Adam Jacoby

Optimizing venous outflow in reconstruction of Gustilo IIIB lower extremity traumas with soft tissue free flap coverage: Are two veins better than one?

The dependent nature of the lower extremity predisposes to venous congestion, especially following significant trauma. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction. This study investigated the effect of an additional venous anastomosis on flap outcomes in lower extremity trauma reconstruction.

Fabrication of capillary-like structures with Pluronic F127® and Kerria lacca resin (shellac) in biocompatible tissue-engineered constructs#

The fabrication of large cellular tissue‐engineered constructs is currently limited by an inability to manufacture internal vasculature that can be anastomosed to the host circulatory system. Creation of synthetic tissues with microvascular networks that adequately mimic the size and density of in vivo capillaries remains one of the foremost challenges within tissue engineering, as cells must reside within 200–300 μm of vasculature for long‐term survival. In our previous work, we used a sacrificial microfibre technique whereby Pluronic® F127 fibres were embedded and then sacrificed within a collagen matrix, leaving behind a patent channel, which was subsequently seeded with endothelial and smooth muscle cells, forming a neointima and neomedia. We now have extended our technique and describe two approaches to synthesize a biocompatible tissue‐engineered construct with macro‐inlet and ‐outlet vessels, bridged by a dense network of cellularized microvessels, recapitulating the hierarchical organization of an arteriole, venule and capillary bed, respectively. Copyright

Flap coverage for the treatment of exposed left ventricular assist device (LVAD) hardware and intractable LVAD infections

Left ventricular assist devices (LVADs) have become useful adjuncts in the treatment of patients with end‐stage heart failure. LVAD implantation is associated with a unique set of problems; one such problem is device infection. We report our experience with flap salvage of infected and/or exposed LVAD hardware.

Abstract 162: in vivo microanastomosis of microvessel containing tissue-engineered constructs: the final frontier.

PurPose: Although autologous tissue transfer has been established as a reliable approach to the reconstruction of complex defects, there are associated consequences including donor site pain, functional loss, paresthesias, dysthesthia, and scarring. The ability to synthesize vascularized constructs for the management of these complex wounds would represent a quantum leap in the field of tissue engineering. In previous work we synthesized and performed an in vivo microvascular anastomosis of a collagen construct containing an unseeded internal longitudinal microchannel with inlet and outlet. Here we fabricate and microsurgically anastomose collagen constructs containing an internal endothelialized microchannel.

Abstract: Robotically Harvested Peritoneal Flaps As a Well-Vascularized Adjunct to Penile Inversion Vaginoplasty

was 180 days (SD 154. 41). When studying potential risk factors for amputation between the amputation vs non-amputation cohorts, none of the following, relevant, variables were found to be statistically significant: Presence of peripheral vascular disease (PVD) (50.0% in the amputation cohort vs 35.6% in the non-amputation cohort, p=0.31), tobacco use (56.3% vs 48.9%, p= 0.61), mean Hemoglobin A1C (7.6+/2.4 vs 7.3 +/2, p=0.74), presence of osteomyelitis/chronic infection (93.8% vs 80.0%, p=0.20), preoperative hemoglobin (9.9 +/0.9 vs 10.2 +/1.1, p=0.41), and pre-operative creatinine (0.9 +/0.3 vs 1 +/0.5, p=0.38).

Abstract 42: Trends of Maintenance Immunosuppression in Hand and Facial Transplantation

PURPOSE: In select patients, vascularized composite allotransplantation (VCA) offers functional and aesthetic outcomes superior to autologous reconstruction. However, its role in the reconstructive armamentarium is limited by the need for life-long immunosuppression. Furthermore, some studies have suggested that skin-containing VCA requires greater maintenance immunosuppression than solid organ transplants due to higher antigenicity. This study evaluates trends of maintenance immunosuppression in skin-containing VCA recipients and kidney recipients to determine differences in therapeutic risk.

Abstract QS10: Comparing Reconstructive Outcomes in Patients with Gustillo Type IIIB Fractures and Concomitant Arterial Injuries

PURPOSE: Despite advances in microsurgery, higher complication rates have persisted among lower extremity free tissue transfers. Historically, the Gustillo Classification has been utilized as a proxy for injury severity, but recent studies have shown that the rate of complications, notably flap failure, directly increase as arterial runoff decreases. When injured arteries are identified in patients requiring lower extremity free tissue transfer, a wide array of treatment options are possible: end-to-end or end-to-side anastomosis can be performed on either the injured vessel in question or on uninjured adjacent vessels. This study aims to compare the outcomes of these different treatment methods based on the number of injured vessels identified.

Abstract: Microsurgery for Parotidectomy Defects

M oday, O cber 1, 2018 The reconstruction of 3D facial surface geometry from pre-injury 2D photographs has recently been established through large scale morphable face modeling. As well, in forensic sciences, models with variable soft-tissue depths are used to determine face shape from skull geometry. This study aims to ‘reverse-engineer’ a forensics’ tissue depth model to determine pre-injury CFS shape from reconstructed 3D facial geometry. It is hypothesized that 3D forensics data can be used to fill in missing gaps in CFS geometry with sufficient accuracy to guide pre-operative planning for CFS reconstruction.

Proximal versus Distal Recipient Vessels in Lower Extremity Reconstruction: A Retrospective Series and Systematic Review

Background Recipient vessels proximal to the zone of injury have traditionally been preferred for lower extremity reconstruction. However, more recent data have shown mixed outcomes when performing anastomoses distal to the zone of injury. We investigated the impact of recipient vessel location on free flap outcomes. Methods Retrospective review (1979‐2016); 312 soft tissue free flaps for open tibia fractures met inclusion criteria. Flap characteristics and perioperative outcomes were examined. Systematic review identified articles evaluating anastomosis location and flap outcomes; pooled data analysis was performed. Results More anastomoses were performed proximal to the zone of injury (80.7%) than distal (19.3%). Distal anastomoses were not associated with increased take back rates (19.6%) compared with proximal (23.8%) anastomoses (p = 0.356). Regression analysis comparing proximal and distal anastomoses found no difference in partial flap failures (7.4% vs 11.9%; p = 0.978) or total flap failures (9.3% vs 9.3%; p = 0.815) when controlling for the presence of arterial injury, flap type, and time from injury to coverage. Systematic review yielded 11 articles with 1,245 proximal and 127 distal anastomoses for comparison. Pooled analysis (p = 0.58) and weighted comparative analysis (p = 0.39) found no difference in flap failure rates between proximal and distal groups. Conclusion Our results are congruent with the current lower extremity literature and demonstrate no difference in perioperative complication rates between anastomoses performed proximal or distal to the zone of injury. These findings suggest that anastomotic location choice should be based primarily on recipient vessel quality/flow and ease of access/exposure rather than orientation relative to the zone of injury.

Comparison of Hand-Sewn versus Coupled Venous Anastomoses in Traumatic Lower Extremity Reconstruction

Background Microvascular reconstruction of the lower extremity has the highest reported complication and flap failure rates of any anatomical region. Despite widespread adoption of the mechanical anastomotic venous coupler and encouraging results in other anatomical regions, there are limited reports examining its use in the lower extremity. This study compares outcomes between coupled and hand‐sewn venous anastomoses in traumatic lower extremity reconstruction. Methods Retrospective review of our institutional flap registry from 1979 to 2016 identified soft tissue free flaps performed for the reconstruction of Gustilo type IIIB/IIIC open tibial fractures. Patient demographics, flap characteristics, use of a venous anastomotic coupler, and perioperative outcomes were examined. Analysis was performed using chi‐square and Students t ‐tests. Results A total of 361 patients received a microvascular free flap for coverage of a Gustilo type IIIB or IIIC tibial fracture following traumatic injury. After excluding cases that lacked adequate information on coupler use, 358 free flaps were included in the study. There were 72 (20%) free flaps performed using a venous coupler and 286 (80%) performed with hand‐sewn venous anastomoses. There were comparable rates of major complications (22.2 vs. 26.1%; p = 0.522), total flap failure (6.5%, vs. 10.2%; p = 0.362), and partial flap failure (9.7 vs. 12.2%; p = 0.579) between venous coupler and hand‐sewn anastomoses, respectively. Furthermore, use of the venous coupler was not associated with increased rates of operative take backs (22.8 vs. 23.0%; p = 0.974). However, reconstructions performed using a venous coupler were significantly more likely to have a second venous anastomosis performed (37.5 vs. 21.3%; p = 0.004). Conclusion Complication and flap failure rates were similar between reconstructions performed with a venous coupler and those performed with hand‐sewn venous anastomoses. These findings suggest that use of the venous anastomotic coupler is safe and effective in lower extremity reconstruction, with comparable outcomes to conventional sutured anastomoses.