Erik M. Wolfswinkel

Salvage of infected left ventricular assist device with antibiotic beads.

Background: The use of left ventricular assist devices has become common for the treatment of end-stage heart failure, both as a bridge to transplantation and as destination therapy. The nature of these devices and the comorbid conditions of the patients in whom the devices are implanted lead to high rates of device infection that are related directly to mortality. Methods: Over 2 years, the senior author (S.A.I.) treated 26 patients with left ventricular assist device infections, ranging from superficial driveline infections to deeper pocket infections and device infections. An algorithm involving the use of repeated débridement and placement of antibiotic beads was used in treatment of these infections. Once cleared of infection, patients were treated with definitive closure or flap coverage of the formerly infected device component. Results: Seventeen of 26 patients with left ventricular assist device–related infections were cleared of their infection using this method. Ten of these patients underwent flap coverage of the device after their infection was cleared. In patients that were cleared of infection, mortality was 29 percent, whereas patients with recalcitrant infections had a mortality of 67 percent over the course of the study. Conclusions: A systematic approach to treating left ventricular assist device–related infections has the potential to treat and clear these infections, with promising overall survival rates. This proposed algorithm led to high infection clearance rates compared with previously published literature. Infection clearance in patients on left ventricular assist device destination therapy may result in mortality rates approaching those of their uninfected peers. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Local foreign-body reaction to commercial biodegradable implants: an in vivo animal study.

Biodegradable plates have been used extensively in fracture fixation since the 1960s. They rarely cause stress-protection atrophy or problems requiring secondary plate removal, common complications seen with metallic plates. However, aseptic foreign-body reactions have been reported, sometimes years after the original implantation. Both inadequate polymer degradation and debris accumulation have been implicated as causes. The current generation of commercial biodegradable plates is formulated to minimize this complication by altering the ratio of polylactic and polyglycolic acids. This in vivo study compares the degree of local foreign-body reaction of two commercially available resorbable plates in rabbits. Two types of biodegradable plates were examined: poly(D/L)lactide acid (PDLLA) and polylactide-co-glycolide acid (PLGA). Each plate was placed into a periosteal pericalvarial pocket created beneath the anterior or posterior scalp of a rabbit. Humane killing occurred at 3, 6, and 12 months postoperatively. Foreign-body reaction was evaluated histologically. The PDLLA plates demonstrated marked local foreign-body reactions within the implant capsule as early as 3 months after implantation, with presence of inflammatory cells and granulomatous giant cells in close association with the implant material. All local foreign-body reactions were subclinical with no corresponding tissue swelling requiring drainage. PLGA plates did not demonstrate any signs of inflammatory reactions. In addition, the PLGA plates did not appear to resorb or integrate at 12 months. Neither PDLLA nor PLGA plates demonstrated inflammation of the soft tissue or adjacent bone outside the implant capsule. In our study, the PDLLA plates demonstrated histological evidence of foreign-body reaction that is confined within the implant capsule, which was not seen with the PLGA plates. This finding may be attributable to the lack of significant resorption seen in the PLGA plates. Both PDLLA and PLGA plates were biocompatible with the rabbit tissue environment and should be considered for continued use in craniofacial, maxillofacial, and orthopedic reconstruction.

The Forehead Flap: The Gold Standard of Nasal Soft Tissue Reconstruction

The forehead flap is one of the oldest recorded surgical techniques for nasal reconstruction. As the gold standard for nasal soft tissue reconstruction, the forehead flap provides a reconstructive surgeon with a robust pedicle and large amount of tissue to reconstruct almost any defect. Modifications provided by masters like Burget and Menick have only increased the utility of this exceptional flap. Maintaining an axial pattern, utilizing the pedicle ipsilateral to the defect, extending the flap at right angles with caution when extra length is needed, using a narrow pedicle, and early subperiosteal dissection are the guiding principles for forehead flap reconstruction of the nose. In addition, lining defects can be addressed simply and reliably with a folded forehead flap.

Breast Reduction in Adolescents: Indication, Timing, and a Review of the Literature

BACKGROUND Adolescent breast hypertrophy can have long-term negative medical and psychological impacts. In select patients, breast reduction surgery is the best treatment. Unfortunately, many in the general and medical communities hold certain misconceptions regarding the indications and timing of this procedure. Several etiologies of adolescent breast hypertrophy, including juvenile gigantomastia, adolescent macromastia, and obesity-related breast hypertrophy, complicate the issue. It is our hope that this paper will clarify these misconceptions through a combined retrospective and literature review. METHODS A retrospective review was conducted looking at adolescent females (≤18 years old) who had undergone bilateral breast reduction surgery. Their preoperative comorbidities, BMI, reduction volume, postoperative complications, and subjective satisfaction were recorded. In addition, a literature review was completed. RESULTS 34 patients underwent bilateral breast reduction surgery. The average BMI was 29.5 kg/m(2). The average volume resected during bilateral breast reductions was 1820.9 g. Postoperative complications include dehiscence (9%), infection (3%), and poor scarring (6%). There were no cases of recurrence or need for repeat operation. Self-reported patient satisfaction was 97%. All patients described significant improvements in self body-image and participation in social activities. The literature review yielded 25 relevant reported articles, 24 of which are case studies. CONCLUSION Reduction mammaplasty is safe and effective. It is the preferred treatment method for breast hypertrophy in the adolescent female and may be the only way to alleviate the increased social, psychological, and physical strain caused by this condition.

The Ultra-thin, Fascia-only Anterolateral Thigh Flap

BACKGROUND While many potential donor sites have been described for fascial (fascia-only) flaps, a fascial flap harvested from the anterolateral thigh (ALT) donor site has not gained popularity, likely because of concerns regarding inadequate perfusion of the deep fascia. However, recent clinical experience demonstrates that the ALT fascia-only flap is a suitable option for reconstructions necessitating thin and pliable coverage. METHODS In this study a retrospective chart review was performed examining the clinical experience of two plastic surgeons with the fascia-only ALT perforator flap from 2008 to 2012. Each flap was initially raised as a standard ALT flap, but all the overlying skin and adipose tissue was excised off the deep fascia before the inset, resulting in the creation of a fascia-only ALT flap. Immediate split- or full-thickness skin grafts were used to cover the flap. The results are reported in this article. RESULTS Overall seven patients underwent reconstruction of wounds using either free (six) or pedicled (one) fascia-only ALT flaps (length, 10-20 cm, width, 5-10 cm). The following regions were successfully reconstructed using a fascia-only ALT flap: occipital scalp, lower extremity, upper extremity, and groin. All patients were followed for at least 6 months postoperatively. CONCLUSIONS The fascia-only ALT flap was successfully used to reconstruct a variety of defects in seven patients. The authors experience demonstrates the viability of the fascia-only version of the ALT flap for reconstructions requiring thin coverage with good contour, and further adds to the versatility of the ALT as a donor site for flaps.

A Prospective Study of Strut versus Miniplate for Fractures of Mandibular Angle.

This prospective randomized clinical trial compared the treatment outcomes of strut plate and Champy miniplate in fixation of mandibular angle fractures. Patients with mandibular angle fracture were consented and enrolled into this study. Exclusion criteria include patients with severely comminuted fractures. The patients were randomly assigned to receive the strut plate or Champy miniplate for angle fracture fixation. Patient demographics, fracture characteristics, operative and postoperative outcomes were collected prospectively. Statistical analysis was performed to evaluate the significance of the outcome. A total of 18 patients were included in this study and randomly assigned to receive either the strut plate or Champy miniplate. Out of which five patients were excluded postoperatively due to complex fracture resulting in postoperative maxillomandibular fixation. The final enrollment was 13 patients, N = 6 (strut) and N = 7 (Champy). There was no statistically significant difference in the pretreatment variables. Nine of these patients had other associated facial fractures, including parasymphyseal and subcondylar fractures. Most of the (11) patients had sufficient follow-up after surgery. Both groups exhibited successful clinical unions of the mandibular angle fractures. The complications associated with the mandibular angle were 20% in the strut plate group and 16.7% in the Champy group. One patient in the strut plate group had a parasymphyseal infection, requiring hardware removal. The strut plate demonstrated comparable surgical outcome as the Champy miniplate. It is a safe and effective alternative for management of mandibular angle fracture.

Cleft Nasal Deformity and Rhinoplasty

The cleft nasal deformity is a complex challenge in plastic surgery involving the skin, cartilage, mucosa, and skeletal platform. Ever since Blair and Brown first described the intricacies of the cleft pathology in 1931, the appropriate approach has been extensively debated in the literature with respect to timing, technique, and extent of surgical intervention. In this article, the authors review the literature and summarize the various modalities for achieving a successful rhinoplasty in the patient with a cleft nasal deformity.

Hyperplastic Breast Anomalies in the Female Adolescent Breast

Macromastia in adolescents is multifactorial and usually idiopathic, associated with obesity or hormonal imbalances. Less commonly, it can result from virginal or juvenile breast hypertrophy, a rare condition of unknown etiology, where an alarmingly rapid breast enlargement occurs during puberty. Breast hypertrophy in the adolescent population can have significant long-term medical and psychological impacts. Although symptoms can be severe, many plastic surgeons, pediatricians, and parents are often reluctant to surgically treat adolescent macromastia. However, reduction mammoplasty is a safe and effective treatment and may be the only way to alleviate the increased social, psychological, and physical strain caused by macromastia in adolescents.

A Novel Quantitative Method for Evaluating Surgical Outcomes in Craniosynostosis: Pilot Analysis for Metopic Synostosis

Objective assessment of head shape has been an elusive goal in the management of craniosynostosis patients. Clinical judgment, craniometric indices, and computed tomography scans are the primary means through which a surgeon assesses this patient population. The purpose of this study was to examine and discuss the utility of the STARscanner for evaluation of surgical outcomes in metopic synostosis patients. A retrospective chart review of patients with metopic synostosis who underwent fronto-orbital advancement with pre- and postoperative STARscanner imaging at Texas Childrens Hospital was performed. Two patients were identified and evaluation and discussion of the data produced by the STARscanner was undertaken. A novel symmetry index created by the authors, called the anterior–posterior volume ratio (APVR), was discussed for use in metopic synostosis patients. The postoperative growth metrics demonstrated an interval increase compared with the preoperative data. The anterior symmetry ratio, posterior symmetry ratio, overall symmetry ratio, cranial vault volumes, cranial vault asymmetry index, and cephalic ratio were not found to be useful in evaluating resolution of dysmorphology after fronto-orbital advancement in metopic synostosis. The APVR does not characterize dysmorphology, but may help show degree of expansion of the anterior cranial vault after fronto-orbital advancement. The STARscanner imaging device does not appear to have significant utility in characterizing head shape for surgical outcomes assessment in metopic synostosis. The minor utility of this device may be that it is a safe and fast way to derive growth parameters for both short-term and long-term follow-up of cranial vault remodeling.

The Delay Phenomenon: A Compilation of Knowledge across Specialties

Objective The purpose of this article is to review and integrate the available literature in different fields to gain a better understanding of the basic physiology and optimize vascular delay as a reconstructive surgery technique. Methods A broad search of the literature was performed using the Medline database. Two queries were performed using “vascular delay,” a search expected to yield perspectives from the field of plastic and reconstructive surgery, and “ischemic preconditioning,” (IPC) which was expected to yield research on the same topic in other fields. Results The combined searches yielded a total of 1824 abstracts. The “vascular delay” query yielded 76 articles from 1984 to 2011. The “ischemic preconditioning” query yielded 6534 articles, ranging from 1980 to 2012. The abstracts were screened for those from other specialties in addition to reconstructive surgery, analyzed potential or current uses of vascular delay in practice, or provided developments in understanding the pathophysiology of vascular delay. 70 articles were identified that met inclusion criteria and were applicable to vascular delay or ischemic preconditioning. Conclusion An understanding of IPCs implementation and mechanisms in other fields has beneficial implications for the field of reconstructive surgery in the context of the delay phenomenon. Despite an incomplete model of IPCs pathways, the anti-oxidative, anti-apoptotic and anti-inflammatory benefits of IPC are well recognized. The activation of angiogenic genes through IPC could allow for complex flap design, even in poorly vascularized regions. IPCs promotion of angiogenesis and reduction of endothelial dysfunction remain most applicable to reconstructive surgery in reducing graft-related complications and flap failure.