatomic location of the defect, type of reconstruction, and number of operations required. RESULTS: A total of 419 patients were included in this study. The most common location for nasal reconstruction was the nasal dorsum and sidewalls (66.35 %). Complications mainly related to reconstruction of defects of the tip ± ala (n = 31), followed by the ala (n = 15) and the dorsum and sidewalls (n = 13). Bulkiness of the flap used (n = 32) and hypertrophic scar (n = 13) were the most common complications. The bilobed flap was the most commonly used flap (n = 145), followed by nasolabial flap (n = 69), FTSGs (n = 63), forehead flap (n = 62), and dorsal glabellar flap (n = 44). CONCLUSIONS: In this article, a simplified approach for nasal defects reconstruction is presented, which is based on commonly performed local flaps and skin grafting. This algorithm can be useful for the novice plastic surgeons in planning a reconstructive strategy that will be efficient, easy to perform, and produces an acceptable esthetic and functional outcome.

The role of ThinPrep cytology in the investigation of ki-67 index, p53 and HER-2 detection in fine-needle aspirates of breast tumors.

PURPOSE: The aim of the current study was to compare the immunocytochemical expression of ki-67, HER-2 and p53 on ThinPrep (TP)-processed smears, obtained by preoperative fine-needle aspiration (FNA) biopsies from primary breast carcinoma with the immunohistochemical results obtained on the corresponding surgical samples. METHODS: FNA biopsies were collected from 119 female patients during a 31-month period. Subsequently, these patients underwent surgical resection of the tumors. RESULTS: The overall accuracy (OA) of the TP cytology for ki-67, p53 and HER-2 expression was 96, 99 and 97%, respectively. There was a strong positive correlation between immunohistochemistry and immunocytochemistry results for ki-67 (Spearman's test 0.875) for p53 (Cramer's phi test 0.965) and HER-2 (Kendall's tau test 0.891). CONCLUSION: This pilot study demonstrates that it is possible to monitor multiple molecular markers by using the TP cytology. Sample collection and storage is simple and permits the assortment of the FNA sample for both morphologic diagnosis and ancillary studies. The accuracy of TP technique in the evaluation of ki-67, p53 and HER-2 expression is comparable to those of the histological evaluation, and could be of paramount importance for the preoperative planning of treatment.

Nerve repair by means of tubulization: past, present, future.

Peripheral nerve injury may result in injury without gaps or injury with gaps between nerve stumps. In the presence of a nerve defect, the placement of an autologous nerve graft is the current gold standard for nerve restoration. The clinical employment of tubes as an alternative to autogenous nerve grafts is mainly justified by the limited availability of donor tissue for nerve autografts and their related morbidity. The purpose of this review is to present an overview of the literature on the applications of nerve conduits in peripheral nerve repair. Moreover, the different steps that are involved in the design of an ideal nerve conduit for peripheral nerve repair, including the choice of biomaterial, fabrication technique, and the various potential modifications to the common hollow nerve tube, are also discussed.

[Eyelid melanoma: our experience a propos of 23 cases]. / Le mélanome palpébral : notre expérience à propos de 23 cas.

INTRODUCTION: Eyelid melanoma is a rare condition corresponding to less than 1% of all eyelid malignancy. The aim of the current study is to present the experience of our department. PATIENTS AND METHODS: From 1986 to 2009, 972 patients with a melanoma have been studied retrospectively. Each patient was evaluated in relation with age, sex, location of the tumor, histology (Breslow and Clark included), surgical treatment, recurrence, and finally with follow up. RESULTS: Twenty-three patients with eyelid melanoma and a strong female incidence (69.5%) were identified. Median age was 68.3 years. In most cases (71.4%), tumor was located on the right inferior eyelid in continuity with the malar region. LMM had the higher incidence (60.8%), followed by the nodular melanoma (21, 7%) and the SSM. The median Breslow was 0.77 while the median Clark 1.68. Surgery was the treatment of choice including direct closure, the use of full thickness skin graft and local or regional flaps. Three patients had local recurrence associated to nodular metastases in one of them. CONCLUSION: Surgical treatment of eyelid melanoma is a challenge for every reconstructive surgeon. Early detection remains the "gold standard" for every reconstructive option respecting the esthetic and function of this precious anatomic location.

One-stage reconstruction of the antihelix and concha using postauricular island flap.

Tissue defects in the antihelix and the concha due to oncological resection and trauma can be successfully repaired with a subcutaneously based postauricular island flap. Alternative methods of regional reconstruction usually need two stages or may require grafts in some patients. We present the one-stage technique, as described by Masson, without grafts, to provide adequate reconstruction and aesthetic restoration of the area, illustrated by 62 patients. In all patients there has been a follow-up period of 12 months. This report provides evidence for the aesthetic superiority of this method. An excellent aesthetic outcome was achieved in 46 patients, an adequate outcome in 15 patients, and a poor result in only 1 patient. No flap necrosis was observed. The method has considerable advantages for the repair of anterior conchal and antihelical defects.

Management of external ear keloids using form-pressure therapy.

Keloids are a frequent finding after physical trauma. Keloids of the pinna (helix and antihelix) as a complication of ear-piercing are the most difficult cases. Clinicians have tended to avoid the surgical approach, preferring local conservative treatment with corticosteroids or other treatments. We report use of intrakeloid resection and a form-pressure device to treat pinna keloids and avoid recurrence. The purpose is to maintain the form of the folds of the pinna. The recommendation for this therapy is to maintain the pressure at 24-30 mmHg, and the duration of the form-pressure therapy in our patients was about 25 weeks.

The role of ThinPrep cytology in the investigation of SLN status in patients with cutaneous melanoma.

INTRODUCTION: The sentinel lymph node (SLN) biopsy in melanoma assesses reliably the status of the regional lymph node basins, provides valuable prognostic information, facilitates early therapeutic lymphadenectomy and identifies patients who are candidates for different adjuvant treatments. The current study was designed to evaluate the feasibility of cytological specimens being placed in PreservCyt as a practical collection methodology for performing evaluation of the SLN status in patients with melanomas. PATIENTS AND METHODS: From January 2004 to December 2006, 70 patients with histologically confirmed cutaneous melanoma underwent intraoperative FNA biopsy of the SLN. After identification of the SLN(s), FNA biopsy of the SLN was performed with a 0.6 mm (23 gauge) diameter needle. All the SLNs specimens were examined (using light microscopy 40 x and 200 x) by the same pathologist and cytopathologist, neither of had any knowledge of the medical history of the patient. The histological result of the excised SLN was considered as the final diagnosis. RESULTS: The unsatisfactory rate for TP cytology was 2.17%. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy (OA) for the TP technique were 92.31%, 100%, 100%, 97.06%, and 97.83%, respectively. Using TP cytology, there was greater intensity and distribution of the staining in comparison with immunohistochemistry. DISCUSSION: The accuracy of TP technique in the evaluation of the SLN status is comparable to those of the histological evaluation, and could be of paramount importance for the preoperative planning of treatment.

Island vertical trapezius myocutaneous flap procedure under the tumescent technique.

We describe the application of local anesthesia with intravenous sedation for covering a large defect of the upper back with the use of the island vertical trapezius myocutaneous flap to an 85-year-old male. According to the anesthesiologist, the patient was graded as ASA IV. A 200-ml solution which consisted of 0.75 mg xylocaine, 2 mg adrenaline (1/2,000,000) and 10 mmol/l sodium bicarbonate in a physiologic saline solution was used. The total operating time was about 90 min. During the first postoperative 24 h, the flap pedicle was checked every hour by Doppler. The postoperative course of the patient was uneventful. We believe that in selected cases, when microsurgery is not indicated due to the general medical condition of the patient, the combination of the tumescent technique with sedation and the vertical trapezius myocutaneous flap can be considered a reliable and low-risk procedure.

Lip defects due to tumor excision: apropos of 899 cases.

Reconstructive surgery of the lips after resection of tumors requires a complete understanding of the anatomy of this region. Most lip cancers remain localized and grow slowly, with a propensity for superficial rather than vertical spread. From January 1983 to December of 2005, 899 patients underwent reconstructive surgery for skin tumors involving the lips. SCCs were the most frequent skin tumors on male patients whereas BCCs were most common on the female patients. The lower lip was the anatomic zone most frequently involved in our series. Preoperative evaluation of the patients was performed in all cases. In the last five-years, we have performed preoperative fine needle aspiration (FNA) biopsy of the tumor. The FNA sample was then examined by ThinPrep technique (Cytolyt; Cytyc, Co, Boxborough, MA, USA). In our series, from the 550 patients who had a five-year follow-up we observed 62 recurrences of the primary tumor. The five-year recurrence rate was 11.28%. The aim of this retrospective study is to report our experience in the treatment of lips tumors with selective combination of treatment modalities.

A rupture of a huge thymic cyst into the pleural cavity: A case report.

Thymic cysts (TCs) represent 1-2% of all mediastinal masses. To the best of our knowledge transudative effusion due to rupture of a TC into the pleural cavity, as it happened with our patient, has never been described before. The patient was admitted in 5th Department of Respiratory Medicine of "SOTIRIA" Hospital complaining of pleuritic chest pain in the right hemithorax and dyspnea on exertion. Clinical and laboratory examinations indicated a right pleural effusion. Then, the patient was transferred to the 2nd Department of Propedeutic Surgery of 'LAIKO' Hospital where he underwent surgery. Video-assisted thoracic surgery (VATS) revealed an enormous 25-cm cyst ruptured into the right pleural cavity. The cyst was removed by open thoracotomy due to adhesion to contiguous tissues. Pathological examination indicated thymic origins.

The role of ThinPrep cytology in the investigation of lung tumors.

AIMS OF THE STUDY: The aim of this study was to evaluate the role of liquid-based cytology with the ThinPrep (TP) (Cytyc; Cytyc, Co, Boxborough, MA, USA) technique, using fine-needle aspiration (FNA) for sampling, in the investigation of suspicious pulmonary lesions. METHODS: We performed percutaneous computed tomography (CT)-guided FNA biopsy of focal pulmonary lesions in 80 adult patients. Study subjects were all consecutive patients and potential candidates for surgery. The sample was then examined by both conventional smears (CS) and TP techniques. TP smears of all FNA were prepared from needle rinsing obtained following preparation of CS. All cytological diagnoses were correlated with the CS and/or thoracotomy histological diagnoses in order to evaluate the role of liquid-based cytology with the TP technique. RESULTS: Using TP technique diagnosis was successfully established in 75 patients out of 80, whereas using CS cytology diagnosis was established in 54 patients (p<0.001, z=3899). Inadequate material was observed in 5 cases (6.25%) with the TP technique and in 13 cases (16.25%) with the CS technique (z=-2.77, p<0.05). CONCLUSIONS: We believe that the TP technique has a good overall yield for the diagnosis of suspicious for malignant lung lesions. We found that the accuracy of determining lung cancer was excellent.

The role of ThinPrep cytology in the evaluation of estrogen and progesterone receptor content of breast tumors.

INTRODUCTION: The objective of the current study was to analyze the potential value of immunocytochemical analysis on ThinPrep (TP)-processed smears, from fine needle aspiration (FNA) biopsies, of breast tumors for the determination of ER and PR content as compared with the immunohistochemical analysis performed on paraffin-embedded breast tumor specimens. PATIENTS AND METHODS: Percutaneous FNA biopsy of focal breast lesions in 119 female adult patients during a 31-month period was performed. Subsequently, these patients underwent surgical resection of the tumors. ER and PR status of the tumors was determined by immunocytochemical analysis on TP-processed smears and by immunohistochemical studies in paraffin-embedded sections. RESULTS: With the use of TP technique adequate material was observed in all cases. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy (OA) of the TP technique for the ER were 98.95%, 100%, 100%, 95.84% and 99.15% respectively. In addition, sensitivity, specificity, PPV, NPV and OA of the TP technique for the PR were 100%, 87.5%, 95.60%, 100% and 96.64%, respectively. CONCLUSIONS: ER and PR status can be evaluated in FNA material from breast carcinomas by using the TP technique. Sample collection and storage is simple and permits the assortment of the FNA sample for both morphologic diagnosis and ancillary studies. The accuracy of TP technique in the detection of ER and PR content is comparable to those of the histological evaluation, and could be of paramount importance for the preoperative planning of treatment.

Reconstructive surgery for kidney transplant recipients.

Many decades have passed since the first kidney transplantation, which is now the most common organ transplant performed worldwide. Despite the impressive advances, some patients may develop posttransplant complications that require proper management and treatment. The plastic and reconstructive surgeon, among others, may be called on to help resolve a number of reconstructive problems present in the immunosuppressed kidney recipients. This study presents our experience with 41 kidney recipients who needed plastic surgical treatment. Patients were placed into one of three study groups according to the type of posttransplant surgical condition. Group 1 included 17 patients with posttraumatic wound healing problems; group 2, 17 patients with skin tumors; and group 3, 7 patients with other posttransplant surgical complications. Only two of these patients had early posttransplant wound dehiscence; the remaining patients suffered late complications. In conclusion, the kidney recipient can successfully undergo minor or major reconstructive procedures. The possibility of surgical problems arising during the early posttransplant period presents increased complication rates, possibly due to high immunosuppressive drug levels.