Neal S. Topham

Osseointegration of preformed polymethylmethacrylate craniofacial prostheses coated with bone marrow-impregnated poly (DL-lactic-co-glycolic acid) foam.

Osseointegration of bone marrow-PLGA-coated, preformed polymethylmethacrylate cranioplasties offers the possibility of reducing: operative time, periimplant seroma and infection, metallic fixation, and periprosthetic resorption following surgical skull remodeling. These alloplastic materials are FDA-approved but previously have not been used together to promote cranioplasty incorporation. The objective of this study was to determine whether the use of PLGA foam coating improves host osseointegration of preformed, textured, polymethylmethacrylate prosthetic cranioplasties. A critical-sized cranial defect was created in two groups of 10 and one group of three rabbits. The defect was filled with either a textured, preformed polymethylmethacrylate disc or a textured, preformed polymethylmethacrylate disc coated with poly (DL-lactic-co-glycolic acid). Both implants were immersed in autologous bone marrow for 20 minutes before implantation. Half of each group of 10 were killed at 3 weeks, and the remainder at 6 weeks. A third group of three rabbits with excised periosteum was evaluated at 6 weeks. Histologic analysis of the discs determined relative amounts of cancellous bone formation adjacent to the prostheses. Woven trabecular bone was present at each host bone to implant perimeter interface at 3 weeks, with fine fibrous capsular formation around the implants. Thicker, lamellar trabeculae were present at 6 weeks with an increased fibrous layer surrounding both types of implants. Bone formed on the superficial and deep implant surfaces in a noncontiguous fashion. Two of five measures showed that total bone formation was significantly greater in the PLGA-coated implants. Polymethylmethacrylate discs coated with bone marrow-impregnated PLGA foam demonstrate increased bone formation at 3 and 6 weeks as compared with non-coated preformed polymethylmethacrylate discs. Only implants with preserved periosteum showed bone formation away from the host-implant interface (centrally) on the superficial surface at 6 weeks.

Improvement of the radial forearm flap donor defect by prelamination with human acellular dermal matrix.

The radial forearm free flap is the standard flap used for functional reconstruction of partial glossectomy defects.1–3 Disadvantages of the radial forearm free flap are primarily related to the forearm donor site, which usually requires skin grafting for closure. Complications include skin graft loss, tendon exposure, significant unsightly scaring, and poor texture.4,5 We introduce a new two-stage technique using human acellular dermal matrix (AlloDerm; LifeCell Corp., Branchburg, N.J.) that permits primary closure of the radial forearm free flap donor site at the time of flap elevation.

Impact of adjuvant chemotherapy on abdominal wall hernias and bulges after muscle-sparing free TRAM flaps for breast reconstruction.

BackgroundFree tissue transfer from an abdominal donor site has become a popular method for postmastectomy breast reconstruction. The detrimental effects of adjuvant chemotherapy on healing and the resulting clinical impact on patient outcome remains somewhat unclear for abdominal bulges and hernias resulting after free tissue transfer from the abdominal donor site. MethodsAn institutional review board-approved retrospective review of 155 free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps performed for breast reconstruction was undertaken to evaluate the effect of adjuvant chemotherapy on abdominal donor-site morbidity. The primary outcome studied was the development of hernias and bulges. Statistical analysis was performed using univariate and multivariate classification and regression tree (CART) analysis. ResultsOf the 155 patients, 51 underwent bilateral MS-TRAM flaps and 104 underwent unilateral MS-TRAM flap reconstruction. Thirty-nine patients underwent adjuvant chemotherapy. A statistically significant association was seen between chemotherapy treatment and the incidence of hernias alone (P < 0.05; odds ratio, 6.42; 95% confidence interval, 0.88–73.58). Multivariable CART analyses corroborated these findings and revealed that presence of diabetes mellitus (DM), bilaterality, and receiving chemotherapy treatment were related to increased incidence of hernias (P = 0.011, 0.005, and 0.017, respectively) after controlling for clinical variables such as smoking status, chronic obstructive pulmonary disease, and type of closure. Univariate analyses also revealed a statistically significant association between bilaterality in conjunction with chemotherapy treatment and the incidence of hernias alone (P = 0.0002; odds ratio, 37.56; 95% confidence interval, 4.56–476.35). This highly significant finding is further augmented by multivariable CART analyses, which found that patients who were bilateral and underwent chemotherapy treatment or those with DM were significantly more likely to develop hernias (P < 0.001 and P = 0.016, respectively). ConclusionsTo date, our study is the single largest series of abdominal donor-site complications in patients receiving chemotherapy and free MS-TRAM breast reconstruction. We have demonstrated an increase in the incidence of abdominal donor-site complications, specifically abdominal bulges and hernias, in patients undergoing chemotherapy for advanced stages of breast cancer. This increased complication rate is most pronounced in patients requiring chemotherapy who undergo bilateral reconstruction, and is also a significant risk for patients receiving chemotherapy who have preexisting DM.

Optimizing donor site closure following bilateral breast reconstruction with abdominal-based free flaps

The abdomen is the primary donor site for autologous free flap breast reconstruction, but violation of the rectus abdominus complex can result in significant morbidity.1,2 Abdominal hernias and bulges are the most concerning donor site complications in the long term, but early wound complications also contribute to significant morbidity during the initial postoperative period. In order to minimize the risk of hernias and bulges, reinforcement of the abdominal wall with placement of mesh may be necessary particularly in the setting of bilateral breast reconstruction.2 Recently, the introduction of a new resorbable monofilament poly-4-hydroxybutyrate mesh (Phasix, Bard Davol Inc., Warwick, RI) provides an alternative for abdominal reinforcement.3 Phasix is a biologically-derived, monofilament mesh that is degraded primarily via hydrolysis over approximately 12–18 months. The degradation of the mesh scaffold causes the deposition of host collagen which transitions from type III collagen to type I collagen over time. Ultimately, the native collagen replaces the mesh monofilaments resulting in increased mechanical strength in the abdomen. The current study was designed to ascertain the utility of Phasix mesh in reinforcing the abdominal wall after flap harvest for bilateral breast reconstruction. We hypothesized that the use of resorbable mesh would result in decreased rates of abdominal donor site complications. All patients undergoing bilateral free flap breast reconstruction with free DIEP (deep inferior epigastric perforator) flaps and MSFT (muscle sparing free TRAM) flaps by the two senior authors (E.I.C. and N.S.T.) were evaluated. Institutional review board approval was obtained and a retrospective review of 66 consecutive patients was performed. The patients were randomly assigned to undergo placement of Phasix (n = 40) or polypropylene mesh (n = 20) and followed prospectively to evaluate the incidence of donor site complications with 6 patients having primary closure as the control group. There were no significant differences among the patient groups in terms of demographics, previous abdominal surgeries, smoking status, medical comorbidities, cancer stage, or use of chemotherapy regimens (Table 1). The mean age of the patients was 48.9 years (range 31–74) and the mean bodymass index (BMI) was 30.4 (range 20.8–44.3). All patients underwent reconstructionwith bilateral free DIEP flaps, bilateral MSFT flaps, or one DIEP and one MSFT flap. A total of 75 DIEP flaps and 57 MSFT flaps were performed, and there were no differences in the type of flap combinations utilized for reconstruction among the study populations (Table 2). Abdominal wound dehiscence and seroma formation were significantly higher in the polypropylene mesh and control groups compared to the resorbable mesh group (20.0% vs. 16.7% vs. 0%, p < 0.05 and 10.0% vs. 16.7% vs. 0%, p < 0.05). Two patients with polypropylene mesh required operative debridement while all other patients with abdominal dehiscence were managed conservatively. Drain removal was also significantly faster in the resorbable mesh group compared to the polypropylene group (17.8 days vs. 21.2 days, p = 0.004). In certain patient populations with various medical comorbidities such as obesity, active tobacco usage, and prior abdominal surgeries, placement of mesh may be particularly beneficial in terms of reducing donor site morbidity ☆This article was presented as a full podium presentation at the Annual Meeting of the American Society for Reconstructive Microsurgery on January 14–16, 2016. Table 1 Demographics of patients undergoing bilateral free flap breast reconstruction.