Superficial Branch of the Radial Nerve Versus Sural Nerve Grafting After Traumatic Adult Brachial Plexus Injury.

The purpose of this study was to compare two sources of nerve graft for brachial plexus reconstruction: the denervated superficial branch of the radial nerve (SBRN) and the sural nerve. Ninety-seven patients who underwent brachial plexus reconstruction with denervated SBRN nerve (24 patients with 24 grafts) or with sural nerve grafting (73 patients with 83 nerve grafts) were included. The two groups were compared with respect to postoperative muscle reinnervation, disabilities of the arm, shoulder, and hand (DASH) scores. In the SBRN group, only four (17%) of the nerve grafts provided grade III or higher muscle function. In the sural nerve group, 31 (37%) of the nerve grafts provided grade III or higher muscle function. Smoking had a negative impact on muscle recovery. Denervated SBRN grafts are associated with inferior outcomes when compared with sural nerve grafts in the treatment of traumatic adult brachial plexus injuries. (Journal of Surgical Orthopaedic Advances 33(2):080-083, 2024).

Long-Term Outcomes of Arm Replantation.

BACKGROUND: Advances in microsurgery have improved the survival rate of arm replantation. However, the functional outcome of the replanted arms remains unpredictable. The authors performed a systematic review to evaluate the long-term outcome of arm replantation and the secondary reconstructive procedures after replantation. METHODS: All available English literature in the PubMed, Embase, and CENTRAL databases was searched for articles reporting functional outcome of successful arm replantation with follow-up period more than 1 yr. Clinical data were extracted including study characteristics, patient demographic information, functional outcome, and the numbers, types, and timing of secondary surgery. Among these, factors identified to influence overall outcome were reviewed and analyzed. RESULTS: Twenty-nine studies representing 79 arm replantations met the inclusion criteria. A total of 111 secondary procedures were recorded in 23 studies. The average number of secondary surgical procedures was 2.6 per patient. The most common procedures were nerve repair (23.4%), followed by functioning muscle transfer (19.8%), tendon transfer (17.1%), wound coverage (11.7%), contracture release (10.8%), bone repair (9.9%), arthrodesis (5.4%), and others (1.8%). Procedures involving wound coverage and nerve repair were mainly conducted in the early stage within 4 mos after replantation, whereas functioning muscle transfer, tendon transfer, and arthrodesis were mostly performed after 1 yr postoperatively. The satisfied (Chen I and II) functional outcome was achieved in 49.4% patients. The level of amputation and the type of injury have significant impact on final outcomes, whereas patients' age and timing of nerve repair do not. Patients with amputation at the distal third of the arms had a better outcome than those at the proximal and middle third of the arms (P < 0.05), and patients injured by sharp-cut recovered better than those by crush and avulsion (P < 0.05). CONCLUSIONS: Optimal outcomes could be achieved in nearly half of patients with arm replantation, although multiple secondary surgical interventions and long periods of recovery are often required.

Comparison Between Human Amniotic/Chorionic Membrane and Cryopreserved Allografts in the Treatment of Genital Burns.

BACKGROUND: Genital burns have devastating effects on patient and have been classified by the American Burn Association as major burn injury. The management of these injuries continues to challenge reconstructive surgeons. Cryopreserved skin allografts have been successfully used to manage partial-thickness skin burns; however, dehydrated human amniotic/chorionic membrane (DHACM) represents novel technology. Dehydrated human amniotic/chorionic membrane outcomes have not been sufficiently studied to guide its use on genital burns. The objective of this study was to report on the outcomes of dehydrated amniotic membrane as a biologic skin dressing on genital burns injury compared with cryopreserved allografts. METHODS: Retrospective review of data collected from our institutional burn registry from 2012 to 2017. The study population included patients with partial-thickness genital burns admitted between 2012 and 2017 treated with either dehydrated human amniotic/chorionic membrane or cryopreserved allografts. Demographic characteristics and outcome measures were compared between the 2 groups. RESULTS: Thirty patients with genital burns who received DHACM skin and cryopreserved allografts were included in the analysis. The mean age for the DHACM group was 27.6 years compared with 33.5 years for the cryopreserved group. The mean total body surface area was 3.8% in the DHACM group compared with 7.2% in the cryopreserved group (P = non-significant (ns)). The mean injury severity score was not significantly different between groups. Patients receiving cadaveric allografts had a higher number of skin substitute surgical reapplications as compared with the DHACM group (28% vs 0%, P ≤ 0.05). All patients who received DHACM skin substitutes healed by 2 weeks postoperative compared with 76% of patients who received cryopreserved skin allografts (P = 0.03, χ). CONCLUSIONS: Dehydrated amniotic membrane skin substitutes are a safe alternative in the treatment of genital burns. Its use achieves comparable benefits with no major significant difference in terms of complication, supporting the safety of amniotic membrane to treat genital burns.

Admission Carboxyhemoglobin: Is It a Marker for Burn Patient Outcomes?

BACKGROUND: Carbon monoxide is a gas produced by the combustion of hydrocarbon products that binds to heme molecules, 240 times more than oxygen, producing carboxyhemoglobin (COHb). As a result of its high affinity, there is shift of the oxyhemoglobin dissociation curve, compromising oxygen transport and delivery to tissues. Our study aim was to evaluate COHb elevation on admission as a predictor of worse outcomes in burn patients. METHODS: This is a 10-year retrospective review of the American Burn Association Burn Registry from 2002 to 2011. We stratified the patients into 2 groups: adult patients with normal COHb on admission (group 1) versus elevated COHb (group 2). Elevated COHb levels were defined as greater than 10% on the first arterial blood gas. Outcome measures included in-hospital mortality rate, hospital length of stay (LOS), intensive care unit LOS (ICU-LOS), and ventilator days. χ and t test analyses were used with significance defined as a P value of less than 0.05. RESULTS: A total of 6365 burn patients meet our inclusion criteria. There were 5775 patients in group 1 and 590 patients in group 2. Group 1 had an average age of 39.29 years compared with 42.62 years in group 2. The total body surface area was higher in group 1 compared with group 2 (6.24 vs 4.65) and with a statistically significant increase in partial thickness burns at 4.97 in group 1 compared with 3.27 in group 2. There was no statistically significant difference between the 2 groups in terms of full thickness total body surface area. The hospital LOS was significantly higher in group 2 compared with group 1 (15.34 vs 9.66). There was a significantly higher ICU-LOS at 12.89 days in group 2 compared with 4.01 in the group 1 (P = 0.0001, t test). There were higher ventilator days in group 2 at 9.23 than those in group 1 at 2.05 (P < 0.0001, t test). The in-hospital mortality was also significantly higher in group 2 at 15.59% than in group 1 at 1.33% (P = 0.0001, χ). CONCLUSIONS: Elevated COHb on admission was associated with an increased hospital and ICU-LOS, average ventilator days, and in-hospital mortality. The presence of elevated COHb of greater than 10% on an initial arterial blood gas suggests worse outcomes and increased need of resource utilization during the index hospital admission.

Using Dehydrated Amniotic Membrane Skin Substitute in Facial Burns: Is There a Outcome Difference Between Adult and Pediatric Patients?

INTRODUCTION: Facial burns have significant physical and psychological effects on patients, and minimizing morbidity continues to be a challenge for reconstructive surgeons. Advancements have allowed the development of various skin substitutes. Among these, human dehydrated amniotic skin substitutes represent novel technology, yet their outcome has not been sufficiently studied to guide practice. The objective of our study is to compare the safety of amniotic membrane skin substitutes in the treatment of adult and pediatric facial burns. METHODS: The authors performed a retrospective review of our institutional burn registry, with 90 burn patients meeting the inclusion criteria. Demographic and outcome measures included age, percentage of total body surface area (TBSA), Injury Severity Score (ISS), and complications (eg, pigmentation, hypertrophic scar, infection, and delayed healing). Paired sample t test and Chi-squared test were used, with significance defined as P < 0.05. RESULTS: Seventy-seven adults and 13 pediatric patients with facial burns who had received dehydrated amniotic membrane skin substitutes were included in the analysis. The mean age was 40.8 years for adults and 5.6 years for children. Mean TBSA was similar, with 9.6% (1-57%) in adults and 6.0% (2-14%) in children. The mean ISS did not significantly differ between groups (4.0 versus 2.2, P = ns). Pediatric patients with facial burns treated with amniotic membranes had a higher incidence of dyspigmentation relative to adult patients (46.2% versus 9.1%, P ≤ 0.05). Remaining morbidities were not significantly different between adult and pediatric patients. All patients, irrespective of group, healed by the second post-operative week. CONCLUSION: Dehydrated amniotic membrane skin substitutes are a safe alternative in the treatment of facial burns across all ages.

The Use of Dehydrated Human Amniotic Membrane Versus Amniotic/Chorionic Membrane Allografts to Treat Partial Thickness Facial Burns.

BACKGROUND: Facial burns have significant physical and psychologic effects on patients. Human dehydrated amniotic membrane represents novel technology, yet its outcome has not been sufficiently studied to guide practice. The objective of our study is to compare the benefits of amniotic membrane (DHAM) to amniotic/chorionic membrane (DHACM) skin substitutes to treat partial thickness facial burns. METHODS: Retrospective review of data collected from our institutional burn registry from 2012 to 2016. Demographic characteristics including age, total body surface area (TBSA) burn and injury severity scores were collected and outcome measures were compared between the 2 groups. Paired sample t-test and Chi-squared were used with significance defined as P < 0.05. RESULTS: A total of 77 adult patients with partial thickness facial burns who received DHAM and DHACM skin substitutes were included in the analysis. The mean age for the DHAM group was 39.8 compared to 41.4 for the DHACM. Mean TBSA was similar, with 10.9% in the DHAM group compared to 8.3% in the DHACM. Patients receiving DHAM had higher requirement for skin substitute surgical reapplications as compared to the DHACM group (23.7% versus 5.1%, P ≤ 0.05). Remaining morbidities remained low and not significantly different between patients receiving DHAM and DHACM substitutes (P > 0.05). CONCLUSION: The DHAM and DHACM skin substitutes are valid and safe alternatives in the treatment of adult partial thickness facial burns.

The Use of Dehydrated Human Amniotic/Chorionic Membrane Skin Substitute in the Treatment of Pediatric Facial Burn.

BACKGROUND: Facial burns have lasting physical and psychological effects on pediatric patients. Proper management to minimize morbidities challenges reconstructive surgeons. New technologies allowed the development of skin substitutes such as amniotic and chorionic membranes, yet the use of these skin dressings and their impact on burn outcomes have not been sufficiently studied to guide practices. The objective of this study is to report on the outcomes of dehydrated amniotic membrane as a biologic skin dressing in pediatric facial burn injury compared to cadaveric allografts. METHODS: Retrospective review of data collected from our institutional burn registry from 2012 to 2016. The study population included patients younger than 16 years with facial burns. Patients between 2012 and 2014 received cadaveric allografts, whereas during 2015 to 2016 patients received dehydrated human amniotic/chorionic membrane as standard treatment. Demographic characteristics and outcome measures were compared between the 2 groups. RESULTS: Included 30 patients with a mean age of 3.7 years and with an average total body surface area burn of 6.8% (2%-27%). Mean injury severity scores did not significantly differ between both groups, 1.8 in amniotic group versus 2.3 in cadaveric skin group (P > 0.05). There were 4 complications (3 hypertrophic scars and 1 wound infection) in the cadaveric allografts group versus no complications in the amniotic membrane group (P < 0.05). CONCLUSION: Dehydrated amniotic/chorionic membrane wound dressings are a safe alternative to cadaveric allografts in treating pediatric partial thickness facial burns.

Mycobacterium longobardum Infection in the Hand.

Mycobacterium longobardum is a slow-growing, nontuberculous mycobacterium that was first characterized in 2012. We report a case of M. longobardum infection in the right middle finger of a diabetic man. He underwent surgery for a presumed diagnosis of an epidermal inclusion cyst. Molecular diagnosis of the surgical specimens demonstrated M. longobardum through RNA polymerase ß-subunit encoding gene sequencing. After surgery, the patient was treated with antibiotics and eventually cured of the infection. To the best of our knowledge, this is only the second reported case of a pathogenic M. longobardum infection worldwide and the first such case in the hand. The purposes of this case study are to alert treating providers to consider nontuberculous mycobacterium infection when an inflammatory process persists, discuss signs and symptoms of the disease, and provide general treatment guidelines.

Significance of Objective Structured Clinical Examinations to Plastic Surgery Residency Training.

INTRODUCTION: Objective structured clinical examinations (OSCEs) have proven to be a powerful tool. They possess more than a 30-year track record in assessing the competency of medical students, residents, and fellows. Objective structured clinical examinations have been used successfully in a variety of medical specialties, including surgery. They have recently found their way into the subspecialty of plastic surgery. METHODS: This article uses a systematic review of the available literature on OSCEs and their recent use in plastic surgery. It incorporates survey results assessing program directors' views on the use of OSCEs. RESULTS: Approximately 40% of programs surveyed use OSCEs to assess the Accreditation Council for Graduate Medical Education core competencies. We found that 40% use OSCEs to evaluate specific plastic surgery milestones. Objective structured clinical examinations are usually performed annually. They cost anywhere between $100 and more than $1000 per resident. Four milestones giving residents the most difficulties on OSCEs were congenital anomalies, noncancer breast surgery, breast reconstruction, and practice-based learning and improvement. It was determined that challenges with milestones were due to lack of adequate general knowledge and surgical ward patient care, as well as deficits in professionalism and system-based problems. Programs were able to remediate weakness found by OSCEs using a variety of methods. CONCLUSIONS: Objective structured clinical examinations offer a unique tool to objectively assess the proficiency of residents in key areas of the Accreditation Council for Graduate Medical Education core competencies. In addition, they can be used to assess the specific milestones that plastic surgery residents must meet. This allows programs to identify and improve identified areas of weakness.

Presentation of soft tissue anatomy of mirror hand: an anatomical case report with implications for surgical planning.

PURPOSE: Mirror hand or ulnar dimelia is a rare and poorly studied congenital anomaly of the upper extremity. Understanding of its anatomy is limited by the rarity of the deformity and the variability in presentation. We present the case of an 80-year-old female donor with an incidental finding of mirror hand. METHODS: Medical history indicated no record of any surgical procedures or interventions to the right upper extremity suggesting that the donor had lived an independent life without the need for prosthetic aids. Unfortunately, no record of a hand examination or any visit to a hand specialist was identified within the medical record. Following imaging and disarticulation of the arm at the glenohumeral joint, an anatomical dissection was performed on the right upper extremity. RESULTS: Findings were recorded and compared to three earlier reports in the limited literature with a strong focus on understanding the anatomy of this deformity important for surgical planning. The anatomy is highlighted with a brief description of the embryology associated with mirror hand deformity. The case presents a classic example of ulnar dimelia. Arterial patterns compared favorably with those described in the literature. In addition an aberrant branch of the median nerve and a deep branch supplying the extensor compartment were noted. CONCLUSION: Based on the observations of this study (and the previous reports) we would recommend a study of vascular tree of the hand either through conventional arteriography or CT angiography prior to pollicization. The surgeon should also be prepared to perform a microsurgical arterial anastomosis if pollicization is not possible in case of an incomplete arch similar to one we described.

Functional outcomes of replantation following radiocarpal amputation.

PURPOSE: To assess the long-term functional and clinical outcomes of patients who have undergone replantation after radiocarpal amputation. METHODS: We performed a retrospective review of radiocarpal joint amputations at a level 1 trauma center over a 13-year period. Medical records of patients treated with replantation were queried for injury data, operative reports, complications, and clinical progress. Patients who met inclusion criteria were contacted for long-term follow-up. We measured total active motion of each digit, strength (grip and pinch), and 2-point discrimination. Functional outcomes were assessed with Disabilities of Arm, Shoulder, and Hand score, Mayo Wrist Score, Patient-Rated Wrist Evaluation, and Michigan Hand Questionnaire. Descriptive statistics were calculated, including frequencies for categorical variables and means and ranges for continuous variables. RESULTS: Six patients met the inclusion criteria. The mean age was 36 years (range, 26-50 y). Five patients were available at a mean follow-up of 3.9 years (range, 1.0-6.9 y). Compared with the contralateral uninjured extremity, total active motion of the hand was 38% (range, 26% to 59%) and grip strength was 9% (range, 0% to 18%). Neither tip nor key pinch was present. Mean 2-point discrimination was 10.6 mm (range, 8-12 mm). All mean outcome scores indicated moderate disability, including Disabilities of Arm, Shoulder, and Hand (76; range, 45-82), Mayo Wrist Score (23; range, 5-50), Patient-Rated Wrist Evaluation (86; range, 56-98), and Michigan Hand Questionnaire (27; range, 15-55). Two patients were able to return to work and 3 were permanently disabled. All patients were satisfied with the hand function. CONCLUSIONS: Successful replantation for a radiocarpal joint amputation is associated with major restriction of motion, decreased strength, and moderate disability on functional outcome assessments. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Congenital hand anomalies: etiology, classification, and treatment.

Congenital hand anomalies have a wide range of presentations and functional consequences. Understanding and treatment of these deformities require an understanding of embryology of upper-extremity development. In this report, common anomalies of the hand and upper extremity have been reviewed according to the International Federation for Societies for Surgery of the Hand classification system. We examine the epidemiology, etiology, functional consequences, and current treatments available for each anomaly.

Brachial plexus injury: treatment options and outcomes.

The brachial plexus is a series of nerves formed by roots of cervical segments 5 to 8 (C5-C8) as well as the first thoracic nerve (T1). It functions to provide sensation and motor innervation to the skin and muscles of the chest and upper limb. It does so through different segments: roots, trunks, divisions, and cords. Injuries to the brachial plexus occur relatively frequently and are due mainly to traumatic accidents that lead to traction or compression of the nerve roots. When considering the etiology and treatment of such injuries, it is important to make a distinction between adult versus obstetric brachial plexus injury. Although several surgical treatment options are described and used for patients with brachial plexus injury, no perfect remedy currently exists. Prevention and safety should be the focus. At the same time, high-quality studies and new technology and techniques are needed to determine more effective treatments for this group.

Squamous cell carcinoma of the hand: a 20-year review.

PURPOSE: Squamous cell carcinoma (SCC) is a common malignancy of the hand; yet, recurrence rates, metastatic rates, and long-term survival rates have not been well defined. This study evaluated the risk factors for local and regional recurrence for this diagnosis. METHODS: Records of patients treated for SCC of the hand over a 20-year period in a single institution were reviewed. Data collected included patient demographics, tumor characteristics, and preoperative and postoperative care received. Overall survival, recurrence-free survival, and survival free of SCC in the same upper extremity were analyzed. RESULTS: A total of 86 patients were identified. Mean age at the time of initial presentation was 69 years (range, 39-89 y). Mean follow-up was 6.4 years (range, 1-15 y). Overall survival was 88% and 57% at 5 and 10 years, respectively. Recurrence-free survival was 67% and 50% at 5 and 10 years, respectively. Rate of metastasis was 4%. Lymph node biopsy was performed in 4 patients who had clinical lymphadenopathy; 2 patients had positive nodes. Average time to first recurrence was 4.1 years (range, 0.5-11 y). Web space location, bilateral tumors, multiple tumors, and prior history of SCC were associated with an increased risk of recurrence. Survival free of SCC in the same upper extremity was 72% and 54% at 5 and 10 years, respectively. Younger age, history of transplantation, multiple tumors, and use of flap or skin graft for closure were associated with an increased risk of another SCC developing in the same extremity. No benefit was noted with wide, Mohs, or shave resection in terms of overall survival, recurrence-free survival, or SCC occurrence in the ipsilateral upper extremity. CONCLUSIONS: Squamous cell carcinoma tumors of the hand have a high tendency for local recurrence but a low rate of metastasis. Specific characteristics of the tumor may increase chances of recurrence. The technique of tumor excision did not have a major role in outcome. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Extraction of cannulated percutaneous screw from scaphoid: a simplified technique.

Removal of a cannulated headless screw following scaphoid fixation, when necessary, can prove to be difficult due to loss of bony integrity and the shape of the screw. This can result in greater exposure and more extensive soft tissue dissection for removal of the hardware. We describe a simple technique for percutaneous extraction of this hardware that can be done reliably with no additional equipment.

A Prospective Study on the Effect of Corticosteroid Injection Dosage for Hand Disorders in Non-Insulin Dependent Diabetics.

Local administration of corticosteroids is an effective yet potentially dangerous intervention in the treatment of hand disorders in diabetics. Prolonged exposure to hyperglycemia contributes to non-enzymatic glycosylation of various organ systems, which may cause detrimental health effects such as blindness, renal failure, and peripheral neuropathy, contributing to the high cost of health care. The purpose of this study is to determine the effects of corticosteroid dosage on serum glucose levels when used to treat common hand disorders in diabetic patients. Twenty-one patients with non-insulin-dependent diabetes mellitus treated with a corticosteroid injection were prospectively enrolled. Either triamcinolone 10 mg (T-10 group, N = 11) or 40 mg (T-40 group, N = 10) was administered with a local anesthetic. Fasting morning serum glucose, QuickDASH scores, and visual analog scale (VAS) pain scores were recorded prior to injection. Post-prandial serum glucose was recorded the evening of the injection, and the fasting serum glucose was recorded each morning. Clinical outcomes were recorded at 6 weeks and again at an average of 26 months. Patients in both cohorts, on average, had improvements in their Quick- DASH and VAS scores after the injection without significant variation. There was a significant elevation in serum glucose in both groups. T-10 had an average glucose increase of 53 mg/dL (41%), which returned to baseline at 21 hours. T-40 had a maximum glucose increase of 50 mg/dL (40%), which returned to baseline in 58 hours. The difference in time to return to baseline was statistically significance. Both T-10 and T-40 are effective in relieving painful symptoms and improving patient functionality after injection. A lower dosage triamcinolone is associated with a quicker return of serum glucose to baseline and may be a safer alternative to higher dosages when considering prolonged hyperglycemia and its known detrimental effects of non-enzymatic glycosylation on various organ systems.

Immediate application of vacuum assisted closure dressing over free muscle flaps in the lower extremity does not compromise flap survival and results in decreased flap thickness.

BACKGROUND: Free muscle flaps are a mainstay for reconstruction of distal third leg wounds and for large lower extremity wounds with exposed bone. However a major problem is the significant postoperative flap swelling, which may take months to resolve. We studied the efficacy and safety of immediate application of a vacuum assisted closure (VAC) dressing after a free muscle flap to the lower extremity. METHODS: Over a 19 months period, all consecutive free muscle flaps for lower extremity reconstruction at a Level I trauma center were evaluated prospectively for postoperative flap thickness, complications and flap survival. Immediate application of a VAC dressing was performed in 9 patients, while the flap was left exposed for monitoring in 8 patients. RESULTS: There was no statistically significant difference in flap survival between both cohorts. Mean flap thickness at postoperative day 5 for the VAC group was 6.4±6.4 mm, while flap thickness for the exposed flap group was 29.6±13.5 mm. Flap thickness was significantly decreased at postoperative day 5 for the VAC dressing group. CONCLUSIONS: Immediate application of VAC dressing following free muscle flaps to the lower extremity does not compromise flap survival or outcomes and results in decreased flap thickness and a better aesthetic outcome.

In vitro microdistraction of preosteoblasts: distraction promotes proliferation and oscillation promotes differentiation.

Osteoblast biology is influenced in vivo by a 3-dimensional (3D) extracellular matrix that mediates their adhesion and interaction and by a constant state of compressive and tensile forces. To study the role of mechanical stress on osteoblasts in vitro, these parameters must be addressed. Therefore, this study describes the use of a novel, in vitro system that subjects cells to distractive and compressive forces in a 3D environment. This system, termed a microdistractor system, was used to apply linear forces to 3D collagen type I gels containing preosteoblasts. Gels were induced for up to 16 days in osteogenic medium and subjected to either constant linear distraction (distraction gels) or to repeating cycles of distraction and compression (oscillation gels). The effect of these stresses was evaluated over time by measuring proliferation rates, protein synthesis (i.e., cellular activity), and osteogenic differentiation levels. While linear forces in general appeared to increase protein synthesis, force-specific effects on proliferation and differentiation were observed. Specifically, distraction forces appeared to enhance MC3T3 proliferation while distraction/compressive forces appeared to accelerate their osteogenic differentiation program. Therefore, these results suggest that the microdistraction system may be an appropriate in vitro system for the study of mechanobiology in osteoblast phenotype.

Biomechanical properties of the superficial fascial system.

BACKGROUND: Surgical repair of the superficial fascial system (SFS) has been claimed to both increase wound strength and enhance surgical outcome through anchoring of deeper tissues. OBJECTIVE: The authors assessed the biomechanical properties of the SFS to determine whether repair of the SFS layer improved early and long-term postoperative wound strength. METHODS: Four complementary studies were conducted to study the dermis and SFS junctional architecture and connective tissue content: gross dissection using a dehydrating agent (Pen-Fix; Richard-Allan Scientific, Kalamazoo, MI), a histologic study with hemotoxylin and eosin staining, soft tissue radiography, and immunofluorescence staining. Freshly excised human abdominal and lower back/buttock tissues underwent a midline incision, followed by repair using dermal sutures only (DRM), dermal sutures plus SFS sutures (DRM/SFS) or repair of the SFS only (SFS). Fresh swine abdominal tissues were similarly excised and repaired. Biomechanical tests were undertaken to compare the ex vivo human and swine tissues. Three types of closure-dermal sutures only (DRM), dermal sutures plus permanent 0-braided nylon suture in the SFS (DRM/SFS/N), and dermal sutures plus absorbable 0-vicryl suture in the SFS (DRM/SFS/V) were also tested in an in vivo swine model. RESULTS: Immunofluorescence studies showed collagen and elastin content and ratios to be comparable in the dermis and SFS. In ex vivo studies of human abdominal and back tissues, cyclic creep did not vary significantly among the different types of repair. DRM/SFS repair had a significantly higher failure load than dermal repair alone in both human abdominal and back tissues. In the in vivo swine study, normal tissue had a significantly higher failure load than all repair groups. The wounds where SFS had been repaired in addition to dermis exhibited an increased tensile strength and, among these, the wounds closed with SFS repair with a nonabsorbable suture exhibited greater tensile strength compared to absorbable suture repair. However, no statistically significant difference was noted, due to the small sample size. CONCLUSIONS: We have determined, using an ex vivo model, that repair of the SFS layer in addition to dermis repair significantly increases the initial biomechanical strength of wound repair. This has the potential to decrease early wound dehiscence. In our in vivo model, the use of a nonabsorbable suture to approximate the SFS demonstrated a trend toward increased long-term wound strength. We believe our studies provide scientific data documenting that SFS is a key contributory strength layer in the early postoperative period, and is likely to be a strength layer even in the later stages of wound healing.

Coagulation Changes following Combined Ablative and Reconstructive Breast Surgery.

BACKGROUND: This study assessed hemostatic function in cancer patients at high risk for venous thromboembolism. METHODS: Thirty-eight female patients (age, 53 ± 9 years) undergoing immediate postmastectomy reconstruction were prospectively studied with informed consent. Blood was sampled preoperatively, on postoperative day 1, and at 1 week follow-up. Rotational thromboelastography clotting time, α-angle (clot kinetics), clot formation time, and maximum clot firmness were studied with three different activating agents: intrinsically activated test using ellagic acid, extrinsically activated test with tissue factor, and fibrin-based extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D. Thromboprophylaxis was unfractionated heparin plus sequential compression devices if not contraindicated. Hypercoagulability was defined by one or more parameters outside the reference range. RESULTS: Preoperatively, 29 percent of patients were hypercoagulable, increasing to 67 percent by week 1 (p = 0.017). Clotting time, clot formation time, and α-angle remained relatively constant over time, but maximum clot formation increased in intrinsically activated test using ellagic acid, extrinsically activated test with tissue factor, and fibrin-based extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D (all p < 0.05). Body mass index was 28 ± 5 kg/m, 23 percent received preoperative chemotherapy, and 15 percent had a history of tobacco use, but there was no association between these risk factors and hypercoagulability. CONCLUSIONS: Despite perioperative thromboprophylaxis, two-thirds of patients undergoing combined tumor resection and reconstructive surgery for breast cancer were hypercoagulable 1 week after surgery. Hypercoagulability was associated with increased clot strength mediated by changes in platelet and fibrin function. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.