John A. Girotto

Revascularization of human acellular dermis in full-thickness abdominal wall reconstruction in the rabbit model.

This study investigates whether human acellular dermis (Alloderm; LifeCell, Branchburg, NJ) revascularizes when used to reconstruct abdominal wall defects in rabbits. This could prove useful in infected situations in which prosthetic mesh is suboptimal. Twenty-five rabbits were randomly assigned to one of three groups: primary closure (n = 5), expanded polytetrafluoroethylene (GoreTex; W.L. Gore, Flagstaff, AZ) repair (n = 10), or AlloDerm (LifeCell) repair (n = 10). The rabbits in the primary closure group received a 7 cm × 0.5 cm full-thickness abdominal wall defect that was closed primarily. A 7 cm × 3 cm full-thickness abdominal wall defect was created in the other two groups. The defects were repaired with a GoreTex Mycromesh (W.L. Gore), or AlloDerm (LifeCell) patch. At 30 days, the following endpoints were evaluated: (1) incidence of herniation; (2) presence of intra-abdominal adhesions; (3) the breaking strength of the patch–fascial interface; and (4) evaluation of graft vascularization by fluorescein dye infusion and histological analysis. There was no incidence of herniation in any of the rabbits. Visceral adhesions to the patch were found in all animals in the Gore-Tex (W.L. Gore) group but in none in the AlloDerm (LifeCell) group. The size of the patch was unchanged in all the rabbits except for two rabbits in the AlloDerm (LifeCell) group that stretched 1 cm in the transverse dimension. The change in size was not statistically significant (p = 0.17) when compared with the change in size in the Gore-Tex (W.L. Gore) group. The mean breaking strength of the primary closure group was significantly higher (521.2 N/mm2 ± 223.0) than that of the two patch-repair groups (p < 0.05). But there was no significant difference between the mean breaking strength of the AlloDerm (LifeCell) fascial interface (288.6 N/mm2 ± 97.1 SD) and that of the Gore-Tex (W.L. Gore) fascial interface (337.0 N/mm2 ± 141.2). Fluorescein dye infusion and histological analysis confirmed vascularization of the AlloDerm (LifeCell) graft. This study demonstrates that AlloDerm (LifeCell) does become vascularized when used as a fascial interposition graft for abdominal wall reconstruction. AlloDerm (LifeCell) also performs mechanically as effectively as Gore-Tex (W.L. Gore) in ventral hernia repair at 1 month after operation in the rabbit model.

Restoring abdominal wall integrity in contaminated tissue-deficient wounds using autologous fascia grafts

&NA; Necrotizing abdominal wall infections, enteric fistulae, or exposed prosthetic material after ventral hernia repair often results in a loss of abdominal wall integrity. Further surgical reconstruction with prosthetic material is usually contraindicated in the contaminated wound because of the high infection rate necessitating prosthetic removal and further abdominal wall debridement. Consequently, for the past 9 years, we have been using free grafts of autologous fascia lata to replace deficient abdominal wall fascia and muscle in situations where prosthetic material is contraindicated and local tissue rearrangement (i.e., component separation) would be inadequate. Thirty‐two patients (mean age 59 years) underwent abdominal wall reconstruction with autologous fascia lata grafts. Indications included exposed mesh (31 percent), enteric fistulae (28 percent), enteric contamination (22 percent), wound infection (13 percent), and immunosuppression alone (6 percent); 31 percent of all patients were immunosuppressed secondary to either a solid organ transplant or a systemic inflammatory disorder. Fascia grafts (mean size 10 × 17 cm) were sutured to the surrounding abdominal wall and covered by local skin flap advancement and/or myocutaneous flap rotation. All abdominal reconstructions were initially successful. Subsequent local abdominal wall complications included cellulitis (n = 3), seroma (n = 2), and skin dehiscence with exposed fascia grafts (n = 7). Five of seven patients with skin dehiscence healed by secondary intention, whereas two had split‐thickness skin grafts successfully applied to the granulating fascia. Thigh donor site complications included hematoma (n = 1), skin dehiscence (n = 1), and seroma (n = 2). There have been no cases of lateral knee instability. The average follow‐up period is 27 months (range 3 to 106 months). Recurrent hernia has been seen in three patients (9 percent). Interestingly, laparotomy has been performed through an intact fascia lata patch in three patients for unrelated intra‐abdominal conditions. In each case, the graft was intact and revascularized, confirming experimental animal data performed in our laboratory. Recurrent hernia has not been observed through the laparotomy site. Our 9‐year experience has demonstrated that in the face of large, contaminated abdominal wounds where prosthetic material is contraindicated and local tissue rearrangement would be inadequate, fascia lata autografts are a reliable adjuvant to abdominal wall reconstruction.

blindness after Reduction of Facial Fractures

&NA; Blindness in patients suffering maxillofacial trauma is usually caused by optic nerve or optic canal injuries. It is, however, an uncommon complication of facial trauma, with a reported incidence of only 2 to 5 percent.1–6 Blindness may also follow surgical repair of facial fractures. Many mechanisms, such as intraoperative direct nerve injury,7 retinal arteriolar occlusion associated with orbital edema,8–11 or delayed presentation of indirect optic nerve injury sustained at the time of the initial trauma,12 have been implicated in causing this blindness. In this article, four cases of visual loss after surgical repair of facial trauma are reported. In a review of the University of Maryland Shock Trauma experience with facial trauma over 11 years, we discovered that 2987 of the 29,474 admitted patients (10.1 percent) sustained facial fractures, and that 1338 of these fractures (44.8 percent) involved one or both of the orbits. One thousand two hundred forty of these patients underwent operative repair of their facial fractures. Three patients experienced postoperative complications that resulted in blindness, a total incidence of only 0.242 percent. Postoperative ophthalmic complications seem to be primarily mediated by indirect injury to the optic nerve and its surrounding structures. The most frequent cause of postoperative visual loss is an increase in intraorbital pressure in the optic canal. When our data were added to the summarized cases, blindness was attributable to intraorbital hemorrhage in 13 of 27 cases (48 percent). In addition, 5 cases in our review attribute the visual loss to unspecified mechanisms of increased intraorbital pressure, bringing the total cases of visual loss caused by intraorbital pressure or hemorrhage to 18 of 27 cases, or 67 percent. Within the restricted confines of the optic canal, even small changes in pressure potentially may cause ischemic optic nerve injury. (Plast. Reconstr. Surg. 102: 1821, 1998.)

Aging of the Facial Skeleton: Aesthetic Implications and Rejuvenation Strategies

Background: Facial aging is a dynamic process involving the aging of soft-tissue and bony structures. In this study, the authors demonstrate how the facial skeleton changes with age in both male and female subjects and what impact these structural changes may have on overall facial aesthetics. Methods: Facial bone computed tomographic scans were obtained from 60 female and 60 male Caucasian subjects. Twenty male and 20 female subjects were placed in three age categories (20 to 40 years, 41 to 64 years, and 65 years and older). Each computed tomographic scan underwent three-dimensional reconstruction with volume rendering. Edentulous patients were excluded. The following measurements were obtained: upper face (orbital aperture area, orbital aperture width, and curvilinear analysis of the superior and inferior orbital rims), midface (glabellar angle, pyriform angle, maxillary angle, and pyriform aperture area), and lower face (bigonial width, ramus breadth, ramus height, mandibular body height, mandibular body length, and mandibular angle). Results: The orbital aperture width and orbital aperture area increased significantly with age for both sexes. There was a significant increase in orbital aperture size (increase in height of the superomedial and inferolateral orbital rim) in both sexes. The glabellar and maxillary angles decreased significantly with age for both sexes, whereas the pyriform aperture area significantly increased for both sexes with age. Mandibular length and height both decreased significantly for each sex. The mandibular angle significantly increased with age for both sexes. Conclusions: These results suggest that the skeletal morphology of the face changes with age. This change in skeletal morphology may contribute to the appearance of the aging face.

Breast reconstruction in the elderly: preserving excellent quality of life.

There is a paucity of information in the literature that focuses on quality-of-life issues after mastectomy with breast reconstruction in elderly women. The purpose of this study was to review the authors’ experience with breast reconstruction after mastectomy in women older than 65 years of age. Emphasis was placed on the types of reconstructions, outcomes, and evaluation of issues related to quality of life. Between July 1997 and July 2001, 316 consecutive women (400 reconstructions) with breast cancer underwent mastectomy with reconstruction at the authors’ institution. Of these women, 24 (28 reconstructions) were at least 65 years old. Mean patient age was 69.3 years (range, 65–77 years). Methods of breast reconstruction included two-stage implant reconstruction (50%), free tissue transfer (transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flap, 25%), pedicle transverse rectus abdominis musculocutaneous flap (14%), or a latissimus dorsi musculocutaneous flap (11%). Outcomes were assessed with the use of a self-reported questionnaire (SF-36) addressing health-related quality of life, body image, and physical functioning. With respect to overall quality-of-life issues after reconstruction, older patients with breast reconstruction scored higher (better outcomes) than age-matched general population patients and previously reported mastectomy-only patients (>55 years) in all surveyed areas. Specifically, study patients reported dramatic increases (better outcomes) in the subscales that are strongly influenced by one’s mental health. However, when compared with prior data for younger patients undergoing mastectomy and reconstruction, the older patients scored lower (worse outcomes) in the areas related to physical function. The older patients maintained superior scores (better outcomes) over the younger patients in the subscales influenced by one’s mental health.

Long-term physical impairment and functional outcomes after complex facial fractures.

To develop an understanding of the expected functional outcomes after facial trauma, a retrospective cohort study of patients with complex facial fractures was conducted. A cohort of adults aged 18 to 55 years who were admitted to the R. Adams Cowley Shock Trauma Center between July of 1986 and July of 1994 for treatment of a Le Fort midface fracture (resulting from blunt force) was retrospectively identified. Outcomes of interest included measures of general health status and psychosocial well being in addition to self‐reported somatic symptoms. General health status was ascertained using the Medical Outcomes Study 36‐Item Short Form Health Survey (SF‐36). The Body Satisfaction Scale was used to define patient concerns about altered body image and shape. To determine whether complex maxillofacial trauma and facial fractures contributed to altered social interactions, the Social Avoidance and Distress scale was used. In addition, information about a patient, his or her injury, and its treatment were ascertained from the medical records. Using the methods described above, 265 patients with Le Fort fractures were identified. These individuals were matched to a similar group of 242 general injury patients. A total of 190 of the Le Fort patients (72 percent of those eligible for the study) and 144 (60 percent) general injury patients were successfully located, and long‐term interview data were acquired. Le Fort fracture patients as a group had similar health status outcomes when compared with the group of general injury patients. However, when outcomes were examined by the complexity of the Le Fort fracture, the authors found that study subjects with severe, comminuted Le Fort injuries (group D) had significantly lower SF‐36 scores (worse outcomes) for the two dimensions related to role limitations: role limitations due to physical problems and role limitations due to emotional problems (p < 0.05). SF‐36 scores for all other dimensions except physical function were also lower for comminuted versus less complex Le Fort fractures, although differences were not statistically significant. Specifically, there was a direct relationship between severity of facial injury and patients reporting work disability. Of group C and D Le Fort patients (severely comminuted fractures) only 55 and 58 percent, respectively, had returned to work at the time of follow‐up interview. These figures are significantly lower than the back‐to‐work percentage of patients with less severe facial injury (70 percent). When study participants were asked if they were experiencing specific somatic symptoms at the time of the interview that they had not experienced before the injury, a significantly larger percent of the Le Fort fracture patients (compared with the general injury patients) responded in the affirmative. Differences between the Le Fort fracture and general injury groups were statistically significant (p < 0.05) for all 11 symptoms. The percentage of patients reporting complaints increased with increasing complexity of facial fracture in the areas of visual problems, alterations in smell, difficulty with mastication, difficulty with breathing, and epiphora, and these differences reached statistical significance. Patients sustaining comminuted Le Fort facial fractures report poorer health outcomes than patients with less severe facial injury and substantially worse outcomes than population norms. It is also this severely injured population that reports the greatest percentage of injury‐related disability, preventing employment at long‐term follow‐up. The long‐term goal of centralized tertiary trauma treatment centers must be to return the patient to a productive, active lifestyle. (Plast. Reconstr. Surg. 108: 312, 2001.)

Recalcitrant abdominal wall hernias: long-term superiority of autologous tissue repair.

Secondary repair of recurrent ventral hernia is difficult, and success depends on re-establishing the functional integrity of the abdominal wall. Current techniques used for closure of these defects have documented recurrence rates as high as 54 percent. The authors’ 8-year experience utilizing variations of the components separation technique for autologous tissue repair of recalcitrant hernias emphasizes that recurrent or recalcitrant hernias benefit from the creation of a dynamic abdominal wall. A total of 389 patients were retrospectively identified as having abdominal wall defects, and 284 of these patients met the selection criteria. Study patients were grouped according to the type of surgical repair used. The recurrence rate was 20.7 percent over all study groups and was directly related to the extent of repair required. Group 1 patients (wide tissue undermining) had a recurrence rate of only 15 percent, while in group 2 (complete components separation), the recurrence rate was 22 percent. Group 3 patients (interpositional fascia lata graft) had a 29 percent recurrence rate. Time to recurrence was also significantly different across treatment groups, with study group 3 experiencing earlier hernia recurrence. The most frequent postoperative complication was wound infection, which was directly related to the repair performed. The relative odds of recurrence versus the risk factors of age, sex, perioperative steroid use, wound infection, defect size, and the presence of enterocutaneous fistula were studied with a logistic regression analysis. These factors did not possess statistical significance for predicting hernia recurrence. The preoperative presence of mesh was independently significant for hernia recurrence, increasing the relative odds 2.2 times (p = 0.01). Similarly, when other risk factors were controlled for, increasing the complexity of the treatment group, from study group 1 (wide tissue undermining) to study group 3 (interpositional fascia lata graft), also increased the odds of hernia recurrence 1.5-fold per group (p = 0.04). Average inpatient cost was

Current surgical practices in cleft care: cleft palate repair techniques and postoperative care.

24,488. The length of inpatient stay ranged from 2 to 172 days (average, 12.8 days). The length of inpatient stay and costs were directly related to the extent of repair required. Using the analysis of variance test for multiple factors, the presence of an enterocutaneous fistula (p = 0.0014) or a postoperative wound infection (p = 0.008) independently increased the length of inpatient stay and hospital costs. A total of 108 successfully repaired patients were contacted by telephone and agreed to participate in a self-reported satisfaction survey. The patients noticed improvements in the appearance of their abdomen, in their postoperative emotional state, and in their ability to lift objects, arise from a chair or a bed, and exercise. These results suggest that recalcitrant hernia defects should be solved, when possible, by reconstructing a dynamic abdominal wall.

Aging of the mandible and its aesthetic implications.

Background: The purpose of this study was to objectively report practices commonly used in cleft palate repair in the United States. This study investigates current surgical techniques, postoperative care, and complication rates for cleft palate repair surgery. Methods: All 803 surgeon members of the American Cleft Palate-Craniofacial Association were sent online and/or paper surveys inquiring about their management of cleft palate patients. Results: Three-hundred six surveys were received, a 38 percent response rate. This represented responses of surgeons from 100 percent of American Cleft Palate-Craniofacial Association registered cleft teams. Ninety-six percent of respondents perform a one-stage repair. Eighty-five percent of surgeons perform palate surgery when the patient is between 6 and 12 months of age. The most common one-stage repair techniques are the Bardach style (two flaps) with intravelar veloplasty and the Furlow palatoplasty. After surgery, 39 percent of surgeons discharge patients within 24 hours. Another 43 percent discharge patients within 48 hours. During postoperative management, 92 percent of respondents implement feeding restrictions. Eighty-five percent of physicians use arm restraints. Surgeons’ self-reported complications rates are minimal: 54 percent report a fistula in less than 5 percent of cases. The reported need for secondary speech surgery varies widely. Conclusions: The majority of respondents repair clefts in one stage. The most frequently used repair techniques are the Furlow palatoplasty and the Bardach style with intravelar veloplasty. After surgery, the majority of surgeons discharge patients in 1 or 2 days, and nearly all surgeons implement feeding restrictions and the use of arm restraints. The varying feeding protocols are reviewed in this article.

Recurrent ventral herniation in Ehlers-Danlos syndrome

Background: Facial aging is a dynamic process involving the aging of soft-tissue and bony structures. In this study, the authors demonstrate how specific bony aspects of the mandible change with age in both genders and what impact these structural changes may have on overall facial aesthetics. Methods: Facial bone three-dimensional computed tomographic scans were obtained from 120 Caucasian subjects (60 women and 60 men). Our study population consisted of 20 male and 20 female subjects in each of three age categories (20 to 40, 41 to 64, and ≥65 years). Edentulous patients were excluded. The following measurements were obtained: bigonial width, ramus breadth, ramus height, mandibular body height, mandibular body length, and mandibular angle. The data were analyzed with one-way analysis of variance and two-tailed t tests, with results considered significant at a value of p < 0.05. Results: There was no significant change with regard to bigonial width or ramus breadth across age groups for either gender. Ramus height, mandibular body height, and mandibular body length decreased significantly with age for both genders, whereas the mandibular angle increased significantly for both genders with increasing age. Conclusions: These results suggest that the bony elements of the mandible change significantly with age for both genders and that these changes, coupled with soft-tissue changes, lead to the appearance of the aged lower third of the face.