Ian L. Valerio

Soft tissue injury management with a continuous external tissue expander

BackgroundBlast exposure is a common cause of soft tissue injury within the battlefield setting, with the extremities often critically involved. The resulting injury pattern presents with massive soft tissue defects that may be further complicated by varying degrees of accompanying orthopedic and peripheral nerve damage. To address the severe soft tissue defect, various combinations of advanced reconstructive methods are typically required to achieve definitive wound coverage. Continuous external tissue expansion has been used by our institution to significantly reduce wound burden and provide for definitive wound closure in certain blast-injured patients. MethodsThe authors present an early series of 14 patients who suffered massive extremity soft tissue injuries and were treated with an external tissue expansion system (DermaClose RC). Outcome measurements included time to definitive closure and method of definitive wound closure. A 5-patient subset of this group was prospectively analyzed to determine measurements including initial wound surface area (WSA), percentage reduction in WSA, and related complications. ResultsOverall time to wound coverage ranged from 1 to 6 days, with mean time to wound coverage being 4.4 days. Of the 14 patients included in the series, 12 (85.7%) were able to undergo delayed primary closure, whereas 2 required split thickness skin grafting. In the 5-patient subgroup, WSA initially ranged from 20.25 to 1031.25 cm2. Mean wound size was 262.7 cm2. Decrease in WSA ranged from 44% to 93% of the initial WSA, with mean decrease being 74.3% (95% confidence interval, 57.33–91.3). ConclusionsIn the management of large complex wounds, external tissue expansion has proven to be a valuable adjunct in achieving definitive wound closure. It can often aid in successful delayed primary closure of certain soft tissue wounds, has low associated morbidities, and can reduce the need for more complex or morbid procedures when used properly. The authors propose an algorithm for the use of continuous external tissue expansion system to achieve effective and successful wound closure, while potentially reducing the need for increased donor-site morbidities associated with more complex or larger reconstruction measures.

Use of intraoperative fluorescent angiography to assess and optimize free tissue transfer in head and neck reconstruction.

PURPOSE Composite tissue defects in the head and neck region present unique challenges. Definitive head and neck reconstruction of these cases is often complicated by complex 3-dimensional defects that may require multiple flap or chimeric flap procedures. These advanced techniques can have serious repercussions should poor perfusion of the flap cause flap failure, which can be devastating. MATERIALS AND METHODS A retrospective review was completed for those complex reconstructions using free tissue transfers and fluorescent indocyanine green angiography (Lifecell SPY Elite imaging, Lifecell Corporation, Bridgewater, NJ) at Walter Reed National Military Medical Center over a 24-month period. Data analyzed included flap type (myocutaneous, osteocutaneous, or fasciocutaneous), flap success and failure rates, and complications. These also were compared with data from the institution before the study period and the incorporation of SPY technology. RESULTS Sixty-one free flaps, including 11 head and neck flaps, were performed. The head and neck flaps included 1 latissimus, 3 gracilis, 1 vastus lateralis, 4 anterior lateral thigh, and 2 fibular flaps. The overall success rate was 98.4%; 1 flap was lost (1.6%) and 2 flaps developed partial flap necrosis (3.3%). Where SPY Elite was used, there was no unpredicted partial flap necrosis. The only total flap loss was related to a hypercoagulable condition. CONCLUSIONS Free tissue transfer can be technically challenging, especially in complex head and neck reconstruction. An algorithmic approach using SPY Elite imaging aids in pedicle location, angiosomal assessment, anastomotic flow visualization, and cutaneous and osteocutaneous flap perfusion assessment. This objective tool can assist the reconstructive surgeon in avoiding perfusion-related complications and total and partial flap losses, thus improving patient outcomes.

The use of urinary bladder matrix in the treatment of trauma and combat casualty wound care.

Treatment of combat injuries and resulting wounds can be difficult to treat due to compromised and evolving tissue necrosis, environmental contaminants, multidrug resistant microbacterial and/or fungal infections, coupled with microvascular damage and/or hypovascularized exposed vital structures. Our group has developed surgical care algorithms with identifiable salvage techniques to achieve stable, definitive wound coverage often with the aid of certain regenerative medicine biologic scaffold materials and advanced wound care to facilitate tissue coverage and healing. This case series reports on the role of urinary bladder matrix scaffolds in the wound care and reconstruction of traumatic and combat wounds. Urinary bladder matrix was found to facilitate definitive soft tissue reconstruction by establishing a neovascularized soft tissue base acceptable for second stage wound and skin coverage options within traumatic and combat-related wounds.

Application of the orthoplastic reconstructive ladder to preserve lower extremity amputation length.

BackgroundA primary goal in traumatic lower extremity amputation management is preservation of limb length. Energy expenditure during ambulation directly correlates with residual limb length, preserved limb segments, and stable joint preservation. An additional factor affecting limb function includes achieving adequate residual limb soft tissue coverage. This report describes techniques for achieving a stable soft tissue envelope to facilitate limb length and joint preservation. MethodsA series of traumatic amputation cases with inadequate soft tissue coverage are reviewed. Concepts from the reconstructive surgery ladder were used to achieve residual limb soft tissue coverage and to preserve lower extremity amputation length. ResultsSoft tissue coverage was accomplished through a series of methods including delayed primary closure with assistance from an external tissue expander, use of acellular dermal regenerative templates combined with split-thickness skin grafting and negative-pressure wound therapy, use of biologic scaffolds such as extracellular porcine urinary bladder matrix combined with delayed skin grafting, and local pedicle flaps or adjacent tissue rearrangements and free tissue transfers. ConclusionsThe preservation of residual limb length in lower extremity amputations is crucial to optimize prosthetic fitting and to obtain the maximal functional outcome. A series of cases are presented that outline soft tissue coverage options for preserving maximal residual limb length. Applying various concepts from the reconstructive ladder may allow for viable soft tissue coverage to maximize functional outcome.

Simultaneous scarless contralateral breast augmentation during unilateral breast reconstruction using bilateral differentially split DIEP flaps.

Background: Simultaneous contralateral augmentation is performed with unilateral breast reconstruction to achieve pleasing and symmetric breast mounds. This prospective study investigated the outcome of simultaneous scarless contralateral augmentation with unilateral breast reconstruction using bilateral differentially split deep inferior epigastric perforator (DIEP) flaps. Methods: Between August of 2009 and May of 2010, six patients with a mean age of 46.2 ± 7 years underwent unilateral breast reconstruction and simultaneous contralateral augmentation using bilateral differentially split DIEP flaps. The ipsilateral internal mammary vessels served as the recipient vessels for the reconstruction split flap. The pedicle of the augmentation split flap was anastomosed to that of the reconstruction split flap in a flow-through manner. The augmentation split flap was inset through the midline with endoscopic assistance. The Modified BREAST-Q questionnaire was administered preoperatively and at the 1- and 3-month follow-up visits. Results: All flaps survived, giving a success rate of 100 percent. One reconstruction split flap required reexploration and was salvaged successfully. Mean flap weights used for reconstruction and augmentation were 410 ± 145 and 192 ± 58 g, respectively. At a mean follow-up of 12.7 ± 3.6 months, all patients were satisfied with the outcome of both reconstructed and augmented breast mounds. There were statistical improvements in breast satisfaction (p = 0.004), psychosocial function (p = 0.000), and sexual well-being (p = 0.004) postoperatively, as assessed by the Modified BREAST-Q. Conclusion: Simultaneous scarless contralateral breast augmentation can be performed safely during unilateral breast reconstruction using bilateral differentially split DIEP flaps with satisfactory outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A decade of conflict: flap coverage options and outcomes in traumatic war-related extremity reconstruction.

Background: War trauma patients who have sustained extremity trauma often exhibit extensive zones of injury with multiple concomitant injuries that can contribute to limited coverage options. Thus, flap availability and choice can become critical in the reconstruction algorithm of these severely traumatized patients. The authors’ purpose was to analyze the outcomes of muscle and fasciocutaneous flaps during their extremity reconstructive experience to determine which option had better flap and limb salvage outcomes. Methods: A retrospective review of servicemembers treated with flap-based limb salvage from 2003 through 2012 at the National Capital Consortium was completed. Patients were divided into cohorts of patients who underwent muscle or fasciocutaneous flaps. Results: Three hundred fifty-nine flap procedures were performed. Of these procedures, 197 were muscle (55 percent) and 152 were fasciocutaneous flaps (42 percent). There was no difference in overall flap complications between groups (30 percent versus 26 percent; p = 0.475). However, there was a significantly higher flap failure rate in the muscle compared with the fasciocutaneous group (13 percent versus 6 percent; p = 0.030). Although there were more overall extremity complications in the muscle group (59 percent versus 47 percent; p = 0.030), there were no significant differences in soft-tissue infection, osteomyelitis, or amputation rates. Conclusions: There are many flap options that provide adequate coverage in extremity salvage. Complication rates did not differ significantly between muscle and fasciocutaneous flaps, with one exception—flap failure rates were significantly higher in our muscle-based flap cohort of patients. Nonetheless, each of these flap types has utility in our patients based on individual wounding patterns, flap availability for reconstruction, and rehabilitation goals. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

An optimized dual-surgeon simultaneous orthotopic hind-limb allotransplantation model in rats.

Composite tissue allograft (CTA) transplantation is a promising treatment in reconstructive surgery for complex tissue injuries in humans. However, continued research is required to optimize the risk to benefit ratios. In this study, we describe, in detail, an optimized simultaneous dual-surgeon orthotopic hind-limb transplantation model in direct comparison to a single-surgeon model. In this study 75 hind-limb CTAs were performed, employing either a dual-surgeon model (n = 60) or a single-surgeon model (n = 15) for the transplantation of two hind-limbs. Operative times, complication rates, and costs were compared. The dual-surgeon approach showed a significant reduction of 45.4% in overall operative time (p < 0.05). Overall complication rate was 8%. The dual-surgeon model was ∼30.5% more cost-effective than the traditional single-surgeon approach. Benefits of the proposed simultaneous dual-surgeon orthotopic rat hind-limb CTA model include decreased operating times, decreased complication rates, and reduced financial costs when compared with the established single-surgeon model.

Regenerative medicine applications in combat casualty care

The purpose of this report is to describe regenerative medicine applications in the management of complex injuries sustained by service members injured in support of the wars in Afghanistan and Iraq. Improvements in body armor, resuscitative techniques and faster transport have translated into increased patient survivability and more complex wounds. Combat-related blast injuries have resulted in multiple extremity injuries, significant tissue loss and amputations. Due to the limited availability and morbidity associated with autologous tissue donor sites, the introduction of regenerative medicine has been critical in managing war extremity injuries with composite massive tissue loss. Through case reports and clinical images, this report reviews the application of regenerative medicine modalities employed to manage combat-related injuries. It illustrates that the novel use of hybrid reconstructions combining traditional and regenerative medicine approaches are an effective tool in managing wounds. Lessons learned can be adapted to civilian care.

Management of decompressive craniectomy defects: modern military treatment strategies.

BackgroundDecompressive craniectomy has become a critical and standard life-saving maneuver in the theater of war. The high number of patients returning with large cranial defects and complex craniofacial injuries often involving the upper orbits or associated with the sunken skin flaps are a reconstructive challenge. We present a review of our treatment protocol highlighting the evolution of decompressive craniectomy and the development of a modern cranial defect treatment algorithmic approach to reconstruct these difficult clinical cases. MethodsA review of previously published data and current data from our warfare treatment unit that reported the treatment of decompressive cranial defects from 2004 to 2011 was performed. Reported data included mechanism of injury, evacuation time, initial Glasgow Coma Scale (GCS), GCS on arrival to the continental United States, type of decompressive craniectomy, type of implants used for reconstruction, and complications such as implant infections, exposures, and removals. Secondary reconstruction techniques used to salvage failed cranioplasty cases with free tissue transfers and cranial bone or dermal fat grafts as indicated were also reviewed and outcomes were reported. ResultsFrom March 2003 to July 2011, more than 200 patients were identified who underwent cranioplasty after decompressive craniectomy. Patient average age was approximately 25 years (range, 18–53 y), and all patients were male. Average follow-up was 870 days (2.4 y). Average GCS at initial presentation was 7 and was 9 on arrival to the continental United States. Average time to evacuation to the continental United States was 6 days. Of all injuries, 46% were associated with an improvised explosive device blast. Of the patients, 90% underwent hemicraniectomies with the remaining 10% having received bifrontal craniectomies. Successful reconstruction and retention of the implant was present in 95% of the overall cohort. Contour abnormalities were the most common adverse outcome encountered (10% of patients after cranioplasty), whereas infections resulting in implant loss (5%) and seizures (<5%) were the most common complications that occurred after cranioplasty reconstruction. ConclusionsWarfare-related decompressive craniectomy defects can be safely reconstructed using custom alloplastic implants with low morbidity and mortality. Risk factors that increase the rate of infection and require implant removal included orbital extension of the craniectomy defect, proximity to facial sinuses, and large contour abnormalities with corresponding large dead spaces. Staging reconstruction of high-risk cranial defects followed by definitive cranial defect reconstruction improved the likelihood of implant retention and successful cranioplasty outcome.

Use of a bioartificial dermal regeneration template for skin restoration in combat casualty injuries

Military personnel who survive combat injuries frequently have large soft tissue wounds complicated by concomitant injuries and contamination. These devastating wounds present a therapeutic challenge to not only restore the protective skin barrier but also to preserve tendon and muscle excursion, provide protective padding around nerves and restore adequate joint motion. Accordingly, regenerative medicine modalities that can accomplish these goals are of great interest. The use of bioartificial dermal regeneration templates (DRT), such as Integra DRT (Integra Lifesciences Corporation, Plainsboro, NJ, USA), in the management of complex soft tissue injuries has an important role in the reconstruction of war wounds. These DRTs provide initial wound coverage and help establish a well-vascularized wound bed suitable for definitive soft tissue coverage.