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INTRODUCTION: Tumors involving the lacrimal drainage apparatus can be effectively treated with oncologic eye-sparing resection, immediate reconstruction, and adjuvant radiation. The extirpative technique is well described, whereas the reconstructive approach and outcomes are limited and largely anecdotal. The present study describes the largest series in the literature evaluating outcomes after reconstruction after globe-preserving oncologic resection. METHODS: A retrospective review was performed for all patients undergoing reconstruction after resection of lacrimal gland tumors from 2008 to 2019. Reconstruction and ophthalmologic outcomes were assessed. RESULTS: Of the 17 patients included, 2 underwent complex repair, 6 were reconstructed with a locoregional flap, and 9 underwent free flap reconstruction. All patients were treated with adjuvant radiation therapy. The median follow-up was 19 months (range, 5-126 months). Defects reconstructed with free flaps had lower rates of wound dehiscence and fistula formation compared with those reconstructed with other techniques (11% vs 25%, P = 0.45). Patients undergoing reconstruction with free tissue transfer also tended to have lower rates of ectropion, keratopathy and decreased visual acuity compared with those undergoing nonmicrosurgical reconstruction (33% vs 50%, P = 0.48; 11% vs 38%, P = 0.20; 56% vs 75%, P = 0.40, respectively). These differences were not statistically significant. CONCLUSIONS: This is the first study to compare reconstructive and functional outcomes of nonmicrosurgical reconstruction and microsurgical free tissue transfer in the setting of eye-sparing surgery for tumors of the lacrimal drainage apparatus. Although various reconstructive options are feasible, microsurgical free tissue transfer is often used at our center and is associated with reliable outcomes.
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Neoplasias Oculares , Doenças do Aparelho Lacrimal , Aparelho Lacrimal , Procedimentos de Cirurgia Plástica , Neoplasias Oculares/radioterapia , Neoplasias Oculares/cirurgia , Humanos , Aparelho Lacrimal/cirurgia , Doenças do Aparelho Lacrimal/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: With the increased use of acellular dermal matrix (ADM) in breast reconstruction, the number of available materials has increased. There is a relative paucity of high-quality outcomes data for use of different ADMs. OBJECTIVES: The goal of this study was to compare the outcomes between a human (HADM) and a bovine ADM (BADM) in implant-based breast reconstruction. METHODS: A prospective, single-blinded, randomized controlled trial was conducted to evaluate differences in outcomes between HADM and BADM for patients undergoing immediate tissue expander breast reconstruction. Patients with prior radiation to the index breast were excluded. Patient and surgical characteristics were collected and analyzed. RESULTS: From April 2011 to June 2016, a total of 90 patients were randomized to a mesh group, with 68 patients (HADM, 36 patients/55 breasts; BADM, 32 patients/48 breasts) included in the final analysis. Baseline characteristics were similar between the 2 groups. No significant differences in overall complication rates were identified between HADM (n = 14, 25%) and BADM (n = 13, 27%) (P = 0.85). Similar trends were identified for major complications and complications requiring reoperation. Tissue expander loss was identified in 7% of HADM patients (n = 4) and 17% of BADM patients (n = 8) (P = 0.14). CONCLUSIONS: Similar complication and implant loss rates were found among patients undergoing immediate tissue expander breast reconstruction with HADM or BADM. Regardless of what material is used, careful patient selection and counseling, and cost consideration, help to improve outcomes and sustainability in immediate breast reconstruction.
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Derme Acelular , Implante Mamário , Implantes de Mama , Neoplasias da Mama , Mamoplastia , Aloenxertos , Animais , Implante Mamário/efeitos adversos , Implantes de Mama/efeitos adversos , Neoplasias da Mama/cirurgia , Bovinos , Feminino , Xenoenxertos , Humanos , Mamoplastia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Telas Cirúrgicas/efeitos adversos , Dispositivos para Expansão de Tecidos/efeitos adversosRESUMO
OBJECTIVE: To summarize the multi-specialty strategy and initial guidelines of a Case Review Committee in triaging oncologic surgery procedures in a large Comprehensive Cancer Center and to outline current steps moving forward after the initial wave. SUMMARY OF BACKGROUND DATA: The impetus for strategic rescheduling of operations is multifactorial and includes our societal responsibility to minimize COVID-19 exposure risk and propagation among patients, the healthcare workforce, and our community at large. Strategic rescheduling is also driven by the need to preserve limited resources. As many states have already or are considering to re-open and relax stay-at-home orders, there remains a continued need for careful surgical scheduling because we must face the reality that we will need to co-exist with COVID-19 for months, if not years. METHODS: The quality officers, chairs, and leadership of the 9 surgical departments in our Division of Surgery provide specialty-specific approaches to appropriately triage patients. RESULTS: We present the strategic approach for surgical rescheduling during and immediately after the COVID-19 first wave for the 9 departments in the Division of Surgery at The University of Texas MD Anderson Cancer Center in Houston, Texas. CONCLUSIONS: Cancer surgeons should continue to use their oncologic knowledge to determine the window of opportunity for each surgical procedure, based on tumor biology, preoperative treatment sequencing, and response to systemic therapy, to safely guide patients through this cautious recovery phase.
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Agendamento de Consultas , Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Oncologia Cirúrgica/tendências , Betacoronavirus , COVID-19 , Tomada de Decisões , Humanos , Pandemias , Seleção de Pacientes , SARS-CoV-2 , Texas/epidemiologia , TriagemRESUMO
BACKGROUND: Locally advanced malignancies of the upper torso and shoulder girdle (UT-SG) necessitate extensive resection and complex reconstruction. Due to the infrequent nature of these operations, a global reconstructive algorithm has not been defined. METHODS: A retrospective review of all patients who received reconstructive surgery following malignant tumor extirpation in the UT-SG from 2008 to 2018 at the University of Texas MD Anderson Cancer Center. Factors predicting the need for flap reconstruction and risk for postoperative complications were evaluated. RESULTS: In total, 252 procedures met inclusion criteria. The most common pathology was sarcoma (76%) and 52% were primary tumors. The median defect area was 112 cm2 (range 4-1350 cm2 ). Reconstructive techniques included pedicled flaps (46%), local tissue rearrangement (38%), and free flaps (16%). On univariate analysis, the probability of needing a free flap increased 39% when the defect size increased by 100 cm2 . The strongest independent predictors of requiring a free flap were major vessel exposure (adjusted odds ratio [OR] = 4.92, 95% confidence interval [CI], 1.36-17.84, P = .015) and major peripheral nerve exposure (adjusted OR = 3.2, 95% CI, 1.1-9.2, P = .031). CONCLUSION: Despite the aggressive nature of their malignancies, patients requiring an UT-SG resection demonstrate high survival rates and therefore demand a durable reconstruction. Exposed critical structures and defect size were predictive of free tissue transfer.
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Algoritmos , Procedimentos de Cirurgia Plástica/métodos , Neoplasias de Tecidos Moles/cirurgia , Feminino , Retalhos de Tecido Biológico , Humanos , Masculino , Melanoma/cirurgia , Pessoa de Meia-Idade , Retalho Perfurante , Estudos Retrospectivos , Sarcoma/patologia , Sarcoma/cirurgia , Ombro/patologia , Ombro/cirurgia , Tronco/patologia , Tronco/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Contradictory data exists on the success rates of employing the external jugular (EJ) vein as a recipient vessel for venous outflow in free flap head and neck reconstruction compared with the internal jugular (IJ) vein. The authors hereby present a retrospective study of prospectively collected data over a 14-year period. METHODS: Five hundred seventy-eight patients underwent 639 free flap head and neck over 14 years. Two hundred seventy-eight free flaps employed the EJ vein as the recipient vessel while 326 free flaps employed the IJ vein. Rates of acute and late complications were compared. RESULTS: There were no differences in rates of complications: flap loss, venous thrombosis, arterial thrombosis, bleeding, hematoma, or infection between the EJ and IJ vein groups. CONCLUSION: The external jugular vein as a recipient vessel for venous outflow in head and neck free flap reconstruction of postoncologic resection defects is a valid option for both primary reconstructions and secondary surgeries.
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Retalhos de Tecido Biológico , Veias Jugulares , Retalhos de Tecido Biológico/efeitos adversos , Retalhos de Tecido Biológico/irrigação sanguínea , Retalhos de Tecido Biológico/estatística & dados numéricos , Retalhos de Tecido Biológico/cirurgia , Humanos , Veias Jugulares/cirurgia , Veias Jugulares/transplante , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Pharyngo-esophageal and tracheostomal defects pose a challenge in head and neck reconstruction whenever microanastomosis is extremely difficult in hostile neck that is previously dissected and irradiated. The deltopectoral (DP) flap was initially described as a pedicled flap for such reconstruction with acceptable postoperative results. A major drawback is still that the DP flap is based on 3 perforator vessels leading to a decreased arc of rotation. The DP flap also left contour deformities in the donor site. The internal mammary artery perforator flap was described as a refinement of the deltopectoral flap. It is a pedicled fasciocutaneous flap based on a single perforator, with comparable and reliable blood supply compared with the DP flap, giving it the benefit of having a wide arc of rotation. It is both thin and pliable, with good skin color match and texture. The donor site can be closed primarily with no esthetic deformity and minimal morbidity. The procedure is relatively simple and does not require microvascular expertise. In this report, the authors describe a patient in whom bilateral internal mammary artery perforator flaps were used for subtotal pharyngo-esophageal reconstruction and neck resurfacing. The flaps healed uneventfully bilaterally with no postoperative complications.
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Laringectomia , Artéria Torácica Interna/cirurgia , Microcirurgia/métodos , Esvaziamento Cervical , Recidiva Local de Neoplasia/cirurgia , Retalho Perfurante/irrigação sanguínea , Retalho Perfurante/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Seio Piriforme/cirurgia , Retalhos Cirúrgicos/irrigação sanguínea , Retalhos Cirúrgicos/cirurgia , Neoplasias da Língua/cirurgia , Idoso , Terapia Combinada , Estética , Feminino , Humanos , Comunicação Interdisciplinar , Colaboração Intersetorial , ReoperaçãoRESUMO
OBJECTIVE: Malignant cancers arising in the scalp may exhibit calvarial invasion, dural extension, and rarely cerebral involvement. Typically, such lesions require a multidisciplinary approach involving both neurosurgery and plastic surgery for optimal resection and reconstruction. The authors present a retrospective analysis of patients with scalp malignancies who underwent resection and reconstruction. METHODS: Patients presenting with scalp malignancies (1993-2021, n = 84) who required neurosurgical assistance for tumor resection were prospectively entered into a database. These data were retrospectively reviewed for this case series. The extent of neurosurgical resection was classified into four levels of involvement: scalp (level I), calvarial (level II), dural (level III), or intraparenchymal (level IV). Complications and evidence of local, locoregional, or regional recurrence were documented. RESULTS: Patients underwent level I (n = 2), level II (n = 61), level III (n = 13), and level IV (n = 8) resections. Pathologies consisted of primarily squamous cell carcinoma (n = 50, 59.5%), basal cell carcinoma (n = 11, 13.1%), and melanoma (n = 9, 10.7%), with infrequent lesions including sarcoma, atypical fibroxanthoma, and malignant fibrous histiocytoma. For cases requiring a cranioplasty, 92.2% were done using titanium mesh and 7.8% with methylmethacrylate. At a mean follow-up of 35.5 ± 45.9 months, the overall survival was 48.8% (n = 41) and recurrence-free survival was 31.0% (n = 43). Scalp-based reconstruction involving plastic surgery was performed in 75 (89.3%) patients. The most commonly used free flap was a latissimus dorsi muscle flap (n = 46, 61.3%). One or more postoperative complications occurred in 21.4% of all patients, the most common being wound dehiscence or delayed wound healing in 13% (n = 11). CONCLUSIONS: A multidisciplinary approach with aggressive neurosurgical resection is associated with good outcomes in patients with primary malignant scalp tumors, despite invasive disease on presentation. This analysis suggests that aggressive resection (level II and higher) is effective at reducing locoregional recurrence and is not associated with a higher risk of complications relative to resection without craniectomy. As most patients require scalp reconstruction to close the postresection defect, usually with vascularized free tissue transfer, involving a plastic surgeon in the surgical planning and execution is essential.
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Retalhos de Tecido Biológico , Procedimentos de Cirurgia Plástica , Humanos , Estudos Retrospectivos , Couro Cabeludo/cirurgia , Recidiva Local de Neoplasia/cirurgia , Recidiva Local de Neoplasia/patologia , Retalhos de Tecido Biológico/cirurgia , Complicações Pós-Operatórias/cirurgiaRESUMO
BACKGROUND: Prepectoral implant-based breast reconstruction (IBR) has become the standard of care for many reconstructive surgeons and is often supplemented with coverage using acellular dermal matrix (ADM). However, more clinical data examining the use of ADM in breast reconstruction are needed. The current study compares complications and patient-reported outcomes (PROs) among three different types of ADM used in IBR. METHODS: The authors performed a retrospective review of consecutive patients who underwent immediate prepectoral IBR from January of 2018 through December of 2019. Surgical outcomes and PROs (using the BREAST-Q) were compared among the AlloDerm, SurgiMend, and Dermacell ADMs. RESULTS: Overall, 557 breasts (383 patients) were included (78.6% AlloDerm, 14% SurgiMend, 7.4% Dermacell). Patients in the Dermacell group were older ( P = 0.001) and more likely to have diabetes ( P = 0.001) compared with AlloDerm and SurgiMend patients. Other patient characteristics were similar among the three groups. The overall complication rate was equivalent among the three ADM groups (AlloDerm 27% vs SurgiMend 33% vs Dermacell 39%; P = 0.209). Multivariable frailty models demonstrated that the type of ADM was not significantly associated with overall complications, infection, major complications, or device explantation. BREAST-Q satisfaction with breasts, psychosocial well-being, and sexual well-being were also similar among the three ADM groups ( P = 0.109, P = 0.439, P = 0.152, respectively). CONCLUSIONS: Three of the most commonly used ADMs in the United States have similar surgical outcomes and PROs when used for prepectoral IBR. No significant differences in infection, overall complications, or device removal rates were identified among AlloDerm, SurgiMend, and Dermacell. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Derme Acelular , Implantes de Mama , Neoplasias da Mama , Mamoplastia , Humanos , Feminino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Mamoplastia/efeitos adversos , Implantes de Mama/efeitos adversos , Estudos Retrospectivos , Medidas de Resultados Relatados pelo Paciente , Neoplasias da Mama/complicaçõesRESUMO
BACKGROUND: Forequarter amputations (FQAs) and extended forequarter amputations (EFQAs) are rare procedures with high morbidity that often require significant soft-tissue or bony reconstruction. The authors describe the largest series of oncologic FQAs and EFQAs to date with associated reconstructive and oncologic outcomes. METHODS: The authors retrospectively reviewed data from all patients who underwent FQA or EFQA at The University of Texas M. D. Anderson Cancer Center from January 1, 2008, to January 1, 2019. Surgical outcomes, survival, and local recurrence rates were summarized and compared. RESULTS: Forty-seven patients met the inclusion criteria, including 14 with EFQAs. Most patients (53%) were male; the median age was 58 years (range, 2 to 74). The most common tumor type was sarcoma (79%), and the most common presentation was recurrent (34%). Nineteen patients (40%) had distant metastases. The median defect size was 351 cm 2 ; flap reconstruction was required in 30 patients (64%). Eight patients (17%) experienced immediate complications and 12 (26%) experienced delayed complications. The median overall survival (OS) time was 21 months and the 5-year OS rate was 28.1%. OS and disease-free survival were superior in the EFQA group (69.8% versus 11.6%, P = 0.017; 58.9% versus 9.8%, P = 0.014, respectively). Metastasis at presentation was the most important predictor of survival on multivariate analysis (OR, 3.98; P = 0.004). CONCLUSIONS: Patients with EFQA had better OS and disease-free survival than did patients with FQA, owing to a lower incidence of metastatic disease. This study suggests a benefit to more aggressive resection and reconstruction when disease is locally confined. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Procedimentos de Cirurgia Plástica , Sarcoma , Humanos , Masculino , Pessoa de Meia-Idade , Feminino , Estudos Retrospectivos , Retalhos Cirúrgicos/patologia , Amputação Cirúrgica , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/cirurgiaRESUMO
BACKGROUND: The goal of this study was to evaluate outcomes after vascularized bone flap (VBF) reconstruction of oncologic bony extremity defects. A secondary goal was to compare union rates based on various insetting methods, including onlay, intermedullary, and intercalary. METHODS: The authors conducted a retrospective review of consecutive patients who received an extremity reconstruction with a fibula flap after oncologic resection between 2001 and 2019. RESULTS: The authors identified a total of 60 fibular VBFs in 55 patients (67% lower extremity, 33% upper extremity). The overall union rate was 91.7% (55 of 60). For lower extremity reconstructions, the mean time to full weightbearing was 16 months (range, 4 to 44 months). Fibula VBFs were onlay in 65% of cases, intercalary in 23%, and intramedullary in 12%. Forty-three percent of patients required a reoperation as a result of a surgical complication. Immediate femur reconstruction subgroup analysis demonstrated that onlay fibula flap orientation was associated with a significantly increased risk for any complication (odds ratio, 6.3; 95% CI, 1.4 to 28.7; P = 0.03) as well as an increased risk for requiring conversion to endoprostheses because of nonunion (OR, 12.1; 90% CI, 1.03 to 143.5; P = 0.03) compared with intramedullary placement. CONCLUSIONS: The free vascularized fibula flap is a reliable option for functional reconstruction of any long bone extremity defect, but complications in these complex procedures are not uncommon. In patients with immediate femur reconstructions, intramedullary fibula placement was associated with significantly lower complication and lower metallic implant conversion rates and a trend toward a more rapid early union compared with onlay VBF. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Neoplasias Ósseas , Retalhos de Tecido Biológico , Humanos , Fíbula , Neoplasias Ósseas/cirurgia , Resultado do Tratamento , Extremidade Inferior/cirurgia , Estudos Retrospectivos , Transplante Ósseo/efeitos adversos , Transplante Ósseo/métodosRESUMO
Muscle flaps must have a strong vascular network to support a large tissue volume and ensure successful engraftment. We developed porcine stomach musculofascial flap matrix (PDSF) comprising extracellular matrix (ECM) and intact vasculature. PDSF had a dominant vascular pedicle, microcirculatory vessels, a nerve network, well-retained 3-dimensional (3D) nanofibrous ECM structures, and no allo- or xenoantigenicity. In-depth proteomic analysis demonstrated that PDSF was composed of core matrisome proteins (e.g., collagens, glycoproteins, proteoglycans, and ECM regulators) that, as shown by Gene Ontology term enrichment analysis, are functionally related to musculofascial biological processes. Moreover, PDSF-human adipose-derived stem cell (hASC) synergy not only induced monocytes towards IL-10-producing M2 macrophage polarization through the enhancement of hASCs' paracrine effect but also promoted the proliferation and interconnection of both human skeletal muscle myoblasts (HSMMs) and human umbilical vein endothelial cells (HUVECs) in static triculture conditions. Furthermore, PDSF was successfully prevascularized through a dynamic perfusion coculture of hASCs and HUVECs, which integrated with PDSF and induced the maturation of vascular networks in vitro. In a xenotransplantation model, PDSF demonstrated myoconductive and immunomodulatory properties associated with the predominance of M2 macrophages and regulatory T cells. In a volumetric muscle loss (VML) model, prevascularized PDSF augmented neovascularization and constructive remodeling, which was characterized by the predominant infiltration of M2 macrophages and significant musculofascial tissue formation. These results indicate that hASCs' integration with PDSF enhances the cells' dual function in immunomodulation and angiogenesis. Owing in part to this PDSF-hASC synergy, our platform shows promise for vascularized muscle flap engineering for VML reconstruction.
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BACKGROUND: Abdominal wall reconstruction (AWR) is one of the most commonly performed procedures, yet large comparative studies comparing outcomes of AWR using bovine acellular dermal matrix (BADM) and porcine acellular dermal matrix (PADM) are lacking. METHODS: In this retrospective cohort study of patients who underwent AWR from March of 2005 to June of 2019, the primary comparative outcome measure was hernia recurrence with BADM versus PADM. The secondary outcome was the incidence of surgical-site occurrence (SSO) and surgical-site infection. A propensity score matching approach was applied to compare the clinical outcomes between the two study groups. RESULTS: The authors identified 725 patients who underwent AWR using BADM (50.5%) or PADM (49.5%). Their mean ± SD age was 59.8 ± 11.5 years, mean body mass index was 31.4 ± 6.7 kg/m 2 , and mean follow-up time was 42 ± 29 months. With propensity score matching, 219 matched pairs were identified. Hernia recurrence rates in BADM (11.4%) and PADM (13.7%) groups did not differ significantly ( P = 0.793). SSO (26.5% versus 29.2%; P = 0.518) and SSI (13.2% versus 11%; P = 0.456) rates did not differ significantly in the PADM and BADM groups, respectively. Conditional logistic regression model and marginal Cox proportional hazards regression model determined that type of acellular dermal matrix was not significantly associated with SSOs (adjusted OR, 1.11; 95% CI, 0.74 to 1.70; P = 0.589) or hernia recurrence (adjusted hazard ratio, 0.85; 95% CI, 0.50 to 1.42; P = 0.52). CONCLUSIONS: Both BADMs and PADMs provide durable, long-term outcomes. The hernia recurrence and postoperative surgical complication rates were not significantly different between BADM and PADM. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Parede Abdominal , Derme Acelular , Hérnia Ventral , Humanos , Animais , Bovinos , Suínos , Pessoa de Meia-Idade , Idoso , Parede Abdominal/cirurgia , Hérnia Ventral/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Pontuação de Propensão , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Recidiva Local de Neoplasia/cirurgia , Telas Cirúrgicas , RecidivaRESUMO
SUMMARY: Thigh-based flaps are increasingly popular options for autologous breast reconstruction in the setting of abdominal donor-site inadequacy, previous surgery, or patient preference, but the volume and skin associated with these flaps are often lacking relative to the abdomen. An individualized, shared decision-making approach to donor-site selection was adopted based on body shape, surgical history, lifestyle, reconstructive needs, and patient expectations. Different thigh-based flaps combined in stacked, bipedicled, or conjoined configurations were selected to maximize efficient use of available soft-tissue skin and volume while optimizing donor-site aesthetics. A total of 23 thigh-based stacked, bipedicled, or conjoined profunda artery perforator (PAP), lateral thigh perforator (LTP), or gracilis musculocutaneous flap components were used in six patients. Configurations included bilateral stacked PAP and LTP flaps, bipedicled posterolateral thigh flaps based on the LTP and PAP (L-PAP), and bipedicled thigh flaps based on the gracilis and PAP pedicles. Most anastomoses were performed to the antegrade and retrograde internal mammary vessels; intraflap anastomoses were performed in one case. There were no partial or total flap losses. There was one donor-site seroma. Design of stacked, bipedicled, and conjoined thigh-based flaps using multiple conventional flap components allows for tailored approaches to donor-site utilization based on individual body shape in selected patients. Bipedicled design with the L-PAP flap represents one strategy in appropriate cases to overcome skin and volume deficiencies while facilitating coning and projection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Músculo Grácil , Mamoplastia , Retalho Perfurante , Humanos , Coxa da Perna/cirurgia , Retalho Perfurante/irrigação sanguínea , Mama/cirurgia , Músculo Grácil/transplante , Estudos RetrospectivosRESUMO
BACKGROUND: Outcomes of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) in the oncologic population are limited. We sought to examine the safety and effectiveness of TMR and RPNI in controlling postamputation pain in the oncologic population. STUDY DESIGN: A retrospective cohort study of consecutive patients who underwent oncologic amputation followed by immediate TMR or RPNI was conducted from November 2018 to May 2022. The primary study outcome was postamputation pain, assessed using the Numeric Pain Scale and Patient-Reported Outcomes Measurement Information System (PROMIS) for residual limb pain (RLP) and phantom limb pain (PLP). Secondary outcomes included postoperative complications, tumor recurrence, and opioid use. RESULTS: Sixty-three patients were evaluated for a mean follow-up period of 11.3 months. The majority of patients (65.1%) had a history of previous limb salvage. At final follow-up, patients had an average Numeric Pain Scale score for RLP of 1.3 ± 2.2 and for PLP, 1.9 ± 2.6. The final average raw PROMIS measures were pain intensity 6.2 ± 2.9 (T-score 43.5), pain interference 14.6 ± 8.3 (T-score 55.0), and pain behavior 39.0 ± 22.1 (T-score 53.4). Patient opioid use decreased from 85.7% preoperatively to 37.7% postoperatively and morphine milligram equivalents decreased from a mean of 52.4 ± 53.0 preoperatively to 20.2 ± 38.4 postoperatively. CONCLUSIONS: In the oncologic population TMR and RPNI are safe surgical techniques associated with significant reductions in RLP, PLP, and improvements in patient-reported outcomes. This study provides evidence for the routine incorporation of TMR and RPNI in the multidisciplinary care of oncologic amputees.
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Amputados , Dor Crônica , Humanos , Estudos Retrospectivos , Analgésicos Opioides/uso terapêutico , Dor Crônica/etiologia , Dor Crônica/cirurgia , Nervos Periféricos/cirurgia , MúsculosRESUMO
Hypoxia inducible factors (HIFs) regulate adaptive responses to changes in oxygen (O(2)) tension during embryogenesis, tissue ischemia, and tumorigenesis. Because HIF-deficient embryos exhibit a number of developmental defects, the precise role of HIF in early vascular morphogenesis has been uncertain. Using para-aortic splanchnopleural (P-Sp) explant cultures, we show that deletion of the HIF-beta subunit (ARNT) results in defective hematopoiesis and the inhibition of both vasculogenesis and angiogenesis. These defects are rescued upon the addition of wild-type Sca-1(+) hematopoietic cells or recombinant VEGF. Arnt(-/-) embryos exhibit reduced levels of VEGF protein and increased numbers of apoptotic hematopoietic cells. These results suggest that HIF coordinates early endothelial cell emergence and vessel development by promoting hematopoietic cell survival and paracrine growth factor production.
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Translocador Nuclear Receptor Aril Hidrocarboneto/fisiologia , Vasos Sanguíneos/embriologia , Fatores de Crescimento de Células Hematopoéticas/fisiologia , Animais , Apoptose , Translocador Nuclear Receptor Aril Hidrocarboneto/deficiência , Translocador Nuclear Receptor Aril Hidrocarboneto/genética , Sequência de Bases , Células da Medula Óssea/fisiologia , Técnicas de Cocultura , DNA/genética , Desenvolvimento Embrionário/efeitos dos fármacos , Desenvolvimento Embrionário/fisiologia , Feminino , Hematopoese , Subunidade alfa do Fator 1 Induzível por Hipóxia/deficiência , Subunidade alfa do Fator 1 Induzível por Hipóxia/genética , Subunidade alfa do Fator 1 Induzível por Hipóxia/fisiologia , Camundongos , Camundongos Knockout , Neovascularização Fisiológica , Gravidez , Proteínas Recombinantes/farmacologia , Técnicas de Cultura de Tecidos , Fator A de Crescimento do Endotélio Vascular/metabolismo , Fator A de Crescimento do Endotélio Vascular/farmacologiaRESUMO
SUMMARY: Vascularized tissue for obliteration of large pelvic dead spaces created by extirpative surgery has been shown to reduce complication rates. As more extensive resections are performed robotically, plastic surgeons have been challenged to reconstruct the resulting defects using a minimally invasive approach. The goal of this study was to report the authors' experience with robotic harvest of the rectus abdominis muscle for reconstruction of pelvic defects. The authors conducted a retrospective case series of patients who underwent robotic flap harvest following robotic extirpative surgery at their institution. Patient demographics, surgical characteristics, and postoperative outcomes were collected. These were compared to a retrospective cohort of patients who underwent open rectus abdominis muscle harvest. The authors identified seven male patients who underwent robotic flap harvest for pelvic reconstruction between 2013 and 2019. Their mean age was 66 ± 6 years and mean body mass index was 31 ± 5 kg/m2. Six patients (86 percent) had a history of radiation therapy and five patients (71 percent) received hormone therapy or chemotherapy. Surgical-site complications occurred in two patients. One patient developed ventral hernia. The donor-site complication rate was 19 percent (n = 18) in patients who underwent open rectus abdominis muscle harvest (n = 95). This study demonstrates the safety, efficacy, and reproducibility of robotic harvest of the rectus abdominis muscle in complex, multidisciplinary, minimally invasive pelvic surgery. The technique avoids violation of the anterior rectus sheath and wound complications related to open flap harvest, and early experience suggests reduced donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
Assuntos
Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias/epidemiologia , Reto do Abdome/transplante , Procedimentos Cirúrgicos Robóticos/métodos , Retalhos Cirúrgicos/transplante , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Pélvicas/cirurgia , Complicações Pós-Operatórias/etiologia , Procedimentos de Cirurgia Plástica/efeitos adversos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Retalhos Cirúrgicos/efeitos adversos , Ferida Cirúrgica/etiologia , Ferida Cirúrgica/cirurgia , Coleta de Tecidos e Órgãos/efeitos adversos , Coleta de Tecidos e Órgãos/métodos , Resultado do TratamentoRESUMO
The clinical results with extracellular matrix biomaterials are confounded by expectations of material response based on years of experience with permanent or degradable synthetic polymers. However, the remodeling or assimilation of extracellular matrix biomaterials is dictated by cell-mediated processes rather than fibrous encapsulation or hydrolytic degradation. Previously, we found that tissue adherence and revascularization were dictated by proximity with de-epithelialized host tissue. We now investigate the effects of polymer and fixation type on attachment strength and rate of cell repopulation in an intra-abdominal implant model. METHODS: An intra-abdominal implant model in rats was used to probe assimilation properties at 4 weeks and 12 weeks with permanent and degradable suture types as well a combination of suture and biologic attachment (mesothelial abrasion). The mechanical strength of the attachment was measured by peel testing and the repopulation by automated cell counting of histologic sections. RESULTS: The intensity of the biologic response was greater with degradable polymers than permanent polypropylene. Tissue attachment strength ranged from 2 to 15 N but changed in elasticity with time. The magnitude and distribution of cell repopulation was highly variable by suture type but ultimately did not affect the long-term strength of the soft tissue attachment. CONCLUSIONS: The tissue approximating polymer sutures were stretchy and of similar strength regardless of degradation rate or polymer type. The strongest attachment, most rapid repopulation of the deep matrix regions, and most uniform distribution of cells were found with the addition of biologic attachment.
RESUMO
Navigating the rapidly evolving field of materials for soft tissue reinforcement is challenging given the volume of clinically available options. Additionally, the current generally accepted classifications of these mesh materials confound the understanding of their utility by grouping disparate materials that have attributes overlapping category boundaries and that do not fully consider their clinically functionality. This review article highlights, from a materials science perspective, the most important attributes of these materials to improve the clinical decision-making process in the selection of the most appropriate features and design for the patient, surgery and clinical need. These characteristics include the physical attributes that directly impact the surgical procedure and immediate postoperative mechanical requirements as well as the post-implantation properties such as an adequate reinforcement time, strength of the resulting tissue and infection risk profile.
Assuntos
Produtos Biológicos/química , Procedimentos de Cirurgia Plástica/métodos , Polímeros/química , Telas Cirúrgicas/classificação , Implantes Absorvíveis , Tomada de Decisões , Humanos , Infecções Relacionadas à Prótese/fisiopatologiaRESUMO
BACKGROUND: With the current focus on value-based outcomes and reimbursement models, perioperative risk adjustment is essential. Specialty surgical outcomes are not well predicted by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP); the Head and Neck-Reconstructive Surgery NSQIP was created as a specialty-specific platform for patients undergoing head and neck surgery with flap reconstruction. This study aims to investigate risk prediction models in these patients. METHODS: The Head and Neck-Reconstructive Surgery NSQIP collected data on patients undergoing head and neck surgery with flap reconstruction from August 1, 2012 to October 20, 2016. Multivariable logistic regression models were created for 9 outcomes (postoperative ventilator dependence, pneumonia, superficial recipient surgical site infection, presence of tracheostomy/nasoenteric (NE)/gastrostomy/gastrojejunostomy(G/GJ) tube 30 days postoperatively, conversion from NE to G/GJ tube, unplanned return to the operating room, length of stay > 7 days). External validation was completed with a more contemporary cohort. RESULTS: A total of 1095 patients were included in the modelling cohort and 407 in the validation cohort. Models performed well predicting tracheostomy, NE, G/GJ tube presence at 30 days postoperatively and conversion from NE to G/GJ tube (c-indices = 0.75-0.91). Models for postoperative pneumonia, superficial recipient surgical site infection, ventilator dependence > 48 h, and length of stay > 7 days were fair (concordance [c]-indices = 0.63-0.69). The predictive model for unplanned return to the operating room was poor (c-index = 0.58). CONCLUSIONS AND RELEVANCE: Reliable and discriminant risk prediction models were able to be created for postoperative outcomes using the specialty-specific Head and Neck-Reconstructive Surgery Specific NSQIP.