Jonathan Bank

Fat grafting to the hand in patients with Raynaud phenomenon: a novel therapeutic modality.

Background: Raynaud phenomenon causes progressively decreasing blood flow to the extremities, resulting from an imbalance between vasoconstriction and vasodilation. Treatment options include biofeedback, phosphodiesterase inhibitors, calcium channel inhibitors, botulinum toxin injection, or surgical sympathectomy. The authors propose fat grafting to the hands as a method to delay progression of the disease. Methods: Indications included symptomatic Raynaud phenomenon with failure of previous management. Fat is harvested from abdominal depots. Approximately 30 ml of decanted fat is injected by means of blunt cannulae: 10 to 15 ml in the dorsum of the hand, 2 to 3 ml in the snuffbox, 1 to 2 ml in each dorsal webspace, 3 to 4 ml along the superficial palmar arch, 1 to 2 ml in volar webspaces 2 to 4, and 2 to 3 ml in the first webspace. Patients underwent preoperative and postoperative laser speckle imaging study to assess changes in perfusion. Results: A total of 13 patients were treated (21 hands). Twelve patients had undergone prior botulinum toxin injection, and 11 patients had prior sympathectomies. Findings included reduced pain (average reduction, 6.86 of 10 to 2.38 of 10), fewer cold attacks, improved skin and soft-tissue texture, decrease in ulcerations, and patient-reported improved function. Three patients had no changes. Increased blood flow per imaging was noted in five of 11 hands tested. Six patients had decreased readings on laser imaging. None of the laser speckle imaging changes were statistically significant, and they did not correlate clinically. There were no major complications. Conclusions: Preliminary results of fat grafting to the hands of patients with Raynaud phenomenon revealed improved symptomatology with evidence suggestive of measurably increased perfusion in some cases. Fat grafting may benefit the management of this patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Inexpensive Method of Liposuction Cannula Port-Site Protection

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of

Use of thoracodorsal artery perforator flaps to enhance outcomes in alloplastic breast reconstruction.

Background: Use of the thoracodorsal artery perforator (TDAP) flap in combination with alloplastic devices has been proven to be a safe method of breast reconstruction. However, preoperative irradiation increases the complication rate and thus some consider preoperative radiotherapy a relative contraindication to alloplastic alone reconstruction. We evaluated the long-term outcomes of patients with preoperative radiotherapy who had delayed alloplastic reconstruction with a TDAP flap. Methods: A retrospective analysis of a prospectively maintained database was performed to identify patients who had received a Latissimus Dorsi (LD), a Muscle Sparing Latissimus Dorsi (MSLD), or a TDAP flap plus a tissue expander or implant between 2005 and 2012. Information regarding patients’ primary diagnosis, radiation history, prior breast reconstructions, and complications was collected and analyzed. Results: Sixteen patients who had a total of 16 breast reconstructions with an LD (6) or TDAP/MSLD1 flap (10). Demographic data, device type, co-morbidities and complications were analyzed. The rate of capsular contracture and size asymmetry were higher in the LD group, but there was no difference noted for major complications. Minor complications were also similar between the 2 groups. Conclusions: Patients who underwent irradiation before TDAP flap did not have a higher complication rate when compared with patients who had a full LD flap following radiation. By integrating well-vascularized, nonradiated tissue of a TDAP flap in reconstruction, overall complication rate may be minimized and the results are comparable to the generally accepted method of utilizing the entire latissimus dorsi muscle.

Superficial Inferior Epigastric Artery: Learning Curve versus Reality.

Background: Breast reconstruction with the superficial inferior epigastric artery (SIEA) free flap continues to gain popularity among reconstructive surgeons. The low risk for abdominal wall morbidity must be weighed against the higher concern for thrombotic events. The aim of this study was to review the authors’ recent experience with the SIEA flap and investigate whether their previously published incidences of vessel thrombosis and flap loss were related to their own “learning curve” or whether these adverse events are attributable to inherent qualities of the SIEA flap. Methods: The authors performed a retrospective chart review of all patients undergoing SIEA flap surgery between January 1, 2008, and July 1, 2014, at their institution. All included operations were performed by the senior author (J.M.S.). The main outcomes of interest included vessel thrombosis and partial/full flap loss. Results: Forty-seven SIEA flaps were performed on 39 patients. Sixty-four percent (n = 30) were immediate reconstructions and 79 percent (n = 37) were bilateral. There were five intraoperative arterial thromboses (10.6 percent) and one intraoperative venous thrombosis (2.1 percent), with eight total thrombotic events (17.0 percent). One total flap loss (2.1 percent) and two partial flap losses (4.3 percent) were experienced. Conclusions: The authors’ recent experience with SIEA-based breast reconstruction shows a similar incidence of thrombotic events and flap loss compared with the authors’ early experience. These incidences remain greater than what is seen with other abdominally based autologous breast reconstruction techniques and do not appear to be attributable to an operator learning curve. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Prelaminated fascia lata free flap for large nasal septal defect reconstruction

Nasal septal defects can be challenging to repair, given their location, size, and the unique, tri-layered structure of the septum, which includes a thin piece of cartilage positioned between mucosal layers. The report herein presents a case of a 47 year-old woman with a large symptomatic nasal septal perforation, despite saline irrigations and ointment. Placement of a septal button or a traditional surgical approach was not considered because of the extremely large nature of the perforation. We describe the use of a tri-layered fascia lata flap prelaminated with buccal mucosa grafts to successfully repair this complicated defect. Subsequent follow-up visits showed complete repair of the defect and patent nasal passages, without the need for any debulking procedures. Based on these results, we conclude that a prelaminated fascia lata flap is a good reconstructive option for large, complex nasal septal defects, bringing thin, healthy mucosalized tissue to the defect and minimizing future surgical procedures.

Reply: Fat Grafting to the Hand in Patients with Raynaud Phenomenon

injection performed in this case is unclear. We concede that it is unlikely that minor differences in technique affect the outcome. However, we do believe that certain factors are important to clarify. The authors do not indicate whether they adhered to the methods we described. In what positions and planes was the fat injected? Was the fat injected with force? Was it injected on withdrawal of the cannula? Were blunt cannulas used for injection? What size cannulas were used? Was epinephrine used in the tumescent solution, and if so, at what concentration? Was the fat filtered after harvest or simply left to decant? Were local anesthetics and epinephrine used in the hands? Simple decanting may cause retention of epinephrine in the injected material, which may be critically detrimental in peripheral vasculopathy, particularly during an ischemic crisis. Second, and more importantly, the indication seemingly applied in this case extends beyond what we may have chosen in the management of this patient. Our study population required an inclusion criterion of medically diagnosed Raynaud phenomenon. We presume that the patient presented had Raynaud phenomenon, although this is not clearly stated in the case report. The description of nasal tip necrosis along with 10-digit necrosis at 36 hours after fat grafting warrants questioning whether an undiagnosed systemic disorder was present before grafting. It is difficult to ascertain whether this outcome was a progression of an underlying process manifesting with peripheral ischemia, or whether the fat injection caused a systemic reaction by an unknown mechanism. One putative explanation may be inadvertent intravascular injection leading to fat embolism, which emphasizes the significance of technical nuances required for safe fat grafting. We take this opportunity to highlight our proviso that we would not perform this procedure during an acute ischemic crisis (which may have occurred in this case, as evidenced by the reported need for hospitalization). Fat transfer to the hands is not a new procedure, but the unknown factors still outnumber the known. Undertaking a change in practice should be done under optimal conditions, after eliminating confounders and excluding other causes of multidigit ischemia. In this particular case, attempts at ischemia reversal were performed before fat grafting. We do not see fat transfer as a reliable means of treating acute ischemic digits. Grafting fat in patients with Raynaud phenomenon stemmed from benefits observed in fibrotic irradiated tissue. The ensuing clinical improvement of the intermittent ischemia of Raynaud phenomenon is a serendipitous outcome that we are still unable to explain. Since submitting our manuscript in June of 2013, we have performed fat grafting to more than a dozen hands and feet of patients with Raynaud phenomenon, with outcomes similar to those reported previously. We welcome further correspondence regarding our technique and indications. Reply: Fat Grafting to the Hand in Patients with Raynaud Phenomenon: A Novel Therapeutic Modality Sir: Thank you for granting us the opportunity to contribute to the discussion on the topic of fat injection to the hands of patients with Raynaud phenomenon. In response to our article1 describing the technique and results published in the May of 2014 edition of Plastic and Reconstructive Surgery, Pavlidis et al. describe a case of an 84-year-old woman with a history of scleroderma that presented with 10-digit ischemia. Subsequent to fat injection, the patient suffered necrosis of 10 digits, requiring surgical débridement. Although we are disheartened by this unfortunate outcome, and appreciate Pavlidis et al.’s cautionary words, several points should be expounded on regarding the case description before far-reaching conclusions can be drawn. First, the precise technique of the circumstances with fat injection technique. In our hands, use of this technique did not prove safe and reliable. DOI: 10.1097/PRS.0000000000000814

Medicinal leech fixation in precarious locations.

Successful use of the medicinal leech Hirudo medicinalis in the salvage of microvascular free flaps has been widely described. The potent anticoagulant hirudin injected by the leech reduces venous engorgement nonsurgically by improving blood drainage from the flap. Potential risks include local infection (mainly by Aeromonas hydrophila), sepsis, blood loss, and leech migration. A method described by Granzow et al employs limiting the movement of medicinal leeches from the surgical site by affixing one end of a surgical suture to the leech and tying the free end to a firm object or dressing. The following case description reports a modification of this technique by suturing a leech to the skin close to an engorged composite graft at the nasal columella. An otherwise healthy 61-year-old woman presented with a large lesion involving the right nostril floor and columella. Tissue biopsy revealed a Morpheus-type basal cell carcinoma. A Mohs procedure was performed excising the nasal columella, the right vestibular mucosa on the septum, the lining mucosa of the right nostril, and the right septal mucosa. Several composite grafting procedures were needed to achieve acceptable structural results. After the last of these operations, the graft appeared to be congested (Fig. 1), and the patient was readmitted to undergo medicinal leech treatment. The proximity of the graft to the nasal orifice posed a therapeutic challenge, as the risk of leech translocation into the nostril and to the mouth was high. This obstacle was overcome by placing a suture piercing through the middle of the leech and fastening it to the underlying tissue using a connective buttonhole, thus preventing migration into the nasal cavity (Fig. 2). The medicinal leech Hirudo medicinalis has been successfully used in the salvage of congested microsurgical flaps by creating an alternative outflow for engorged blood in a flap compromised by poor venous drainage. Attachment is achieved by manipulation of the leech toward the designated area, both physically and chemically by creating a feeding substrate such as a sucrose solution or fresh blood by needle pricking the target tissue. Once sated, the leech will spontaneously detach, at which point arises the risk of translocation. Traditional methods of gauze application surrounding the treatment site may not be applicable in areas anatomically proximal to apertures such as the nose, ears, mouth, and genital orifices. Transmigration into virtually every bodily cavity has been described, posing an impending risk of internal bleeding. The emotional apprehension associated with leech therapy at any site is further heightened when applied near these challenging sites. These factors warrant the conception

Non-Invasive Imaging of Preoperative Mapping of Superficial Veins in Free Flap Breast Reconstruction

Vascular anatomy is imperative in reconstructive surgery to ensure perfusion and accurate flap design, but venous anatomy can be difficult to determine preoperatively. Anatomic landmarks can be used to locate structures; however there can be considerable variation in anatomy and location of veins. Techniques such as radiographic imaging, Doppler probes, and ultrasonography have been used to assess veins. However, radiographic imaging incurs a cost and radiation exposure. Doppler probes are easy to use but are more useful for arterial anatomy. Ultrasonography is limited by cost, time, and accessibility. Several vein visualization devices, including the AccuVein (Avant Medical, Cold Spring Harbor, NY, USA), have been previously reported as an adjuvant to locate veins [1] and to aid intravenous cannulation. These devices were helpful to visualize veins, especially in difficult patients (extremes of age, obese, dark-skinned) [2,3,4]. The AccuVein is a portable device (size, 5×6×20 cm; weight, 275 g) that emits a red laser at 642 nm and an infrared laser at 785 nm. Hemoglobin preferentially absorbs infrared light so the skin the skin illuminated a red color and veins are silhouetted as dark outlines (Fig. 1). The color schemes can also be inverted to display veins as red silhouettes on the skin. Fig. 1 (A, B) Hand-held vein visualization device, (AccuVein) uses a red laser and infrared laser to illuminate basilic and cephalic venous vasculature for the forearm. The AccuVein device was used in our study for abdominal-based free flap breast reconstruction to aid in locating abdominal veins and to evaluate candidacy for superficial inferior epigastric artery (SIEA) perforator flaps. To the best of our knowledge the use of this device in breast reconstruction has not been reported. The current practice at our institution for planned free flap breast reconstruction involves intraoperative decision-making to determine flap type [5]. Routine preoperative radiographic imaging is not obtained. After making the inferior incision on the abdomen the SIEA is carefully identified. If the SIEA is absent, injured, or of insufficient caliber (<1.5 mm) then an SIEA flap is not used and the deep inferior epigastric system is assessed next. Medial and lateral row perforators are identified and a decision is then made to use either a deep inferior epigastric artery perforator flap or a muscle-sparing free transverse rectus abdominis musculocutaneous flap [5]. In our study the AccuVein was used for preoperative venous mapping of the superficial inferior epigastric veins (SIEV), superficial circumflex iliac veins, and to help guide dissection and flap design of the inferior skin paddle incision (Fig. 2). If an adequate SIEV was visualized preoperatively, the inferior skin incision was occasionally redesigned and made more inferior to ensure inclusion of the vascular pedicle before it arborizes. Fig. 2 Preoperative visualization of left superficial epigastric vein before breast reconstruction. The AccuVein was used on ten patients. In eight patients at least one SIEV was identified preoperatively in all patients and there was 100% positive and negative correlation of preoperative markings with intraoperative exploration (Fig. 3), and all veins were able to be identified intraoperatively. In the other two patients had abdominal striae that interfered with venous imaging and abdominal veins were not able to be visualized. In two patients preoperative vein mapping changed the flap design: the inferior incision was lowered to explore the vein before it bifurcates to include a larger caliber vessel in the flap for flap drainage or when patients were possible SIEA flap candidates. There were no AccuVein related complications and no false negatives that led to adverse flap planning. There were also no other perioperative complications or microvascular complications or flap losses for all ten patients and patients were on average, discharged on postoperative day 4.1 (range, 4–5). Fig. 3 (A, B) Preoperative and intraoperative photographs of superficial epigastric vein during the donor site dissection of abdonimal-based free flap breast reconstruction using right hemi-abdomen. The AccuVein is a non-invasive, portable, fast, and easy to use device to assess veins in real time. The disadvantages of this device are that it only produces a two dimensional image and the vein is displayed based on vessel content and not the actual vessel caliber. Although there were no false positives in our study, we recommend direct visualization of vessel caliber before any surgical decisions are made. The AccuVein can provide preoperative information about venous anatomy that can be useful in aiding dissecting veins and flap design. The AccuVein is not necessary to successfully perform free flap breast reconstruction but we believe the AccuVein is an effective adjuvant that can help aid flap design and expedite dissection. The SIEV is a useful lifeboat that can be used as venous outflow for abdominal-based flaps and also used as a vein graft. Anatomic landmarks exist for most critical structures, and the SIEV is also consistently found midway between the anterior superior iliac spine and the midline. But anatomy can be variable and the AccuVein can expedite dissection and flap design. Preoperative vein mapping can be useful for those starting to perform SIEA perforator breast free flap reconstructions. Preoperative venous mapping can help guide flap design and speed dissection of the SIEV and SIEA vena comitans. Radiographic imaging provide much more information than can AccuVein, but also costs more, is invasive if contrast-enhanced imaging is used, may require radiation exposure, and needs time to schedule, perform, and review images. On the other hand, the AccuVein device is often already available in many hospitals in the nursing units and is a simple, cheap, noninvasive, and quick method for preoperative mapping of superficial veins.

Mechanical Leeching with Venocutaneous Fistula and Monitoring with Near-infrared Spectroscopy.

Summary: The report herein describes the use of a venocutaneous fistula with angiocatheter attachment and near-infrared spectroscopy device to correct venous congestion of a vertical upper gracilis free flap used for breast reconstruction. This method of mechanical leeching was precisely controlled through monitoring trends in the tissue oxygen saturation levels of the flap, allowing venous congestion to be relieved before it became clinically apparent.

Curcumin protects against ischemia/reperfusion injury in rat skeletal muscle.

The body of literature describing preventative modalities against ischemia reperfusion injury (IRI) seems to be expanding with the ferocity of the oxidative burst that it seeks to ablate. This is clearly an unresolvedmatter that spans multiple surgical and nonsurgical fields. Understanding that the body’s ability to neutralize the surge of free radicals during reperfusion is overwhelmed, an exogenous antioxidant is introduced with the intention of augmenting naturally occurring antioxidants, thus minimizing lipid peroxidation and subsequent cellular damage. In this study, similar in concept to multiple others published, the authors hypothesize that blocking the effects of the reactive oxygen species (being one of the culprit end products of the leukocytic reaction following IRI) could minimize the tissue damaged incurred [1]. Awad and El-Sharif recently reported on the protective effects of curcumin in IRI, attributing the molecule’s potency to immunomodulatory and anti-apoptotic features [2]. Avci et al. explore the utility of the curcumin molecule in mitigation of tissue injury inflicted by the ischemiareperfusion process [1]. This potential therapeutic strategy is an interestingly simple alternative in comparison to modalities recently reported in the literature, including injection of progenitor cells [3] that decrease inflammation and fibrosis by mechanisms yet to be elucidated, and multiple other strategiesmodulating the immune system or targeting blockade of cytokines and chemokines, adhesion molecules, NF-kappaB, MAP kinases, metalloproteinases, and induction of protective genes. Lutz et al. offered a comprehensive review of these approaches in 2010 [4]. Avci’s report follows a growing series of antioxidants that have been experimentally shown to have potential benefits inminimizing IRI, including, but not limited, to alipoic acid [5], bucillamine [6, 7], vitamin E [8, 9], pyridoindole derivatives [10], and recently dihydrolipoyl histidinate zinc complex [11]. The investigators chose to exploit the antioxidative properties of the phytochemical curcumin to these ends, analyzing activity levels of antioxidant enzymes SOD, CAT, as well as tissue levels of GSH, MDA, and PO to gauge curcumin’s antioxidant properties in vivo in a muscle IRI model in rats. Measuring levels of global indicators of inflammation (TNF-a, IL-1b) adds another dimension to their report. The results of this experiment confirm the authors’ hypothesis that curcumin attenuates IRI primarily by its direct and indirect antioxidant properties.