Kyle Sanniec

Predictive factors of wound complications after sarcoma resection requiring plastic surgeon involvement.

IntroductionThe most effective management of a patient with sarcoma is surgical resection. Often the resection is performed, the wound is irradiated, adjuvant chemotherapy is administered, and the wound is closed without plastic surgery consultation. Wound complications, after these treatment protocols, often require plastic surgery involvement and the treatment may require more advanced reconstructive techniques with higher rates of complications than if involvement occurred earlier. MethodsA retrospective review of all patients who underwent sarcoma excision from 2001 to 2011 was performed. Factors such as tumor size, radiation, chemotherapy, delayed reconstruction (>3 weeks), and immediate reconstruction (<3 weeks) were analyzed for their correlation with wound complications or flap loss. ResultsA total of 127 patients underwent sarcoma resection. Wound complications occurred in 49 (38%) patients. All 15 delayed reconstructions had a wound complication, whereas only 11 (37%) of immediate reconstructions had a wound complication. Wound complications with tissue excision less than 500 g occurred in 18 (26%) patients and occurred in 31 (54%) patients with excision greater than 500 g. Seventy-two patients underwent radiation with a wound complication rate of 46% compared with 29% for patients who were not radiated. Chemotherapy was used in 35 patients with a wound complication rate of 49%. ConclusionsThe most predictive factor of sarcoma complication is whether the procedure was a delayed or immediate reconstruction. The second most predictive factor is the amount of tissue excised, greater than 500 g of tissue excised was associated with significantly higher complication rates. Other aspects of sarcoma treatment that may be correlated with higher incidence of wound complications are radiation and the use of adjuvant chemotherapy. Early plastic surgery involvement can help with preoperative planning and reduce the complication rates in patients with sarcoma resection.

Decompression–Avulsion of the Auriculotemporal Nerve for Treatment of Migraines and Chronic Headaches

Summary: Surgical decompression of peripheral branches of the trigeminal and occipital nerves has been shown to alleviate migraine symptoms. Site II surgery involves decompression of the zygomaticotemporal branch of the trigeminal nerve by the technique developed by Guyuron. Failure of site II surgery may occur secondary to an inability to recognize a second temporal trigger: site V, the auriculotemporal nerve. A direct approach for site V has been used with no clear description in the literature. Herein, we describe a safe and efficient method for auriculotemporal nerve decompression during the Guyuron endoscopic approach. Close attention to all temporal sites is necessary to avoid potential failure of migraine decompression surgery.

Simplifying the Forehead Flap for Nasal Reconstruction: A review of 420 consecutive cases

Background: The forehead flap is an important tool in nasal reconstruction. The authors present objective data and recommendations based on over a decade of consecutive forehead flap nasal reconstructions performed by the senior author (J.F.T.). In addition, the authors separate the technique into its individual steps and provide details of the senior author’s approach to each. Methods: The authors performed a retrospective analysis of patients who underwent nasal reconstruction with the forehead flap over a 10-year period performed by the senior author (J.F.T.). Each case was evaluated for defect location, pedicle design, time of division, number of stages, use of cartilage grafts, lining reconstruction, donor-site closure, and complications. Results: Four hundred twenty patients underwent forehead flap nasal reconstruction. Average time to pedicle division was 32 days. Three-fourths of patients completed reconstruction in two stages. Defects most commonly involved the nasal ala and tip. Approximately half of patients received cartilage grafts and half underwent lining reconstruction. There were 16 complications, ranging from partial flap loss to postoperative death (n = 1). Conclusions: Confidently grasping the nuances of forehead flap nasal reconstruction arms the reconstructive surgeon with a reliable tool that can effectively treat a variety of defects. It is safe to use in an outpatient setting even in elderly patients. Recommendations include ipsilateral flap design and turn-in component as the first choice for lining replacement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Immediate versus Delayed Sarcoma Reconstruction: Impact on Outcomes

Background. Sarcoma is a rare malignancy, and more recent management algorithms emphasize a multidisciplinary approach and limb salvage, which has resulted in an increase in overall survival and limb preservation. However, limb salvage has resulted in a higher rate of wound complications. Objective. To compare the complications between immediate and delayed (>three weeks) reconstruction in the multidisciplinary limb salvage sarcoma patient population. Methods. A ten-year retrospective review of patients who underwent sarcoma resection was performed. The outcome of interest was wound complication in the postoperative period based on timing of reconstruction. We defined infection as any infection requiring intravenous antibiotics, partial flap failure as any flap requiring a debridement or revision, hematoma/seroma as any hematoma/seroma requiring drainage, and wound dehiscence as a wound that was not completely intact by three weeks postoperatively. Results. 70 (17 delayed, 53 immediate) patients who underwent sarcoma resection and reconstruction met the inclusion criteria. Delayed reconstruction significantly increased the incidence of postoperative wound infection and wound dehiscence. There was no difference in partial or total flap loss, hematoma, or seroma between the two groups. Discussion and Conclusion. Immediate reconstruction results in decreased wound complications may reduce the morbidity associated with multidisciplinary treatment in the limb salvage sarcoma patient.

Split-Thickness Skin Grafts to the Foot and Ankle of Diabetic Patients

BACKGROUND There is an increased prevalence of foot ulceration in patients with diabetes, leading to hospitalization. Early wound closure is necessary to prevent further infections and, ultimately, lower-limb amputations. There is no current evidence stating that an elevated preoperative hemoglobin A1c (HbA1c) level is a contraindication to skin grafting. The purpose of this review was to determine whether elevated HbA1c levels are a contraindication to the application of skin grafts in diabetic patients. METHODS A retrospective review was performed of 53 consecutive patients who underwent split-thickness skin graft application to the lower extremity between January 1, 2012, and December 31, 2015. A uniform surgical technique was used across all of the patients. A comparison of HbA1c levels between failed and healed skin grafts was reviewed. RESULTS Of 43 surgical sites (41 patients) that met the inclusion criteria, 27 healed with greater than 90% graft take and 16 had a skin graft that failed. There was no statistically significant difference in HbA1c levels in the group that healed a skin graft compared with the group in which skin graft failed to adhere. CONCLUSIONS Preliminary data suggest that an elevated HbA1c level is not a contraindication to application of a skin graft. The benefits of early wound closure outweigh the risks of skin graft application in patients with diabetes.

Anatomical Regional Targeted (ART) BOTOX Injection Technique: A Novel Paradigm for Migraines and Chronic Headaches

Summary: Migraine headaches are a debilitating disease that causes significant socioeconomic problems. One of the speculated etiologies of the generation of migraines is peripheral nerve irritation at different trigger points. The use of Onabotulinum toxin A (BOTOX), although initially a novel approach, has now been determined to be a valid treatment for chronic headaches and migraines as described in the Phase III Research Evaluating Migraine Prophylaxis Therapy trials that prompted the approval by the Food and Drug Administration for treatment of chronic migraines. The injection paradigm established by this trial was one of a broad injection pattern across large muscle groups that did not always correspond to the anatomical locations of nerves. The senior author developed the Anatomical Regional Targeted BOTOX injection paradigm as an alternative to the current injection model. This technique targets both the anatomical location of nerves known to have causal effects with migraines and the region where the pain localizes, to provide relief across a wide distribution of the peripheral nerve. This article serves as a guide to the Anatomical Regional Targeted injection technique, which, to our knowledge, is the first comprehensive BOTOX injection paradigm described in the literature for treatment of migraines that targets nerves and nerve areas rather than purely muscle groups. This technique is based on the most up-to-date anatomical and scientific studies and large-volume migraine surgery experience.

Simplifying Lip Reconstruction: An Algorithmic Approach

Abstract The authors provide an overview of lip reconstruction after Mohs surgery based on the senior authors practice. Lip reconstruction offers unique challenges to preserve not only lip function but also aesthetics. Lip reconstruction must take into consideration the three anatomical layers that comprise the lip and defects that involve the mucosa, the muscle, the skin or more than one layer will help determine the modality of repair. The authors offer an algorithm based on defect location, tissue involvement, and severity of defect to simplify an often complex decision‐making process.

Management of Migraine Headaches: OnabotulinumtoxinA Injection

Chronic migraines are a common debilitating headache disorder. Recently, there has been increasing interest in the use of onabotulinumtoxinA as a preventative treatment, as studies have shown significant benefits. In line with current accepted theories on the pathophysiology of migraines, the toxin works by both direct and indirect means to prevent peripheral and central nerve sensitization. While efficacy has been established, the technique for extracranial delivery of onabotulinumtoxinA continues to see changes in an effort to seek better outcomes. The PREEMPT injection protocol is the original injection paradigm design targeting broad muscle groups. The ART injection paradigm offers the ability to deliver onabotulinumtoxinA closer to culprit nerves, thus increasing its effect and also decreasing adverse effects. OnabotulinumtoxinA is an effective and well-tolerated option for selective patients seeking relief from migraine headaches.

Surgical Management of Migraine Headaches

Although migraines are experienced by a significant portion of the population, current medical therapies often fail to completely alleviate the symptoms of many migraine sufferers, leading to significant residual disability. Within the last decade, migraine surgery has arisen as a viable option for patients who have exhausted all other medical treatments. Despite early resistance in the headache care community, it has become more accepted due to an increasing number of studies demonstrating efficacy and safety, and increasing evidence supporting the influence of peripheral nerves in the progression of migraine pathophysiology. Yet, it remains crucial to carefully select appropriate surgical candidates based on the assessment of various factors such as medication use, pain distribution, and any other medical conditions that may contribute to headache. It is equally important to ensure that the patient has a strong relationship with a neurologist for optimal medical management and postoperative medical support. After the appropriate trigger sites are identified, various techniques can be used to decompress the involved larger nerves, avulse the smaller nerves, and address any intranasal pathology that could be causing migraines.

Management of Tissue Ischemia in Mastectomy Skin Flaps: Algorithm Integrating SPY Angiography and Topical Nitroglycerin.

Summary: Tissue ischemia can be managed in several different ways based on the cause of the perfusion defect, including topical nitroglycerin or surgical intervention. However, there are times when tissue perfusion is questioned and clinical examination is unable to determine definitively the cause of ischemic tissue and whether it will survive. In this technique article, we describe our comprehensive algorithm for the management of tissue ischemia in mastectomy skin flaps, which can be applied to other plastic surgery procedures by integrating SPY angiography and topical nitroglycerin.