Bridget Harrison

Wound Healing: Part I. Basic Science

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe the basic physiologic events in normal wound healing. 2. Understand the differences in healing among skin, bone, cartilage, and tendon. 3. Identify factors that may compromise or delay wound healing. 4. Describe methods for optimal closure of a wound. SUMMARY Understanding the physiology and pathophysiology of normal wound healing and potential impediments to its end will allow the plastic surgeon to maximize postoperative outcomes and, in some instances, avoid unnecessary surgical interventions. Continuous advancements in our understanding of this process require frequent reviews of available data to permit reliable, evidence-based recommendations for clinical application. This is the first of a two-part article summarizing the science and clinical recommendations necessary for successful wound healing.

Timing of traumatic upper extremity free flap reconstruction: a systematic review and progress report.

Background: The recommendations on the timing of microsurgical extremity reconstruction are as variable and numerous as the flaps described for such reconstruction. Original articles suggested that reconstruction should take place within 72 hours of injury. However, significant changes in perioperative and intraoperative management have occurred in this field, which may allow for more flexibility in the timing of reconstruction. This article aims to review current literature on timing of upper extremity reconstruction to provide the microsurgeon with up-to-date recommendations. Methods: A structured literature search including Spanish and English language articles published between January of 1995 and December of 2011 was performed using the MEDLINE and Scopus databases. The search strategy was conducted using groups of key words, and articles were subsequently reviewed for relevance. Bibliographies of selected articles were further reviewed for additional relevant publications. Rates of total flap loss, infection, hospital stay, and bony nonunion were recorded and analyzed according to emergent (<24 hours), early (<5 days), primary (6 to 21 days), or delayed (>21 days) reconstruction. Results: Fifteen articles met inclusion criteria. There was no significant association between timing of reconstruction and rates of flap loss, infection, or bony nonunion. Linear regression analysis displayed a significant association between length of hospital stay and timing of reconstruction. Conclusions: No conclusive evidence exists to suggest that emergent, early, primary, or delayed reconstruction will eliminate or decrease complications associated with posttraumatic upper extremity reconstruction. Earlier reconstruction may decrease length of hospital stay and limit associated medical costs.

Evidence-Based Scar Management: How to Improve Results with Technique and Technology.

Background: Scars represent the visible sequelae of trauma, injury, burn, or surgery. They may induce distress in the patient because of their aesthetically unpleasant appearance, especially if they are excessively raised, depressed, wide, or erythematous. They may also cause the patient symptoms of pain, tightness, and pruritus. Numerous products are marketed for scar prevention or improvement, but their efficacy is unclear. Methods: A literature review of high-level studies analyzing methods to prevent or improve hypertrophic scars, keloids, and striae distensae was performed. The evidence from these articles was analyzed to generate recommendations. Each intervention’s effectiveness at preventing or reducing scars was rated as none, low, or high, depending on the strength of the evidence for that intervention. Results: For the prevention of hypertrophic scars, silicone, tension reduction, and wound edge eversion seem to have high efficacy, whereas onion extract, pulsed-dye laser, pressure garments, and scar massage have low efficacy. For the treatment of existing hypertrophic scars, silicone, pulsed-dye laser, CO2 laser, corticosteroids, 5-fluorouracil, bleomycin, and scar massage have high efficacy, whereas onion extract and fat grafting seem to have low efficacy. For keloid scars, effective adjuncts to excision include corticosteroids, mitomycin C, bleomycin, and radiation therapy. No intervention seems to have significant efficacy in the prevention or treatment of striae distensae. Conclusion: Although scars can never be completely eliminated in an adult, this article presents the most commonly used, evidence-based methods to improve the quality and symptoms of hypertrophic scars, as well as keloid scars and striae distensae.

The Association Between Glomus Tumors and Neurofibromatosis

PURPOSE To determine whether an epidemiologic association exists between glomus tumors and neurofibromatosis. METHODS Using a pathology database, we established a study cohort consisting of all patients who had undergone excision of a glomus tumor of the hand between 1995 and 2010. We created a control cohort by randomly selecting 200 patients who had undergone excision of a ganglion cyst over the same period. We reviewed medical records for each cohort to identify patients with a diagnosis of neurofibromatosis. We calculated the odds ratio was calculated and performed Fishers exact test to determine the significance of the association. RESULTS We identified 21 patients with glomus tumors of the hand. Six of these patients carried the diagnosis of neurofibromatosis (29%). In contrast, no patients in the control group carried the diagnosis of neurofibromatosis. The odds ratio for a diagnosis of neurofibromatosis in association with a glomus tumor compared with controls was 168:1. CONCLUSIONS This study provides evidence of a strong epidemiologic association between glomus tumors and neurofibromatosis. Glomus tumor should be included in the differential diagnosis in neurofibromatosis patients who present with a painful lesion of the hand or finger. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic III.

Evidence-Based Strategies to Reduce Postoperative Complications in Plastic Surgery.

Summary: Reconstructive plastic surgery is vital in assisting patients with reintegration into society after events such as tumor extirpation, trauma, or infection have left them with a deficit of normal tissue. Apart from performing a technically sound operation, the plastic surgeon must stack the odds in the favor of the patient by optimizing them before and after surgery. The surgeon must look beyond the wound, at the entire patient, and apply fundamental principles of patient optimization. This article reviews the evidence behind the principles of patient optimization that are commonly used in reconstructive surgery patients.

The discordant histology of grafted fat: a systematic review of the literature.

Background: All combinations of harvesting, processing, and injection have been attempted to maximize fat graft take following transplantation. Two theories behind fat transplantation have been proposed: cell survival and host replacement. Although the cell survival theory states that fat cells survive and undergo neovascularization following transfer, host replacement theory predicts adipocyte necrosis and replacement of cells by host tissues. Whether or not transferred fat survives, proliferates, or is replaced by fibrous tissue is relevant for the investment of future resources into this thriving field of research. Methods: A literature search of the MEDLINE and Cochrane databases was performed for studies focusing on the histology of grafted fat after transplantation up to December of 2013. Histologic examinations of grafted fat were reviewed and compared in humans and animals. Results: Sixty-six articles met inclusion criteria, and eight of them were human studies. There was widespread diversity in the method of fat harvest and transfer among the studies, and the date of examination after transfer. Many studies reported the presence of viable adipocytes, although an extensive amount of fibrosis and inflammatory infiltration was also seen, depending on the period of examination. Conclusions: Free fat grafts show a variable response following transplantation, with significant disagreement in the reported evidence. Although neovascularization and preservation of adipocyte architecture appear possible, other fat grafts are completely replaced by necrotic ghost cells and fibrotic ingrowth. Adipocyte survival likely contributes to volume maintenance, but fibrosis may also play a role.

Involuntary movement during mastication in patients with long-term facial paralysis reanimated with a partial gracilis free neuromuscular flap innervated by the masseteric nerve

Background: Midface reanimation in patients with chronic facial paralysis is not always possible with an ipsilateral or contralateral facial nerve innervating a free neuromuscular tissue transfer. Alternate use of nonfacial nerves is occasionally indicated but may potentially result in inadvertent motions. The goal of this study was to objectively review videos of patients who underwent one-stage reanimation with a gracilis muscle transfer innervated by the masseteric nerve for (1) inadvertent motion during eating, (2) characterization of masticatory patterns, and (3) social hindrance perceived by the patients during meals. Methods: Between the years 2009 and 2012, 18 patients underwent midfacial reanimation with partial gracilis muscle transfer coapted to the masseter nerve for treatment of midfacial paralysis. Sixteen patients were videotaped in detail while eating. Involuntary midface movement on the reconstructed side and mastication patterns were assessed. In addition, 16 patients were surveyed as to whether involuntary motion constituted a problem in their daily lives. Results: All 16 patients videotaped during mastication demonstrated involuntary motion on the reconstructed side while eating. Several unique masticatory patterns were noted as well. Only one of the 16 patients reported involuntary motion as a minor disturbance in daily life during meals. Conclusions: All patients with chronic facial paralysis who plan to undergo midface reanimation with a free tissue transfer innervated by the ipsilateral masseter nerve should be told that they would universally have involuntary animation during mastication. Most patients do not consider this a major drawback in their daily lives. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Fat Graft Viability in the Subcutaneous Plane versus the Local Fat Pad

Background: Fat grafting has been increasingly utilized in both aesthetic and reconstructive surgical procedures, yet the basic scientific understanding of fat grafting has lagged behind the pace of clinical innovation and utilization. This lack of basic scientific understanding has perhaps manifested itself in the wide range of graft viability reported across the literature. This study attempts to further the underlying mechanisms of fat graft take and viability through the comparison of the subcutaneous plane and the local fat pad in athymic rats. Methods: Lipoaspirate from a consenting patient was grafted into 2 locations in the subcutaneous plane and into the 2 inguinal fat pads in each of 4 athymic rats. Specimens were then collected after 47 days, and immunohistochemistry was utilized to determine angiogenesis in the fat grafts as a measure of fat graft take. Data were analyzed using the Student’s t test and analysis of variance followed by multiple comparisons. Results: There was no statistically significant difference (P = 0.2913) between the inguinal fat pad and the subcutaneous plane when measuring neovascularization. Analysis of variance comparing the graft locations also indicated no statistically significant difference when comparing each of the rats. Conclusions: Investigation into fat graft injection location indicates that there is no statistically significant difference in angiogenesis signals between the subcutaneous plane and the local fat pad in the athymic rat model. Further research should aim to continue to close the gap between clinical practice and basic scientific understanding of fat grafting.

Glomus tumors and neurofibromatosis: a newly recognized association.

Background: Glomus tumors are painful benign tumors arising from the neuromyoarterial elements of the glomus body, typically in a subungual location. Historically, glomus tumors have been considered isolated or sporadic, not typically associated with other disease processes. Over the last few years, however, multiple case reports, a molecular genetics study, and an epidemiologic study have confirmed an association between type I neurofibromatosis and glomus tumors. The purpose of this review is to summarize the existing information about the association between neurofibromatosis and glomus tumors and to determine whether glomus tumors that are associated with neurofibromatosis differ from isolated glomus tumors in terms of tumor number, location, and sex distribution. Methods: A PubMed, Ovid Medline, and Cochrane Database search was performed using the terms “glomus tumor,” “glomus tumour,” and “glomangioma” each combined with the search term “neurofibromatosis.” Fifteen English language articles were included. Information about the molecular genetics, patient sex, number of tumors per patient, and tumor location were recorded. Results: A total of 36 patients with glomus tumors and neurofibromatosis have been reported in the literature. Seventy-nine percent were female. Tumors were multifocal in 32% of patients, with an average of 1.4 glomus tumors per patient. Glomus tumors arose in a nonsubungual location in 38% of patients. Conclusions: A strong association between type I neurofibromatosis and glomus tumors has been identified. In neurofibromatosis patients with glomus tumors, the sex distribution, tumor location, and tumor burden appear similar to those in patients with isolated glomus tumors. Treating providers should be aware of this association to facilitate prompt diagnosis and treatment.

Collagenopathies—Implications for Abdominal Wall Reconstruction: A Systematic Review

Background: The etiology of hernia formation is strongly debated and includes mechanical strain, prior surgical intervention, abnormal embryologic development, and increased intraabdominal pressure. Although the most common inciting cause in ventral hernias is previous abdominal surgery, many other factors contribute. We explore this etiology through an examination of the current literature and existing evidence on patients with collagen vascular diseases, such as Ehlers–Danlos syndrome. Methods: A systematic review of the published literature was performed of all available Spanish and English language PubMed and Cochrane articles containing the key words “collagenopathies,” “collagenopathy,” “Ehlers-Danlos,” “ventral hernia,” and “hernia.” Results: Three hundred fifty-two articles were identified in the preliminary search. After review, 61 articles were included in the final review. Conclusions: Multiple authors suggest a qualitative or quantitative defect in collagen formation as a common factor in hernia formation. High-level clinical data clearly linking collagenopathies and hernia formation are lacking. However, a trend in pathologic studies suggests a link between abnormal collagen production and/or processing that is likely associated with hernia development.