James M. Economides

Analyzing implant movement with tabbed and nontabbed expanders through the process of two-stage breast reconstruction.

Background: Tabbed tissue expanders have the potential benefit of less migration during the expansion process, which may allow for more predictable outcomes. Despite this theoretical benefit, no study has critically evaluated the proposed advantage as compared with traditional nontabbed expanders. Therefore, the authors photographically analyzed the migration and movement of tabbed and nontabbed expanders throughout the reconstructive process. Methods: The authors performed a retrospective review of patients who underwent two-stage expander-to-implant reconstruction from 2010 to 2012. Standardized frontal photographs were used for analysis. Adobe Photoshop was used to measure the relative movement of each patient’s expander from insertion until immediately before implant exchange and after implant exchange. Results: Forty-four breasts were analyzed. Migration was reduced significantly in all four directions for both the tissue expander and permanent implant stages of reconstruction. Medial, lateral, superior, and inferior migration of the tissue expander in the tabbed cohort was reduced by 59.5 percent (p = 0.001), 48.3 percent (p = 0.004), 53.4 percent (p = 0.0005), and 73.4 percent (p < 0.0001), respectively, compared with the nontabbed cohort. Likewise, medial, lateral, superior, and inferior migration of the permanent implant in the tabbed cohort was reduced by 44.3 percent (p = 0.049), 73.7 percent (p < 0.0001), 67.7 percent (p = 0.0008), and 61.0 percent (p = 0.003), respectively. Conclusions: Two-stage implant reconstruction allows for precision in implant placement after an appropriately placed expander. Tabbed expanders appear to maintain better positioning on the chest wall compared with nontabbed expanders during the expansion process, and may allow for more precise mound creation with the permanent implant. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Outcomes after combined radical resection and targeted biologic therapy for the management of recalcitrant hidradenitis suppurativa.

BackgroundTrials demonstrating the efficacy of biologic therapy for moderate to severe hidradenitis suppurativa (HS) have inspired new multidisciplinary treatment strategies. We present our experience with combined biologic and surgical therapy for recalcitrant HS. MethodsBetween 2011 and 2014, 21 patients (57 cases) with Hurley Stage III HS underwent radical resection with delayed primary closure alone, or in combination with adjuvant biologic therapy. Demographic data, treatment regimen, outcomes, and complications were retrospectively reviewed for all cases. ResultsEleven patients underwent combined surgical and biologic therapy, whereas radical resection alone was performed in 10 patients. The average soft tissue deficit, before closure, for the combined and surgery-only patients was 56 cm2 and 48.5 cm2, respectively (P = 0.66). Biologic agents including infliximab (n = 8) and ustekinumab (n = 3) were initiated 2 to 3 weeks after closure and were continued for an average of 10.5 months. Recurrence was noted in 19% (4/29) and 38.5% (10/26) of previously treated sites for combined and surgery-only patients (P < 0.01). For the combined cohort, the disease-free interval was approximately 1 year longer on average (P < 0.001); however, this difference was reduced to 4.5 months when considering time to recurrence after cessation of biologic therapy (P = 0.09). New disease developed in 18% (2/11) and 50% (5/10) of combined and surgery-only patients, respectively (P < 001). No adverse events were noted among patients who received biologic therapy. ConclusionsLower rates of recurrence and disease progression, as well as a longer disease-free interval may be achieved with the use of adjuvant biologic therapy after radical resection for recalcitrant HS.

Correlating patient-reported outcomes and ambulation success following microsurgical lower extremity reconstruction in comorbid patients.

Introduction: Microsurgical lower extremity flap reconstruction provides a valuable option for soft tissue reconstruction in comorbid patients. Limb salvage with flap reconstruction can result in limb length preservation. Despite this, few studies have examined the impact of salvage on patient‐centered metrics in this cohort of patients. Therefore, we investigated quality of life and patient satisfaction following microsurgical lower extremity reconstruction in this high‐risk patient population. Factors that resulted in improved patient‐centered outcomes were also identified. Methods: A retrospective review was conducted of all patients who had lower extremity free flap reconstruction (FFR) following lower extremity wounds. High‐risk patients were identified as having multiple comorbidities and chronic wounds. Patients with traumatic wounds were excluded from analysis. Quality of life was evaluated with the Short Form‐12 (SF‐12) validated survey. Phone interviews were conducted for survey evaluations. Results: From 2005 to 2010, 57 patients had lower extremity flap reconstruction that met the inclusion criteria. Average follow‐up was 236.6 weeks (range, 111–461). Comorbidities included diabetes (36%), PVD (24.6%), and ESRD (7%). Limb length preservation and ambulation occurred in 82.5% (47/57). Revisional surgery occurred in 33.3% (19/57). Survey response rate was 63%. Average SF‐12 PCS and MCS scores were 44.9 and 59.8 for patients able to achieve ambulation and 27.6 and 61.2 for nonambulatory patients. Conclusions: Microsurgical flap reconstruction is a valuable reconstructive option in high‐risk patients. Quality of life is comparable with a normalized population if limb salvage is successful. Quality of life is decreased significantly when failure to ambulate occurs in this patient cohort.

Systematic Review of Patient-Centered Outcomes Following Lower Extremity Flap Reconstruction in Comorbid Patients

BACKGROUND Lower extremity soft tissue defects pose a challenging problem to patients with comorbidities. Reconstruction with tissue transfer offers an effective alternative to amputation in this population. Although abundant with data on success and complication rates, the literature has not focused on assessing patient-centered outcomes of these reconstructive procedures. METHODS A systematic review was performed by searching an electronic database for relevant studies. The full text of relevant articles was retrieved and the reference lists of those articles reviewed. Single case reports or articles reporting data on wounds sustained from trauma were excluded. RESULTS In total, 318 articles were identified. After applying inclusion and exclusion criteria, 50 articles reporting data on 1,079 flaps remained for inclusion in this review. Ambulation outcomes were reported by 35 articles with a weighted mean rate of postoperative ambulation of 77.4%. Postoperative time to ambulation ranged from an average of 9 months to 22 months. Quality of life and patient satisfaction outcomes were infrequently and inconsistently reported in the literature. CONCLUSION There is a dearth of patient-centered outcomes for lower extremity flap reconstruction currently in the literature. A standardized method to assessing patient-centered outcomes should be employed to better understand the effectiveness of these procedures.Level of Evidence III Therapeutic.

Systematic Review and Comparative Meta-Analysis of Outcomes Following Pedicled Muscle versus Fasciocutaneous Flap Coverage for Complex Periprosthetic Wounds in Patients with Total Knee Arthroplasty

Background In cases of total knee arthroplasty (TKA) threatened by potential hardware exposure, flap-based reconstruction is indicated to provide durable coverage. Historically, muscle flaps were favored as they provide vascular tissue to an infected wound bed. However, data comparing the performance of muscle versus fasciocutaneous flaps are limited and reflect a lack of consensus regarding the optimal management of these wounds. The aim of this study was to compare the outcomes of muscle versus fasciocutaneous flaps following the salvage of compromised TKA. Methods A systematic search and meta-analysis were performed to identify patients with TKA who underwent either pedicled muscle or fasciocutaneous flap coverage of periprosthetic knee defects. Studies evaluating implant/limb salvage rates, ambulatory function, complications, and donor-site morbidity were included in the comparative analysis. Results A total of 18 articles, corresponding to 172 flaps (119 muscle flaps and 53 fasciocutaneous flaps) were reviewed. Rates of implant salvage (88.8% vs. 90.1%, P=0.05) and limb salvage (89.8% vs. 100%, P=0.14) were comparable in each cohort. While overall complication rates were similar (47.3% vs. 44%, P=0.78), the rates of persistent infection (16.4% vs. 0%, P=0.14) and recurrent infection (9.1% vs. 4%, P=0.94) tended to be higher in the muscle flap cohort. Notably, functional outcomes and ambulation rates were sparingly reported. Conclusions Rates of limb and prosthetic salvage were comparable following muscle or fasciocutaneous flap coverage of compromised TKA. The functional morbidity associated with muscle flap harvest, however, may support the use of fasciocutaneous flaps for coverage of these defects, particularly in young patients and/or high-performance athletes.

Traction-assisted Internal Negative Pressure Wound Therapy With Bridging Retention Sutures to Facilitate Staged Closure of High-risk Wounds Under Tension

BACKGROUND/OBJECTIVE Loss of domain often complicates attempts at delayed wound closure in regions of high tension. Wound temporization with traction-assisted internal negative pressure wound therapy (NPWT), using bridging retention sutures, can minimize the effects of edema and elastic recoil that contribute to progressive tissue retraction over time. The investigators evaluated the safety and efficacy of this technique for complex wound closure. MATERIALS AND METHODS Between May 2015 and November 2015, 18 consecutive patients underwent staged reconstruction of complex and/or contaminated soft tissue defects utilizing either conventional NPWT or modified NPWT with instillation and continuous dermatotraction via bridging retention sutures. Instillation of antimicrobial solution was reserved for wounds containing infected/exposed hardware or prosthetic devices. Demographic data, wound characteristics, reconstructive outcomes, and complications were reviewed retrospectively. RESULTS Eighteen wounds were treated with traction-assisted internal NPWT using the conventional (n = 11) or modified instillation (n = 7) technique. Defects involved the lower extremity (n = 14), trunk (n = 3), and proximal upper extremity (n = 1), with positive cultures identified in 12 wounds (67%). Therapy continued for 3 to 8 days (mean, 4.3 days), resulting in an average wound surface area reduction of 78% (149 cm² vs. 33 cm²) at definitive closure. Seventeen wounds (94%) were closed directly, whereas the remaining defect required coverage with a local muscle flap and skin graft. At final follow-up (mean, 12 months), 89% of wounds remained closed. In 2 patients with delayed, recurrent periprosthetic infection (mean, 7.5 weeks), serial debridement/hardware removal mandated free tissue transfer for composite defect reconstruction. CONCLUSION Traction-assisted internal NPWT provides a safe and effective alternative to reduce wound burden and facilitate definitive closure in cases where delayed reconstruction of high-tension wounds is planned.

Combined Subcutaneous Heparinization and Negative Pressure Wall Suction as a Mechanical Adjunct for Digital Replant Salvage.

Fig. 1. Left index finger zone 2 replant, on postoperative day 3, with progressive venous congestion despite 24 h of medicinal leech therapy. High-dose heparin (1,000 U/mL) was infiltrated into the congested segment to sustain outflow through a carefully undermined, cutaneous defect (8 mm) along the volar surface of the middle phalanx. Direct application of negative pressure wall suction (−120 mm Hg), for 10 min each hour, serves to expedite decompression of stagnated blood from the open wound. The site is swabbed hourly using a cotton-tip applicator soaked in dilute heparinized saline (100 U/mL) to prevent surface clot formation. Sir: V insufficiency after digital replantation can lead to catastrophic ischemia and progressive tissue necrosis. In situations where surgical correction is either infeasible or fails, medicinal leeches (Hirudo medicinalis) can be used to facilitate egress and maintain physiologic requirements until microvenous circulation regenerates (i.e., 4 to 10 d).1 The focal improvements in flap perfusion observed with leeching are attributed to both direct (i.e., active feeding) and indirect (i.e., passive bleeding) mechanisms that exploit the anticoagulant, vasoactive and enzymatic properties of leech saliva.1,2 Despite reportedly high rates of replant/flap salvage (70% to 80%), the efficacy and reliability of medicinal leeches decline with increasing venous impairment.1–3 Numerous “chemical” and “mechanical” alternatives have been described to promote blood loss and prevent clot formation within severely congested tissues.3,4 Basic strategies common to all successful protocols include controlled surgical wounding, chemical anticoagulation, mechanical agitation, and suction. Quantitative studies comparing the efficacy of mechanical versus traditional leech therapy demonstrate greater improvements in both spatial and volumetric measures of perfusion, blood retrieval, and flap survival with the former.4 Nevertheless, widespread adoption of more effective mechanical prototypes has been limited by the need for experimental and/or highly specialized equipment. Extrapolating from previous concepts, we describe a simple and effective technique for augmenting venous outflow and sustaining tissue viability in the setting of refractory venous compromise. In cases of persistent or progressive congestion— despite optimal leech therapy—alternate mechanical avenues are pursued (Fig. 1). An 8-mm full-thickness ellipse is incised over the volar pad/middle phalanx to provoke drainage from more distal (zone 1)/proximal (zone 2) replants, respectively. Undermining between the dermal and hypodermal layers (10-mm diameter) in these areas provides access to larger cutaneous vessels. To further optimize bleeding, 5 intradermal injections (0.2 mL) of concentrated heparin (1,000 U/mL) are infiltrated into the replant and redosed every 24 to 48 hours by examination. Negative pressure wall suction (−120 mm Hg)—utilizing standard surgical tubing—is applied directly to the wound for 10 minutes each hour to facilitate removal of stagnated blood (approximately 5 to 10 mL). Endpoints for suction include a global improvement in replant color and brightred capillary bleeding (Fig. 2). The site is reassessed hourly and swabbed with dilute heparinized saline (100 U/mL) to remove surface clots. This protocol is repeated/titrated until vascular stability is achieved and/or medicinal leech therapy can be resumed. The technique described, herein, provides an applicable, cost-effective adjunct for digital replant salvage that utilizes readily available materials. Limited subdermal undermining through a small elliptical window increases the area of decongestion without the need for larger cutaneous defects.3 As noted by Iglesias and Butrón,5 direct infiltration of high-dose heparin (1,000 U/mL) produces local concentrations as high as 33,000 to 40,000 U/kg within the congested segment. At these levels, the half-life Copyright

Abstract P35: Outcomes Following Combined Radical Resection and Targeted Biologic Therapy for the Management of Recalcitrant Hidradenitis Suppurativa

RESULTS: Eleven patients underwent combined surgical and biologic therapy, whereas radical resection alone was performed in the remaining 10 patients. The average wound for patients in the combined and surgical cohorts was 56.3 cm and 48.5 cm, respectively (p > 0.05). Biologic agents were initiated two weeks following closure and continued for an average of 10.5 months (r, 6–15 months). Recurrence in the combined cohort was noted in 4 of 29 sites (18.8%) compared with 10 of 26 sites (38.5%) for patients in the surgery alone cohort (p < 0.01). For those in the combined cohort, the mean diseasefree interval was approximately one year longer (18.5 versus 6 months; p < 0.05); however, this difference was reduced to 4.5 months when time to recurrence following cessation of biologic therapy was considered (p > 0.05). New disease developed in 2 (18.2%) and 5 (50%) patients in the combined and surgical cohorts, respectively (p < 0.05). No adverse events were noted among patients who received biologic therapy.