Matthew L. Iorio

Efficacy and safety of venous thromboembolism prophylaxis in highest risk plastic surgery patients.

Background: The purpose of this study was to stratify plastic surgery patients into venous thromboembolism risk categories; identify patients at highest risk for venous thromboembolism; and quantify rates of postoperative all-cause mortality, venous thromboembolism, and hematoma/bleeding on different forms of thromboprophylaxis. Furthermore, this study aimed to determine the compliance and average duration of outpatient chemoprophylaxis. Methods: A retrospective cohort study was carried out on a single plastic surgeons experience. Venous thromboembolism risk stratification identified patients at highest risk. Records were reviewed for regimen of thromboprophylaxis and for occurrences of all-cause mortality, venous thromboembolism, and hematoma/bleeding. Outpatient compliance and duration of low-molecular-weight heparin chemoprophylaxis was also documented. Results: During the study time period, 173 operations involved 120 patients at highest risk for venous thromboembolism. Among highest risk patients, one (0.8 percent) suffered a pulmonary embolism, eight (6.7 percent) experienced a deep vein thrombosis, and 15 (12.5 percent) endured a hematoma/bleed. Thirteen of 14 outpatients (92.9 percent) were compliant with low-molecular-weight heparin and remained on chemoprophylaxis for an average of 7.4 days. Conclusions: Mechanical prophylaxis plus subcutaneous heparin (unfractionated or low-molecular-weight heparin) conferred a statistically significant reduction in the rate of venous thromboembolism without a significant increase in bleeding versus mechanical prophylaxis alone. Subgroup analysis of patients placed on mechanical prophylaxis plus low-molecular-weight heparin revealed similar statistically significant findings. Outpatients placed on low-molecular-weight heparin chemoprophylaxis demonstrated excellent compliance and comfort with self-administration. Therefore, the use of mechanical prophylaxis supplemented with low-molecular-weight heparin is strongly recommended as the first-line regimen for thromboprophylaxis in plastic surgery patients at highest risk for venous thromboembolism.

Cutaneous Angiosome Territory of the Medial Femoral Condyle Osteocutaneous Flap

PURPOSE The medial femoral condyle flap is used for treatment of nonunions with or without intercalary bone loss. Most reported uses have been without a skin segment, but this flap can provide a skin component supplied by the saphenous artery branch (SAB) of the descending genicular artery (DGA) pedicle. Experience with this flap suggests that an additional distinct, reliable, more-distal, DGA-cutaneous branch can be found at condyle level, capable of supporting skin without using the SAB. This cadaver study evaluated SAB and DGA-cutaneous branch angiosome territories. A clinical case series assesses the DGA-cutaneous branchs clinical utility. METHODS The DGA and SAB were isolated in 12 cadaveric legs, divided, and separately cannulated. Red dye and methylene blue were selectively injected into each vessel manually. Skin perfusion was measured and photographed. RESULTS In all specimens, the DGA was present, originating 14.2 cm proximal to the joint line, and demonstrated a distinct cutaneous branch at condyle level. This vessel provided an average perfusion area of 70 cm(2), centered over the medial knee. The SAB was identified in 11 specimens (92%), with an average perfusion area of 361 cm(2) along the medial aspect of the distal thigh and proximal leg. The DGA communicating branch was present and used for perfusion of the skin paddle in 17 of 20 cases. The SAB was present in 18 of 20 cases, used with DGA-communicating branch in 4 cases, and the sole source of skin perfusion in 1 case. In 2 remaining cases, neither the SAB nor DGA communicating branch was adequate for perfusion of a skin segment. CONCLUSIONS The medial femoral condyle flap can be harvested with a large skin paddle based on the SAB. A smaller skin segment can be harvested using the more distal DGA-communicating branch at condyle level. CLINICAL RELEVANCE Improved understanding of the skin island associated with the DGAs saphenous and cutaneous branches can provide a rapid, reliable method of skin-segment harvest.

Functional limb salvage in the diabetic patient: the use of a collagen bilayer matrix and risk factors for amputation.

Background: The diabetic foot ulcer presents a therapeutic challenge with a high rate of limb infection and extremity amputation. Adequate debridement and stable coverage of exposed structures are paramount to preserving limb length. The authors reviewed their use of a collagen bilayer matrix in the diabetic population for the preservation of functional limb length. Salvage rates were stratified with patient comorbidities of severe peripheral arterial disease and/or persistent infection. Methods: A retrospective review was performed of all consecutive patients who underwent application of Integra by the senior authors (J.S.S., C.E.A.) for lower extremity salvage between January of 2004 and December of 2008. Results: A total of 105 patients with 121 separate wounds were analyzed. Patient age ranged from 22 to 80 years (mean, 58 years). The average wound size was 25.9 cm2 in the diabetic population. Average follow-up was 325 days, and average number of operations before closure was 1.28. In the diabetic population, of the 59 patients identified as low risk for amputation, 10 (17 percent) progressed to amputation. Of the 28 patients identified as high risk for amputation, 15 (54 percent) progressed to amputation. In the nondiabetics, 31 patients were classified as low risk for amputation, and one (3 percent) went on to an amputation. Conclusions: Use of a collagen bilayer matrix appears to be a viable option for reconstruction and stable closure in the diabetic patient at low risk for amputation, with risk based on available blood supply and evidence of infection. In the diabetic patient at high risk for amputation, however, the rate of salvage may not be improved with the use of Integra.

Innovative treatment of peripheral nerve injuries: combined reconstructive concepts.

Background:Although autografts are the gold standard for failed primary nerve repairs, they result in donor-site morbidity. Nerve conduits and decellularized allografts are a novel solution for improved functional outcomes and decreased donor-site morbidity. Unfortunately, previous reconstructive algorithms have not included the use of decellularized allograft nerve segments, either for repair of the primary injury or reconstruction of the autograft donor site. To identify the optimal sequence of techniques and resources, we reviewed our cases of upper extremity peripheral nerve reconstruction. Methods:A retrospective review was performed on consecutive patients who underwent upper extremity nerve reconstruction between August 2003 and September 2009. Outcomes were evaluated with the QuickDASH (disabilities of the arm, shoulder, and hand) questionnaire. Grouped outcome results were evaluated with analysis of variance analysis. A literature review of available options for nerve reconstruction was performed. Results:In all, 47 patients were identified. Complete demographic/injury data were obtained in 41 patients with 54 discrete nerve repairs: 8 were repaired primarily, 27 with nerve conduits, 8 with allografts, and 11 with autografts. Time from injury to repair averaged 22.3 ± 38.3 weeks, with 12 repairs occurring immediately after tumor resection. Average QuickDASH score was 23.2 ± 19.8. An analysis of variance between repair-type outcomes revealed a P value of 0.58, indicating no outcome difference when each repair was applied for an appropriate gap. No comparable algorithm was identified in the literature analyzing the use of allograft in conjunction with conduit and autografts. Conclusion:To restore maximal target-organ function with minimal donor-site morbidity, we have created an algorithm based on evidence for nerve reconstruction using allograft, conduit, and autologous donor nerve. Based on our clinical outcomes, despite small sample study, the adoption of the proposed algorithm may help provide uniform outcomes for a given technique, with minimal patient morbidity. Individualized reconstructive technique, based not only on nerve gap size but also on functional importance and the anatomical level of the nerve injury are important variables to consider for optimal outcome.

Chronic postoperative breast pain: danger zones for nerve injuries.

Background: Postoperative breast pain is a frequent complaint, reported by 50 percent of women following a breast procedure. Breast pain interferes with sexual activity, as reported by 48 percent of patients, exercise (36 percent), social activity (13 percent), and employment (6 percent). Methods: To define neurogenic causes of chronic postoperative breast pain, the authors performed a retrospective review of consecutive patients from a single surgeon and performed 10 anatomical bilateral dissections. The authors evaluated the most commonly injured nerves, based on zone of injury, injury type, and precedent breast procedure. Dissections referenced the zone of injury with the specific procedure and designated the individual nerves at risk. Results: The authors identified 57 patients with chronic breast pain from breast reconstruction (n = 38), reduction (n = 2), mastopexy (n = 2), augmentation (n = 4) and irradiation (n = 11). On the basis of anatomic innervation, the authors designated five zones of nerve injury: superior, medial, inferior, lateral, and central/nipple-areola complex. The lateral zone was most commonly injured (79 percent), followed by inferior (10.5 percent), medial (5 percent), central (3.5 percent), and superior (2 percent) zones. Forty-two patients suffered intercostal nerve neuromas from mechanical nerve trauma/entrapment, with pain at the surgical scar or nearby tissue dissection. Four patients with traction-stretch neuropathy had pain from blunt augmentation pocket dissection. Eleven patients with irradiation-induced neuropathy had diffuse, nonlocalized nerve pain. Conclusions: By shifting the approach to chronic breast pain from “global chronic breast pain” to defined danger zones of nerve injury, the practitioner can identify the type of nerve injury and associate the most common nerve injury to a given breast procedure. This approach should assist in diagnosis and treatment, and ultimately improve patient morbidity.

A systematic review and pooled analysis of peroneal artery perforators for fibula osteocutaneous and perforator flaps.

Background: Despite the availability of cadaveric, anatomic, and clinical models to identify peroneal artery perforators in the lower leg, there is no consensus on the optimal fibula interval to reliably capture perforators for flap and skin paddle design. Methods: A systematic review of the MEDLINE and Cochrane databases was performed to identify all anatomical, clinical, and radiographic reports of peroneal artery perforators in the lower leg. Locations were indexed along tenths of the total fibula length to incorporate a uniform format. Results: Three clinical and six cadaveric reports identified 445 legs and 1710 perforators. The 0.6 interval had the greatest total perforator frequency at 19.1 ± 1 percent, with 310 perforators and a positive probability of 79.1 ± 2.1 percent. Chi-square analysis found a statistical difference in perforator frequency at the flanking intervals of 0.5 and 0.8 (p = 0.0058 and p = 0.0019) and beyond. Subgroup analysis of septocutaneous perforators was based on 345 legs and 608 perforators. The 0.6 interval was the densest, with 110 perforators and a frequency of 18.1 ± 1.6 percent. The musculocutaneous subgroup analysis found 292 legs and 831 perforators, and a densest interval at 0.4, based on 157 perforators and a frequency of 18.9 ± 1.4 percent. Conclusions: This systematic review and pooled analysis of all available and complete peroneal artery perforator data demonstrates clustering over the 0.6 interval of the lateral leg. This interval should be considered during flap design and elevation to reliably capture irrigating perforators for free and local flap applications.

A Systematic Review of Topical Vasodilators for the Treatment of Intraoperative Vasospasm in Reconstructive Microsurgery.

Background: Intraoperative vasospasm during reconstructive microsurgery is common, often unpredictable, and potentially devastating with regard to flap survival. Current methods of pharmacologic management vary, and may be shifting as a result of changes in the availability of individual medications. This review aims to provide a concise examination of the published literature regarding use, efficacy, and adverse effects of the agents described for local management of vascular spasm during microsurgery. Methods: A systematic review of the literature was performed to identify articles relevant to pharmacologic treatment of intraoperative vasospasm in vivo. An additional review of the literature was performed with regard to each agent identified in order to provide clinical background information. Results: Systematic review identified 20 articles, in which 14 vasodilator agents were evaluated. Drugs were classified into five pharmacologic categories: phosphodiesterase inhibitors (papaverine, pentoxifylline, and amrinone), local anesthetics (lidocaine), calcium channel blockers (nicardipine, verapamil, nifedipine, and magnesium sulfate), direct vasodilators (sodium nitroprusside, prostaglandin E1, nitroglycerin, and hydralazine), and alpha antagonists (phentolamine and chlorpromazine). Despite a variety of methods, these studies indicate some degree of experimental evidence of efficacy for each of these agents. Conclusions: Available literature regarding use of topical vasodilating agents for intraoperative management of vasospasm during microsurgery is limited and largely based on animal models, which may not reliably generalize to the reconstructive patient population. Well-controlled translational study in clinically applicable and reproducible models is needed to guide evidence-based clinical management of this important phenomenon.

The Use of Negative Pressure Wound Therapy for Random Local Flaps at the Ankle Region

Local random flaps are seldom used for reconstruction of complex ankle wounds because of concern for flap failure attributable to vascular compromise and tissue edema. Negative pressure wound therapy has been shown to improve perfusion and limit tissue edema. The objective of this study was to demonstrate the utility of negative pressure wound therapy in improving outcomes for local flaps of the ankle. Ten consecutive patients presenting with complex ankle wounds and reconstructed using local flaps were treated with negative pressure wound therapy postoperatively. Type of flap, immediate and long-term outcomes, and complications were assessed. Seventeen local flaps were performed on 10 patients to reconstruct their ankle wounds. Mean follow up was 88 days. All flaps healed without tissue compromise or necrosis. Only one partial dehiscence and no infections were observed. This study demonstrates that negative pressure therapy may contribute to the viability of random local flaps by decreasing venous congestion. Our experience using negative pressure wound therapy on local flaps suggests that it may serve as a useful adjunct to ensure successful closure of high-risk wounds.

Presurgical planning and time efficiency in orthognathic surgery: the use of computer-assisted surgical simulation.

UNLABELLED Orthognathic procedures require extensive preoperative planning to maintain high fidelity of fabricated splints to anticipated skeletal and soft tissue changes. The authors report their use of the computer-assisted surgical simulation modeling system in preoperative planning and splint fabrication and the significant reduction in their overall preoperative time. Upper and lower bite registrations were sequentially created on a single bite jig with fast-drying bis-acryl material, which was then mounted to a fiducial-based facebow for facial skeleton indexing. Indexing data were submitted, and occlusal splints were fashioned and returned to the senior surgeon. Between September 2010 and January 2011, 10 consecutive patients were enrolled. Surgical indications included six Le Fort I advancements and four combined Le Fort I/bilateral sagittal split osteotomy cases. Average time for bite registration was 10 minutes 16 seconds ± 1 minute 33 seconds, with an additional 8 minutes 6 seconds ± 4 minutes 45 seconds needed for modeling and virtual splint confirmation. Six patients required cephalometric tracings, for an additional 12 minutes 50 seconds ± 1 minute 10 seconds. Average total session time for all patients was 26 minutes 14 seconds ± 9 minutes 13 seconds. Computer-assisted surgical simulation markedly decreased the time for preoperative splint planning and fabrication time, and had a positive impact on reimbursement rates for orthognathic surgery, as calculated on a per-hourly basis. The improved accuracy generated may lead to decreased operative times and improved outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Autologous fat grafting and injectable dermal fillers for human immunodeficiency virus-associated facial lipodystrophy: a comparison of safety, efficacy, and long-term treatment outcomes.

Background: Facial lipoatrophy is a common side effect of human immunodeficiency virus treatment with highly active antiretroviral therapy. To identify the most clinically durable and efficient way of addressing facial lipoatrophy, the authors reviewed all available evidence for the use of injectable dermal fillers and autologous fat transfers as treatment modalities, focusing on safety, outcomes, and long-term durability. Methods: A systematic review of the Cochrane and MEDLINE databases for autologous fat transfer and injectable dermal fillers for the treatment of human immunodeficiency virus–associated lipodystrophy was performed. Based on U.S. Food and Drug Administration approval in human immunodeficiency virus lipoatrophy, studies were limited to the use of hyaluronic acid and/or poly-L-lactic acid. Facial volume, subjective patient satisfaction, standardized outcome scales, reinjection rates, and complications were recorded. Results: Nineteen studies were included representing 724 patients, with 549 patients in the hyaluronic acid/poly-L-lactic acid cohort and 175 in the autologous fat transfer cohort. Improvements in facial volume and durability of treatment were similar between dermal fillers and fat transfer, as measured by both objective means and subjective patient outcomes. However, poly-L-lactic acid was reinjected at a rate three times that of autologous fat, and was associated with a relatively high rate of subcutaneous papule formation at 22 percent (range, 3 to 44 percent). Conclusions: Dermal fillers and autologous fat transfer are effective treatment modalities for human immunodeficiency virus–associated facial lipoatrophy, with high rates of facial volume restoration and patient satisfaction. Autologous fat transfer may offer similar to superior long-term durability but with less of a financial burden compared with injectable fillers.