Darl Vandevender

Prediction of postoperative seroma after latissimus dorsi breast reconstruction

Background: The latissimus dorsi flap has become a first-line option in reconstruction of the breast cancer patient. Donor-site seroma is a commonly described postoperative complication of the latissimus dorsi flap. Methods: A retrospective chart review from 1998 to 2003 of all patients undergoing latissimus dorsi breast reconstruction was performed (n = 50). Age of the patients, timing of breast reconstruction, type of nodal dissection (axillary versus sentinel versus none), and chemotherapy status of the patients were examined. Results: The overall incidence of seroma formation was 47 percent. Those patients who had undergone prior or concurrent nodal dissection at the time of breast reconstruction were found to have a higher incidence of seroma formation than patients who had no nodal dissection (52 percent versus 25 percent ) (p = 0.15). Age also was a risk factor for seroma formation, as 63 percent of patients older than 50 had formed seroma as compared with 39 percent of those younger than age 50 (p = 0.08). Conclusion: The authors conclude that advanced age and the presence of nodal disruption before or concurrent with latissimus dorsi breast reconstruction are predictors of donor-site seroma formation.

The use of free tissue transfers in acute thermal and electrical extremity injuries.

BACKGROUND This article presents a retrospective analysis of a case series of patients requiring free tissue transfers for acute thermal and electrical injuries in a single burn center. METHODS Eight patients, in the period between 1997 and 2001, were referred for evaluation of extensive thermal injury to one or more extremities, which required free tissue transfer to achieve coverage. A total of 12 flaps were performed on eight patients. Data including flap type, flap viability, complications, hospital stays, length of rehabilitation, and time until return to work were collected. RESULTS Twelve flaps were performed on eight patients. One patient died. We report a flap failure rate of 9% (1 of 12) and two postoperative infections. Follow-up ranged from 3 months to 4 years. Flap types included lateral arm, radial forearm, rectus abdominis, posterior lateral thigh, and omentum and temporoparietal fascia. Mean hospital stay was 22 days, with a mean rehabilitation time of 9.7 months. Sixty-two percent of patients returned to work. CONCLUSION Free tissue transfer is a safe and efficacious method of early surgical management of thermal and electrical burns. Electrical burns account for a disproportionate number of injuries requiring free tissue transfers. These injuries frequently necessitate the use of multiple free flaps. Postoperative complications and length of stay can be minimized by the use of split donor flaps during one operative session.

Transplantation of lymph node fragments in a rabbit ear lymphedema model : A New method for restoring the lymphatic pathway

&NA; The treatment of lymphedema by medical or surgical means remains a difficult task, and no technique is presently satisfactory. We established a rabbit ear chronic lymphedema model in which sequential lymph node fragments were transplanted to restore lymphatic pathways. Twenty New Zealand White rabbits were divided into two groups of 10 animals. One group served as the control, and the other was the transplantation group. A 3‐cm‐wide strip of skin and subcutaneous tissue including all the lymphatics was excised circumferentially from the root part of the right ear in each rabbit. The vascular pedicle in the control group was wrapped with a “bridge” strip of skin from the ventral ear to protect it from drying. In the transplantation group, the auricular lymph node was harvested from the contralateral ear, cut into 1‐ to 2‐mm slices, and implanted next to the vascular pedicle where the lymph vessels had been resected. Water displacement measurements in both groups revealed significant edema (p < 0.001) compared with the contralateral ear at 3 days. Peak swelling was observed at 10 days in both groups. Volumes decreased in both groups postoperatively. The volume measured as percentage change in the lymph node transplantation group was significantly lower than in the control group at 2 months and continuing to the end of the experiment (p < 0.001). Indirect lymphographic examination revealed that the distal lymphatic vessels of the control group were increased in number, dilated, and did not allow proximal passage of dye. Light microscopy revealed the vascular pedicle to be surrounded by dense scar tissue in the “bridge.” The transplantation group showed free passage of dye through the bridge. Microscopic examination showed regenerated lymphoid tissue with sinuses along the artery and vein of the “bridge.” Many channels with a layer of endothelial cells were also noted. Electron microscopy confirmed these sites to be regenerated lymph vessels. Lymphatic tissue can regenerate after fragment transplantation. This lymph tissue seems to regenerate lymphatic vessels that may function for drainage. The results suggest that this simple technique may be applicable in a clinical situation to prevent or treat obstructive lymphedema. (Plast. Reconstr. Surg. 101: 134, 1998.)

Combined anterior and anterolateral approaches to the cranial base: complication analysis, avoidance, and management.

OBJECTIVE: During the past decade, applications of anterior and anterolateral cranial approaches for both benign and malignant pathologies have expanded in frequency and application. Complications associated with these procedures impact significantly on patient outcome. The primary aim of this study is to detail the strategies for complication management and avoidance developed from experience with 120 patients who underwent anterior and anterolateral cranial base procedures during the past 14 years. METHODS: Between July 1990 and February 2004, 62 male and 58 female patients underwent 120 combined (neurological surgery and otolaryngology joint participation) anterior and anterolateral cranial base procedures. Fifty-four percent had malignant pathology, and 46% had benign pathology. The approaches taken were transfacial (10%), extended subfrontal (33%), lateral craniofacial (23%), and anterior craniofacial (35%). Thirty-day morbidity and mortality were analyzed. RESULTS: Twenty (17%) patients experienced at least one complication. Malignancy and reoperation, regardless of histology, appeared to affect the complication rate. A decline in complications occurred with experience, in part because of changes in management that reflected the complication experience (25% in Patients 0–31, 18% in Patients 32–70, 10% in Patients 71–120). Methodology is detailed for avoidance and management of retraction injury, infection, tension pneumocephalus, cerebrospinal fluid leak, pericranial flap failure, free flap sizing, dural banding, intracranial hypotension, and cerebrovascular events. Individual patient analysis, complications timing, and strategy for management are discussed. CONCLUSION: Improved patient outcomes for anterior and anterolateral cranial base surgery are, in part, directly related to the ability to avoid and manage associated complications. Experience, avoidance, and interdiction are key factors in complication management.

A Comparison of Full and Split Thickness Skin Grafts in Radial Forearm Donor Sites

To formally evaluate the functional and aesthetic outcomes between full versus split thickness skin graft coverage of radial forearm free flap donor sites. A retrospective chart review of 47 patients who underwent pedicled or free radial forearm free flap reconstruction from May 1997 to August 2004 was performed. Comparisons were made between patients who had donor site coverage with split thickness skin grafts (STSG) or full thickness skin grafts (FTSG). There was no statistically significant difference between the STSG and FTSG in the number of post-operative dressings, incidence of tendon exposure, time to healing at the skin graft donor site, and time to healing at the skin graft recipient site. The questionnaire data showed there was a trend toward higher scores with the radial forearm scar aesthetics and satisfaction in the FTSG group. Full thickness skin graft coverage of radial forearm free flap donor site is superior to split thickness skin graft coverage in terms of aesthetic outcome, and has no statistically significant difference in terms of tendon exposure, time to healing at the skin graft donor site, time to healing at the skin graft recipient site, or post operative pain.

Facial paralysis associated with glomus jugulare tumors.

Objective: To review the intraoperative findings and facial nerve management in nine patients who presented with facial paralysis associated with glomus jugulare tumors. Study Design: A retrospective analysis of patient medical records. Setting: Tertiary care academic medical center. Patients: All patients who presented with facial paralysis and a glomus jugulare tumor who underwent surgical resection of their tumors at our institution. Intervention: A postauricular infratemporal fossa approach for tumor removal and greater auricular interposition neural repair. Main Outcome Measure: Intraoperative facial nerve findings and long-term facial recovery. Results: One hundred two patients underwent a postauricular infratemporal approach for resection of glomus jugulare tumor from July 1988 through July 2005. Nine of these patients presented with ipsilateral facial paralysis. The medial surface of the vertical segment was invaded by tumor in all nine cases. Facial recovery at 2 years was House-Brackmann Grade III in eight patients and Grade IV in one individual. Facial recovery did not significantly change after 2 years (mean follow-up of 7.4 years). Discussion: Facial nerve invasion of the vertical segment occurred in 9 (9%) of 101 patients in our series. Facial nerve resection with interposition grafting resulted in House-Brackmann Grade III in eight (89%) of nine patients. Facial nerve dissection and preservation was not possible when preoperative facial paralysis was evident.

Closure of complex lateral skull base defects.

Objective: To discuss surgical reconstructive options and complications in patients with extensive lateral skull base defects. Study Design: Retrospective case review. Setting: Tertiary referral center. Patients: Eligibility criteria included patients seen between July 1999 and July 2003 with malignant neoplasms of the lateral skull base requiring surgical therapy, with resultant surgical defect not amenable to primary closure. Intervention: Surgical extirpation of malignant skull base neoplasm requiring free tissue transfer or rotational flap closure. Main Outcome Measure: Closure and healing of surgical defect, intraoperative and postoperative complications, patient survival. Results: There were 11 patients, 8 males and 3 females, with an average age of 65 years. Eight patients required trapezius flap reconstruction, whereas one patient required temporalis rotational flap closure, and two patients required rectus abdominus free tissue transfers. There was one perioperative death secondary to cardiac disease. There were no immediate wound complications. One patient developed a delayed partial trapezius flap failure successfully treated with a rectus abdominus flap. Conclusions: The trapezius rotational flap is a reliable means of closing complex lateral skull base defects with minimal morbidity.

Management of thoracic aortic graft infections with the omental flap.

BackgroundInfection of thoracic aortic grafts occurs infrequently; however, once present, it is associated with high patient morbidity and mortality. We report our successful experience in the treatment of 11 patients who developed infection of their thoracic aortic graft. MethodsThis is an institutional review board–approved retrospective review of 11 patients who had documented thoracic aortic graft infections with associated mediastinitis or empyema. After diagnosis, plastic surgery consultation was obtained, and the patients underwent formal operative debridement with cardiovascular service. Intraoperative cultures were obtained, and the patients were placed on specific antibiotic regimens. After the wound bed was adequately prepared, the omentum was harvested and was based on the right gastroepiploic vessels. The flap was circumferentially wrapped around the aortic graft and simultaneously used to fill the mediastinal dead space. In a certain subset of patients, a cryopreserved homograft replaced the synthetic graft before omental flap reconstruction. ResultsThe infections were eventually controlled in all surviving patients. Ten of 11 patients were discharged either to a rehab or to a nursing facility. There was 1 perioperative death secondary to multisystem organ failure. Mean follow-up period was 36 months and revealed a greater than 90% survival rate. Serial imaging reported no suture-line complications. ConclusionsWe report our series on the treatment of patients with infection of thoracic aortic grafts. Debridement and tissue coverage with an omental flap provided these patients with successful recovery and survival.

Assessing the safety and efficacy of combined abdominoplasty and gynecologic surgery.

Background:Combined surgery is an attractive option for both patients and surgeons. Unfortunately, it remains unclear to patients whether plastic surgery can be combined safely and efficaciously with other surgeries, particularly gynecologic surgery. The goal of this study was to determine the safety and efficacy of combined abdominoplasty and gynecologic surgery. Methods:A case-control study of 25 patients undergoing combined abdominoplasty and intra-abdominal gynecologic surgery was performed. These combined patients were compared with control group patients undergoing abdominoplasty alone and gynecologic surgery alone. Demographic data, operative time, estimated blood loss, pre- and postoperative hemoglobin, length of hospitalization, and complications were compared between combined and control groups. Results:Statistically significant reductions were seen in operative time, estimated blood loss, and total days of hospitalization when comparing the combined group to the sum of the control groups. In this study, no major complications, including the need for blood transfusion or pulmonary embolus, were noted in any of the patients. Conclusions:These results demonstrate success in performing abdominoplasty with gynecologic surgery, which may be an acceptable option for patients.

Intermeshing breast reconstruction and postmastectomy radiation

In women with advanced breast cancer or those with early-stage cancer for whom there is a contraindication for breast-conserving therapy, mastectomy is the primary surgical treatment. This is often followed by breast reconstruction in either an immediate or delayed fashion. There is a great psychological and emotional benefit for the patient to have immediate reconstruction at the time of initial mastectomy. Recently, evidence has demonstrated that postmastectomy radiation therapy (PMRT) administered in conjunction with systemic therapy improves not only locoregional control but also survival. This has increased the number of women receiving PMRT and resulted in much debate in the literature regarding the timing of radiation therapy and the types of reconstructive options. In this article, the authors review the literature for controversies and currently accepted practices for intermeshing PMRT and breast reconstruction following mastectomy. We also summarize the key issues related to the integration of breast reconstruction with PMRT and detail the experience and complications arising from this integration.