Christine M. Jones

Posterior Component Separation with Transversus Abdominis Release: Technique, Utility, and Outcomes in Complex Abdominal Wall Reconstruction.

Background: Ventral hernia formation is a frequent and increasingly difficult problem. Nonmidline hernias, parastomal hernias, hernias near bony landmarks, and recurrent ventral hernias (especially after anterior component separation) present particular challenges. Typical reconstructive techniques may struggle to reestablish abdominal domain and to create a lasting repair. Posterior component separation with transversus abdominis release is a novel technique that offers a durable solution to a variety of complex ventral hernias. Methods: The posterior rectus sheath is incised and the retrorectus plane is developed. In a modification of the Rives-Stoppa technique, the transversus abdominis is released medial to the linea semilunaris to expose a broad plane that extends from the central tendon of the diaphragm superiorly, to the space of Retzius inferiorly, and laterally to the retroperitoneum. This preserves the neurovascular bundles innervating the medial abdominal wall. Mesh is placed in a sublay fashion above the posterior layer. In an overwhelming majority of patients, the linea alba is reconstructed, creating a functional abdominal wall with wide mesh reinforcement. Results: The technique is reliable and durable, with a 5 percent recurrence rate at 2 years. Although wound complications occur with a frequency similar to that of other techniques, they tend to be less severe, rarely requiring operative débridement. The technique is applicable to a broad range of hernias, including midline, parastomal, flank, subcostal, and recurrent hernias after prior component separations. Conclusion: Posterior component separation with transversus abdominis release is a versatile, easy-to-learn technique of hernia repair that offers a reliable, durable solution to complex abdominal wall reconstruction.

Fibroblast expression of α-smooth muscle actin, α2β1 integrin and αvβ3 integrin: Influence of surface rigidity

Open wound contraction necessitates cell and connective tissue interactions, that produce tension. Investigating fibroblast responses to tension utilizes collagen coated polyacrylamide gels with differences in stiffness. Human foreskin fibroblasts were plated on native type I collagen-coated polyacrylamide gel cover slips with different rigidities, which were controlled by bis-acrylamide concentrations. Changes in alpha smooth muscle actin (αSMA), α2β1 integrin (CD49B) and αvβ3 integrin (CD-51) were documented by immuno-histology and Western blot analysis. Cells plated on rigid gels were longer, and expressed αvβ3 integrin and αSMA within cytoplasmic stress fibers. In contrast, cells on flexible gels were shorter, expressed α2β1 integrin and had fine cytoskeletal microfilaments without αSMA. Increased tension changed the actin makeup of the cytoskeleton and the integrin expressed on the cells surface. These in vitro findings are in agreement with the tension buildup as an open wound closes by wound contraction. It supports the notion that cells under minimal tension in early granulation tissue express α2β1 integrin, required for organizing fine collagen fibrils into thick collagen fibers. Thicker fibers create a rigid matrix, generating more tension. With increased tension cytoskeletal stress fibers develop that contain αSMA and αvβ3 integrin that replaces α2β1 integrin, consistent with cell switching from collagen to non-collagen proteins interactions.

Structural Fat Grafting to Improve Reconstructive Outcomes in Secondary Cleft Lip Deformity

Objective To describe the technique and results of structural fat grafting in cleft lip revision, including patient satisfaction and aesthetic outcome. Design Retrospective case series Setting Multidisciplinary cleft care center. Patients All patients who underwent structural fat grafting between June 2006 and September 2012 for cleft lip revision, with appropriate photographic follow-up included. Twenty-two cases were reviewed; 18 had sufficient data to be included. Interventions Patients underwent structural fat grafting for cleft lip revision, most commonly injecting fat under deficient philtral columns, the nostril base, and upper lip. Main Outcome Measures Blinded observers rated outcomes using the Asher-McDade nasolabial appearance rating scale. Patients completed questionnaires assessing their satisfaction. A paired Students t-test was used to test outcomes for significance (alpha = 0.05). Results Patients were an average of 16 years old (range 6-43); average length of follow up was 11.7 months. Overall symmetry and aesthetics were improved based on the nasal form (P = 0.006) and vermillion border (P - 0.04) when rated using the Asher-McDade scale. No complications were recorded. Patients were significantly happier with their appearance after fat grafting (P < 0.001) and were uniformly positive when questioned about the ease of the surgery and rate of recovery. Conclusions Structural fat grafting is a safe and effective way to improve symmetry and enhance facial proportions in patients with cleft lip. Given the high degree of patient satisfaction, few complications, and durable results, fat grafting offers many advantages in cleft lip revision.

Evidence-Based Medicine: Wound Management

Learning Objectives: After reading this article, the participant should be able to: 1. Describe the basic science of chronic wounds. 2. Discuss the general and local factors that should be considered in any patient with a chronic wound. 3. Discuss the rationale of converting a chronic wound into an acute wound. 4. Describe techniques used to prepare chronic wounds. 5. Discuss the appropriate use of different dressings presented in this article. 6. Discuss the pros and cons of the adjuncts to wound healing discussed in this article. Summary: This is the second Maintenance of Certification article on wound healing. In the first, Buchanan, Kung, and Cederna dealt with the mechanism and reconstructive techniques for closing wounds. In this article, the authors have concentrated on the chronic wound. The authors present a summary of the basic science of chronic wounds and the general and local clinical factors important in assessing any chronic wound. The evidence for interventions of these conditions is presented. The surgical and nonsurgical methods of wound preparation and the evidence supporting the use of the popular wound dressings are presented. The authors then present the evidence for some of the popular adjuncts for wound healing, including hyperbaric oxygen, electrotherapy, and ultrasound. A number of excellent articles on negative-pressure wound therapy have been written, and are not covered in this article.

Reply: Posterior Component Separation with Transversus Abdominis Release

563e Reply: Posterior Component Separation with Transversus Abdominis Release: Technique, Utility, and Outcomes in Complex Abdominal Wall Reconstruction Sir: We would like to thank our Italian colleagues for their thoughtful comments about our technical overview and for adding their modification of a similar method. We would like to make a few comments about their modification in comparison with the transversus abdominis release we described.1 First, one of the advantages of transversus abdominis release is the elimination of all skin flaps with the Dublin, Ireland).5 The size of this aid should provide for an overlap of a minimum of 6 cm. The two muscle bellies of the rectus muscle are then sutured with interrupted stitches on the midline, anchoring them to the underlying mesh and posterior sheath (Fig. 1). This maneuver allows the surgeon to obliterate dead spaces, minimizing fluid collection and mesh displacement. The anterior fascia is sutured with both interrupted and running sutures. Analogous to the previous layer, this suture should anchor the anterior fascia to the underlying rectus muscle (Fig. 2). The adipocutaneous excess is excised as in a common tummy-tuck procedure. Once the Scarpa fascia is synthesized, subcutaneous closure and intradermal suturing are performed. Our technique allows negligible scar overlapping (cutaneous and abdominal wall incisions), minimizing contaminations. The subcutaneous dissection allows an easier approximation of recti muscles and fascia, whereas the adipocutaneous excision produces a tight cutaneous layer that is able to effectively contain the underlying wall. DOI: 10.1097/PRS.0000000000002453

Sparing a Craniotomy: The Role of Intraoperative Methylene Blue in Management of Midline Dermoid Cysts

Background: Midline nasal dermoid cysts are rare congenital anomalies that extend intracranially in approximately 10 percent of cases. Cysts with intracranial extension require a craniotomy to avoid long-term complications, including meningitis, abscesses, and cavernous sinus thrombosis. Current guidelines recommend preoperative imaging with either magnetic resonance imaging or computed tomography to determine appropriate management. Methods: Patients who underwent excision of a midline nasal dermoid cyst between January 1995 and September 2016 were identified using Current Procedural Terminology codes. In cases with equivocal imaging findings or uncertain stalk extent during surgical dissection, methylene blue was used intraoperatively. Demographics, preoperative imaging findings, intraoperative dye findings, surgical approach, and complications were collected. Results: A total of 66 midline dermoid cyst excisions were identified; 17 (25.8 percent) had intracranial extension requiring craniotomy. Preoperative imaging showed a subcutaneous cyst in 41 (62.1 percent), intraosseous tracking in three (4.5 percent), and intracranial extension in 15 (22.7 percent). Twelve patients (18.2 percent) had preoperative imaging that was inconsistent with intraoperative findings. Methylene blue was used in 17 cases and indigo carmine was used in one case. Intraoperative dye findings changed management in five cases, and in three cases a craniotomy was avoided without evidence of cyst recurrence. Conclusions: This report is the largest published series of midline dermoid cysts with intracranial extension. In almost 20 percent of cases, preoperative imaging was not consistent with intraoperative findings. Given disparate radiographic and intraoperative findings, methylene blue is a valuable tool that can facilitate appropriate, morbidity-sparing management of midline dermoid cysts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Americleft Project: Comparison of Ratings Using Two-Dimensional Versus Three-Dimensional Images for Evaluation of Nasolabial Appearance in Patients with Unilateral Cleft Lip and Palate

Abstract This study was conducted to determine if nasolabial appearance is rated with comparable results and reliability on 3-dimensional stereophotogrammetric facial images versus standard clinical photographs (2-dimensional). Twenty-seven consecutively treated patients with repaired complete unilateral cleft lip and palate were selected. Six trained and calibrated raters assessed cropped 2- and 3-dimensional facial images. Nasolabial profile, nasolabial frontal, and vermillion border esthetics were rated with the 5-point scale described by Asher-McDade using the modified Q-sort method. Cropped 3-dimensional images were available for viewing by each rater, allowing for complete rotational control for viewing the images from all aspects. Two- and three-dimensional ratings were done separately and repeated the next day. Interrater reliability scores were good for 2-dimensional (&kgr; = 0.607–0.710) and fair to good for 3-dimensional imaging (&kgr; = 0.374–0.769). Intrarater reliability was good to very good for 2-dimensional (&kgr; = 0.749–0.836) and moderate to good for 3-dimensional imaging (&kgr; = 0.554–0.855). Bland–Altman analysis showed satisfactory agreement of 2- and 3-dimensional scores for nasolabial profile and nasolabial frontal, but more systematic error occurred in the assessment of vermillion border. Although 3-dimensional images may be perceived as more representative of a direct clinical facial evaluation, their use for subjective rating of nasolabial aesthetics was not more reliable than 2-dimensional images in this study. Conventional 2-dimensional images provide acceptable reliability while being readily accessible for most cleft palate centers.

Do Pharyngeal Flaps Restrict Early Midface Growth in Patients With Clefts

Objective To compare facial growth characteristics in patients with cleft palate who have undergone pharyngeal flap with those who had palatal lengthening or pharyngoplasty and to control subjects who have not had surgery for velopharyngeal insufficiency (VPI). Design Matched retrospective cohort study. Setting Multidisciplinary cleft care center. Patients All patients with cleft palate who had undergone pharyngeal flap or pharyngoplasty/palatal lengthening for VPI were included. Patients with craniofacial syndromes or those who had undergone maxillary protraction were excluded. A control group did not undergo surgery for VPI. The three groups were matched based on cleft type and ages at VPI surgery and cephalogram. Main Outcome Measures Thirteen craniofacial measurements were evaluated on postoperative cephalograms using an analysis of variance with a Bonferroni adjustment for significant measures (α = 0.05). Results Seventy-two patients were included; mean ages at VPI surgery and postoperative cephalogram were 5 and 8 years, respectively. Twelve of thirteen craniofacial measures were not significantly different; notably, this included maxillary height and projection. Only gonial angle was found to differ significantly (P = .018) in that pharyngoplasty and pharyngeal flap yielded a smaller angle compared with that in control subjects. Conclusion Facial growth, and in particular maxillary growth, was not altered as expected after pharyngeal flap surgery. Pharyngeal flap appears to be equivalent to pharyngoplasty and palatal lengthening in that no significant effects on early facial growth were detected after surgery for VPI in this cohort of children with cleft palate.

Pedicled lower extremity fillet flap for coverage of massive pelvic wounds

Fillet flaps are traditionally harvested from nonsalvagable extremities to reconstruct complex soft tissue defects. This method results in minimal donor site morbidity, and can be effective in reconstructing large pelvic wounds requiring significant soft tissue coverage. Here, we present their application in three young patients with extensive pelvic wounds secondary to trauma and its sequelae. In each case, neurologic injury limited limb function, and fillet flaps were used to fill soft tissue defects and pad bony prominences. The fillet flaps have been successful in providing wound coverage in all cases, and have all remained intact to date, with a mean follow up time of 29 months. These results demonstrate a role for fillet flaps in the management challenging pelvic wounds, as they can provide both satisfactory tissue coverage and improved functional outcomes.