Charles E. Butler

Pelvic, abdominal, and chest wall reconstruction with AlloDerm in patients at increased risk for mesh-related complications

Background: The use of polypropylene mesh in the reconstruction of trunk defects increases complication rates when the mesh is placed directly over viscera or the operative site has been irradiated or contaminated with bacteria. An alternative is AlloDerm (decellularized human cadaveric dermis), which becomes vascularized and remodeled into autologous tissue after implantation. When used for fascial reconstruction, AlloDerm forms a strong repair, causes minimal abdominal adhesions, and resists infection. Methods: We did a retrospective study of cancer patients at increased risk for mesh-related complications who underwent trunk reconstruction with AlloDerm over a 1-year period. Risk factors included unavoidable placement of mesh directly over the bowel or lung, perioperative irradiation, and/or bacterial contamination of the defect. The indications, defect characteristics, reconstructive techniques, complications, and surgical outcomes were evaluated. Results: Thirteen patients were included in the study. Indications for reconstruction were oncologic resection, resection of enterocutaneous fistula, and/or ventral hernia repair. Seven patients had bacterial contamination at the operative site and seven patients received perioperative radiation. The mean musculofascial defect size was 435 cm2. AlloDerm was placed directly over the bowel or lung in all patients. Nine patients required flap reconstruction, including 14 pedicled and two free flaps. The mean follow-up was 6.4 months. Complications occurred in six patients, however, there were no clinically evident mesh infections, hernias, or bulges. Conclusions: AlloDerm successfully can be used in reconstructions for large, complex pelvic, chest, and abdominal wall defects even when placed directly over viscera and when the operative field is irradiated and/or contaminated with bacteria.

Reduction of adhesions with composite AlloDerm/polypropylene mesh implants for abdominal wall reconstruction

Ventral hernia repair often includes the use of structural prosthetic materials, such as polypropylene mesh, that can induce dense abdominal adhesions to peritoneal structures. AlloDerm (LifeCell Corp., Branchburg, N.J.), a commercially available decellularized human dermal analogue with its native basement membrane components intact, is gradually revascularized and replaced with autologous tissue after implantation. The authors hypothesized that AlloDerm integrated with polypropylene mesh would reduce adhesions and provide a biodegradable scaffold to generate an autologous vascularized tissue layer separating the abdominal viscera from the mesh. Ventral hernia defects (3 x 1 cm) in 19 guinea pigs were repaired using an inlay technique with polypropylene mesh alone (n = 6) or with composite implants constructed by integrating polypropylene mesh and AlloDerm with its basement membrane surface oriented toward (polypropylene/AlloIn, n = 7) or away from (polypropylene/ AlloOut, n = 6) the peritoneal cavity. At 4 weeks, the authors determined the amount of mesh implant surface area covered by adhesions, the strength of the adhesions [graded from 0 (none) to 3], and the incidence of bowel adhesions. Histologic analyses were performed on full-thickness tissue sections from the repair sites. The mean surface areas affected by adhesions and mean adhesion strength were significantly lower in the polypropylene/AlloIn (area, 12.4 percent; mean grade, 1.0) and polypropylene/AlloOut (area, 9.5 percent; mean grade, 0.5) groups than in the polypropylene group (area, 79.5 percent; mean grade, 2.9); there were no such differences between the polypropylene/AlloIn and polypropylene/AlloOut groups. The bowel was adherent to 67 percent of polypropylene repairs and 0 percent of the composite mesh repairs. The AlloDerm was remodeled to form a vascularized tissue layer beneath the mesh in composite repairs, unlike the significantly thinner, dense scar layer that formed in the polypropylene repairs. Immunohistochemical labeling for factor VIII showed neovascularization throughout the AlloDerm. The AlloDerm thus functioned as a biodegradable tissue scaffold, guiding the formation of a thick, well-vascularized tissue layer separating the polypropylene mesh from intraperitoneal structures. This significantly reduced both the amount of surface area covered by adhesions and adhesion strength. Basement membrane orientation had no effect. Composite mesh implants composed of structural prosthetic materials integrated with AlloDerm may have useful clinical applications for abdominal wall reconstruction by reducing adhesions and providing a vascularized tissue layer to separate and protect the peritoneal structures from polypropylene mesh fibers.

Outcomes of Immediate Vertical Rectus Abdominis Myocutaneous Flap Reconstruction for Irradiated Abdominoperineal Resection Defects

BACKGROUND Perineal wound complications after chemoradiotherapy and abdominoperineal resection (APR) for anorectal cancer occur in up to 60% of patients, including perineal abscess and wound dehiscence. Vertical rectus abdominis myocutaneous (VRAM) flaps have been used in an attempt to reduce these complications by obliterating the noncollapsible dead space with vascularized tissue and closing the perineal skin defect with nonirradiated flap skin. Many surgeons are reluctant to use VRAM flaps unless primary closure is not possible. STUDY DESIGN All patients who underwent chemoradiotherapy and APR during a 12-year period at the University of Texas MD Anderson Cancer Center were retrospectively reviewed. Patient, tumor, and treatment characteristics and surgical complications and outcomes were compared between patients who underwent VRAM flap reconstruction of wounds that could have been closed primarily (flap group, n = 35) and those who had primary closure of the perineal wound (control group, n = 76). RESULTS Overall, there were no significant differences in the incidence of perineal wound complications between the groups; the flap group had a significantly lower incidence of perineal abscess (9% versus 37%, p = 0.002), major perineal wound dehiscence (9% versus 30%, p = 0.014), and drainage procedures required for perineal/pelvic fluid collections (3% versus 25%, p = 0.003) than the control group had. Despite flap harvest and the need for donor site closure in the flap group, there was no significant difference in abdominal wall complications between groups during the studys mean patient followup of 3.8 years. CONCLUSIONS VRAM flap reconstruction of irradiated APR defects reduces major perineal wound complications without increasing early abdominal wall complications. Strong consideration should be given to immediate VRAM flap reconstruction after chemoradiation and APR.

Recurrence following treatment of ductal carcinoma in situ with skin-sparing mastectomy and immediate breast reconstruction

&NA; Skin‐sparing mastectomy with immediate breast reconstruction can provide an excellent cosmetic result. Despite its increasing popularity, few studies have assessed the risk of recurrence when the procedure is used for the treatment of ductal carcinoma in situ. To evaluate the oncologic safety of skin‐sparing mastectomy used for the treatment of ductal carcinoma in situ, the recurrence rate was analyzed. Patients with ductal carcinoma in situ or invasive carcinoma or both who underwent skin‐sparing mastectomy with immediate breast reconstruction between 1985 and 1994 and had a follow‐up period of at least 6 years were included in this retrospective analysis. The recurrence rates were determined for invasive carcinoma (with or without foci of ductal carcinoma in situ) and ductal carcinoma in situ alone. A total of 221 patients were included, 177 patients with invasive carcinoma and 44 patients with ductal carcinoma in situ alone. The immediate breast reconstructions were performed with transverse rectus abdominis muscle (TRAM) flaps in 62 percent of patients, implants in 34 percent of patients, and latissimus dorsi myocutaneous flaps (with or without implants) in I percent of patients. The local recurrence rate was zero of 44 for patients with ductal carcinoma in situ and 5.6 percent (10 of 177) for patients with invasive carcinoma during a mean follow‐up period of 9.8 years. There was a 6.8 percent (12 of 177) metastatic recurrence rate in the invasive carcinoma group. All recurrences were invasive ductal carcinoma. Of the patients with ductal carcinoma in situ alone, none developed metastatic disease. The combined metastatic and local recurrence rates for the invasive carcinoma group (n = 177) with each type of reconstruction were 13 percent (14 of 110), 12 percent (seven of 60), and 14 percent (one of seven) for TRAM flaps, implants, and latissimus dorsi flaps, respectively. The risk of recurrence following skin‐sparing mastectomy and immediate breast reconstruction for ductal carcinoma in situ is low during this follow‐up period. Therefore, skinsparing mastectomy with immediate breast reconstruction seems to be a safe oncologic treatment option for ductal carcinoma in situ; however, a longer follow‐up period is important to determine the long‐term risk of recurrence. (Plast. Reconstr. Surg. 111: 706, 2003.)

Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects

Background: Reconstruction following abdominoperineal resection or pelvic exenteration is commonly performed with regional flaps from the thigh or abdomen. This study compared the surgical outcomes and complications in cancer patients who underwent immediate reconstruction of these defects with vertical rectus abdominis myocutaneous (VRAM) versus thigh flaps. Methods: One hundred thirty-three patients who underwent abdominoperineal resection or pelvic exenteration for cancer resection and immediate VRAM (n = 114) or thigh flap (n = 19) reconstruction of the perineal/pelvic defect were studied. Patient, tumor, and treatment characteristics; surgical outcomes; and postoperative donor- and recipient-site complications were compared between the two groups. Multivariate logistic regression analysis was used to identify predictive/protective factors for complications. Results: The thigh flap group had a significantly greater incidence of major complications (42 percent versus 15 percent) than the VRAM flap group. They also had significantly higher rates of donor-site cellulitis (26 percent versus 6 percent) and recipient-site complications, including cellulitis (21 percent versus 4 percent), pelvic abscess (32 percent versus 6 percent), and major wound dehiscence (21 percent versus 5 percent). Abdominal wall complications were not increased in the VRAM group despite flap harvest from the abdominal wall. Obesity was an independent predictor of any donor-site complication (odds ratio, 3.3) and previous abdominal surgery was a predictor of any complication (odds ratio, 3.6), any recipient-site complication (odds ratio, 3.5), and any major complication (odds ratio, 3.6). Conclusion: Immediate VRAM flaps result in fewer major complications than thigh flaps without increased early abdominal wall morbidity when used to repair abdominoperineal resection and pelvic exenteration defects.

Comparison of cross-linked and non-cross-linked porcine acellular dermal matrices for ventral hernia repair

BACKGROUND Porcine acellular dermal matrices (PADMs) have been used clinically for abdominal wall repair. The newer non-cross-linked PADMs, however, have not been directly compared with cross-linked PADMs. We hypothesized that chemical cross-linking affects the biologic host response to PADMs used to repair ventral hernias. STUDY DESIGN Fifty-eight guinea pigs underwent inlay repair of surgically created ventral hernias using cross-linked or non-cross-linked PADM. After animals were sacrificed at 1, 2, or 4 weeks, the tenacity of and surface area involved by adhesions to the repair sites were measured. Sections of the repair sites, including the bioprosthesis-musculofascia interface, underwent histologic analysis of cellular and vascular infiltration plus mechanical testing. RESULTS Compared with cross-linked PADM repairs, non-cross-linked PADM repairs had a significantly lower mean tenacity grade of adhesions at all timepoints and mean adhesion surface area at week 1. Mean cellular and vascular densities were significantly higher in non-cross-linked PADM at all timepoints. Cells and vessels readily infiltrated into the center of non-cross-linked PADM, but encapsulated cross-linked PADM, with a paucity of penetration into it. Mechanical properties were similar for the two PADMs (in isolation) at all timepoints; however, at the bioprosthesis-musculofascia interface, both elastic modulus and ultimate tensile strength were significantly higher at weeks 1 and 2 for non-cross-linked PADM. CONCLUSIONS Non-cross-linked PADM is rapidly infiltrated with host cells and vessels; cross-linked PADM becomes encapsulated. Non-cross-linked PADM causes weaker adhesions to repair sites while increasing the mechanical strength of the bioprosthesis-musculofascia interface at early timepoints. Non-cross-linked PADM may have early clinical advantages over cross-linked PADM for bioprosthetic abdominal wall reconstruction.

Retrospective study of the management of chemotherapeutic extravasation injury

Despite the now widespread experience with the administration of chemotherapeutic agents in oncology, extravasation injuries still occur. Furthermore, the most appropriate management of such injuries is not known. The authors examined the current treatment options for extravasation injury and the incidence of this problem. All cases of extravasation referred to the plastic surgery service at one institution from 1994 through 1996 were examined. During a 6-year period there were 44 cases of extravasation injury identified in 42 patients. Comparison with a previous study conducted 15 years before at the same institution revealed a significant reduction in the incidence of extravasation injuries during that time (0.01% vs. 0.1%;p = 0.00). The site of extravasation was peripheral in 32 cases and central in 12. Paclitaxel and doxorubicin were the two most common drugs involved. The local infusion of antidotes was not performed routinely. Only 26 of the 42 patients were referred to the plastic surgery service for care. Only 10 of those 26 patients required local ulcer excision and closure to achieve a healed wound. The mean time between injury and referral was 40 days. This time did not predict the subsequent need for a surgical procedure. Most patients, including the remaining 16 referred to the plastic surgery service, did not require surgical intervention. All were watched expectantly, and their injuries healed spontaneously. In conclusion, the incidence of extravasation is decreasing, most likely as a result of the diligence in the administration and identification of extravasation injuries as well as the result of the use of more central infusion sites. Most cases can be managed conservatively, with directed surgical treatment of the ulceration when appropriate.

Minimally invasive component separation with inlay bioprosthetic mesh (MICSIB) for complex abdominal wall reconstruction

Background: Ventral hernia repair can be challenging, particularly in patients with serious comorbidity. Minimally invasive component separation with inlay bioprosthetic mesh (MICSIB) uses tunnel incisions for external oblique aponeurosis release. It preserves both the rectus abdominis myocutaneous perforator vessels that supply the overlying skin and the connection between the subcutaneous fat and anterior rectus sheath, thereby reducing subcutaneous dead space and potentially improving overlying skin flap vascularity. Inlay bioprosthetic mesh reinforces the musculofascial repair. This study evaluated surgical outcomes of the technique used to repair challenging ventral hernias in cancer patients. Methods: Data from all patients who underwent minimally invasive component separation with inlay bioprosthetic mesh abdominal wall reconstruction from 2007 to 2010 were analyzed. Surgical outcomes assessed included wound complications, hernia recurrence, and repair-site bulge/laxity. Results: Thirty-eight cancer patients (mean age, 63.3 years) considered at high risk for wound healing complications and hernia recurrence were included: 80 percent had preexisting medical comorbidities, 42 percent had infected or contaminated defects, and 26 percent had previous ventral hernia repairs. Despite the mean fascial defect size of 494 ± 229 cm2, only seven patients required a bridged repair. During a mean follow-up of 12.4 months, three patients (8 percent) required operative interventions, and nonoperative complications occurred in eight (21 percent). None developed a postoperative laxity/bulge; one (3 percent) had a hernia recurrence requiring operative repair. Conclusion: Minimally invasive component separation with inlay bioprosthetic mesh yields acceptable early outcomes in complex patients, likely because it reduces subcutaneous dead space, preserves the vascularity of overlying skin, and reinforces the musculofascial repair with mesh. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Complete Surgical Excision Is Essential for the Management of Patients With Breast Implant–Associated Anaplastic Large-Cell Lymphoma

PURPOSE Breast implant-associated anaplastic large-cell lymphoma (BI-ALCL) is a rare type of T-cell lymphoma that arises around breast implants. The optimal management of this disease has not been established. The goal of this study is to evaluate the efficacy of different therapies used in patients with BI-ALCL to determine an optimal treatment approach. PATIENTS AND METHODS In this study, we applied strict criteria to pathologic findings, assessed therapies used, and conducted a clinical follow-up of 87 patients with BI-ALCL, including 50 previously reported in the literature and 37 unreported. A Prentice, Williams, and Peterson model was used to assess the rate of events for each therapeutic intervention. RESULTS The median and mean follow-up times were 45 and 30 months, respectively (range, 3 to 217 months). The median overall survival (OS) time after diagnosis of BI-ALCL was 13 years, and the OS rate was 93% and 89% at 3 and 5 years, respectively. Patients with lymphoma confined by the fibrous capsule surrounding the implant had better event-free survival (EFS) and OS than did patients with lymphoma that had spread beyond the capsule (P = .03). Patients who underwent a complete surgical excision that consisted of total capsulectomy with breast implant removal had better OS (P = .022) and EFS (P = .014) than did patients who received partial capsulectomy, systemic chemotherapy, or radiation therapy. CONCLUSION Surgical management with complete surgical excision is essential to achieve optimal EFS in patients with BI-ALCL.

Non-cross-linked porcine acellular dermal matrices for abdominal wall reconstruction

Background: Non–cross-linked porcine acellular dermal matrices have been used clinically for abdominal wall repair; however, their biologic and mechanical properties and propensity to form visceral adhesions have not been studied. The authors hypothesized that their use would result in fewer, weaker visceral adhesions than polypropylene mesh when used to repair ventral hernias and form a strong interface with the surrounding musculofascia. Methods: Thirty-four guinea pigs underwent inlay repair of surgically created ventral hernias using polypropylene mesh, porcine acellular dermal matrix, or a composite of the two. The animals were killed at 4 weeks, and the adhesion tenacity grade and surface area of the repair site involved by adhesions were measured. Sections of the repair sites, including the implant-musculofascia interface, underwent histologic analysis and uniaxial mechanical testing. Results: The incidence of bowel adhesions to the repair site was significantly lower with the dermal matrix (8 percent, p < 0.01) and the matrix/mesh combination (0 percent, p < 0.001) than with polypropylene mesh alone (70 percent). The repairs made with the matrix or the matrix/mesh combination, compared with the polypropylene mesh repairs, had significantly lower mean adhesion surface areas [12.8 percent (p < 0.001), 9.2 percent (p < 0.001), and 79.9 percent] and grades [0.6 (p < 0.001), 0.6 (p < 0.001), and 2.9]. The dermal matrix underwent robust cellular and vascular infiltration. The ultimate tensile strength at the implant-musculofascia interface was similar in all groups. Conclusions: Porcine acellular dermal matrix becomes incorporated into the host tissue and causes fewer adhesions to repair sites than does polypropylene mesh, with similar implant-musculofascia interface strength. It also inhibits adhesions to adjacent dermal matrix in the combination repairs. It has distinct advantages over polypropylene mesh for complex abdominal wall repairs, particularly when material placement directly over bowel is unavoidable.