Nicole Conkling

Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: results of a prospective trial.

Background: Intraoperative vascular imaging can assist assessment of mastectomy skin flap perfusion to predict areas of necrosis. No head-to-head study has compared modalities such as laser-assisted indocyanine green dye angiography and fluorescein dye angiography with clinical assessment. Methods: The authors conducted a prospective clinical trial of tissue expander–implant breast reconstruction with intraoperative evaluation of mastectomy skin flaps by clinical assessment, laser-assisted indocyanine green dye angiography, and fluorescein dye angiography. Intraoperatively predicted regions of necrosis were photographically documented, and clinical assessment guided excision. Postoperative necrosis was directly compared with each prediction. The primary outcome was all-inclusive skin necrosis. Results: Fifty-one tissue expander–implant breast reconstructions (32 patients) were completed, with 21 cases of all-inclusive necrosis (41.2 percent). Laser-assisted indocyanine green dye angiography and fluorescein dye angiography correctly predicted necrosis in 19 of 21 of cases where clinical judgment had failed. Only six of 21 cases were full-thickness necrosis, and five of 21 required an intervention (9.8 percent). Risk factors such as smoking, obesity, and breast weight greater than 1000 g were statistically significant. Laser-assisted indocyanine green dye angiography and fluorescein dye angiography overpredicted areas of necrosis by 72 percent and 88 percent (p = 0.002). Quantitative analysis for laser-assisted indocyanine green dye angiography in necrotic regions showed absolute perfusion units less than 3.7, with 90 percent sensitivity and 100 percent specificity. Conclusions: Laser-assisted indocyanine green dye angiography is a better predictor of mastectomy skin flap necrosis than fluorescein dye angiography and clinical judgment. Both methods overpredict without quantitative analysis. Laser-assisted indocyanine green dye angiography is more specific and correlates better with the criterion standard diagnosis of necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

Compression syndromes of the popliteal neurovascular bundle due to Baker cyst

BACKGROUND The purpose of this study was to perform a comprehensive search of the literature for all studies, case reports, and series describing Baker cyst compression of the neurovascular bundle in the popliteal fossa and index their findings according to the structures compressed. METHOD Case reports and series obtained after a thorough MEDLINE search were indexed according to compressed structures. Patient demographics, main findings, method of diagnosis, cyst size, outcomes, and follow-up were recorded for each publication. RESULTS Signs and symptoms related to popliteal vein and tibial nerve compression were the most frequent presentation of symptomatic Baker cysts, due to the anatomic vulnerability of these structures within the popliteal fossa and their relative sensitivity to compression. Patients with tibial nerve entrapment demonstrated gastrocnemius muscle atrophy, paresthesias, and pain. Those with popliteal vein compression experienced swelling, pain, and rarely, venous thromboembolism. Isolated arterial compression, presenting with intermittent claudication, is a rare occurrence because it is a relatively stiff-walled vessel, has a higher pressure, and is located deep in the popliteal fossa. Combinations of these compression syndromes are most frequently encountered in the context of cyst rupture and resulting compartment syndrome. CONCLUSIONS Baker cyst is an important pathology for the differential diagnosis of popliteal neurovascular compression phenomena. It has a wide spectrum of presentation, therefore requiring accurate diagnosis for proper patient management. Because Baker cyst is by definition a chronic disorder, long-term follow-up is necessary to monitor patient recovery and prevent recurrence.

Sentinel lymph node detection using laser-assisted indocyanine green dye lymphangiography in patients with melanoma.

Introduction. Sentinel lymph node (SLN) biopsy is a vital component of staging and management of multiple cancers. The current gold standard utilizes technetium 99 (tech99) and a blue dye to detect regional nodes. While the success rate is typically over 90%, these two methods can be inconclusive or inconvenient for both patient and surgeon. We evaluated a new technique using laser-assisted ICG dye lymphangiography to identify SLN. Methods. In this retrospective analysis, we identified patients with melanoma who were candidates for SLN biopsy. In addition to tech99 and methylene blue, patients received a dermal injection of indocyanine green (ICG). The infrared signal was detected with the SPY machine (Novadaq), and nodes positive by any method were excised. Results. A total of 15 patients were evaluated, with 40 SLNs removed. Four patients were found to have nodal metastases on final pathology. 100% of these 4 nodes were identified by ICG, while only 75% (3/4) were positive for tech99 and/or methylene blue. Furthermore, none of the nodes missed by ICG (4/40) had malignant cells. Conclusion. ICG dye lymphangiography is a reasonable alternative for locating SLNs in patients with melanoma. Prospective studies are needed to better ascertain the full functionality of this technique.

Subjective rating of cosmetic treatment with botulinum toxin type A: do existing measures demonstrate interobserver validity?

BackgroundThroughout the literature, investigators have assessed the cosmetic efficacy of botulinum toxin (BT) treatment by using various subjective, qualitative measures, including the Facial Wrinkle Scale (FWS) and Subject Global Assessment (SGA). The widely used FWS and SGA attempt to quantify both the magnitude and duration of cosmetic outcomes as assessed by physician and patient. We sought to determine the interobserver validity of these scales relative to the level of observer experience. MethodsBotulinum toxin injections were performed to cosmetic effect in 6 patients recruited as part of an institutional review board-approved investigation. Subjects were photographed at rest and during animation (raising eyebrows, frowning, and blinking) before treatment and at 1, 2, 4 weeks, and monthly with follow-up to 6 months. Standardized digital 8″ × 10″ prints were scored using the FWS by board-certified plastic surgeons (n = 5), general surgery residents (n = 3), and medical students (n = 4). Photographs at each time point were then compared to baseline using the SGA. Statistical analysis of observer data was performed using SPSS v19. Cohen &kgr; (FWS) and Spearman &rgr; (SGA) were calculated for each pairwise comparison of observer data, with a conservative &agr; of 0.01. ResultsThe FWS observer scores for the upper face overall were generally in agreement, with no negative &kgr; values. The distribution, even among members of a single group, was highly variable. Agreement among plastic surgeons was the greatest (&kgr;, 0.194–0.609). Resident concordance was moderate, and medical students displayed the most variable agreement. Spearman &rgr; for SGA scores was much higher, with surgeons approaching excellent agreement (&kgr;, 0.443–0.992). In comparisons between members of different groups, agreement was unpredictable for both the FWS and SGA. Comparisons using scores from individual areas of the face were least concordant. ConclusionsThe FWS and SGA represent the current standard of cosmetic outcomes measures; however, when subjected to scrutiny they display relatively unpredictable agreement even among plastic surgeons. Compared to the FWS, the SGA has a more acceptable user concordance, especially among plastic surgeons accustomed to using such scales. The interobserver variability of FWS and SGA scoring underlines the need to explore objective, quantitative cosmetic outcomes measures.

Perineal flap reconstruction following oncologic anorectal extirpation: an outcomes assessment.

Background: The poorly healing perineal wound is a significant complication of abdominoperineal resection. The authors examined criteria for immediate flap coverage of the perineum and long-term cross-sectional surgical outcomes. Methods: Patients who underwent abdominoperineal resection or pelvic exenteration for anorectal cancer were retrospectively analyzed. Demographic characteristics, premorbid and oncologic data, surgical treatment, reconstruction method, and recovery were recorded. Outcomes of successful wound healing, surgical complications necessitating intervention (admission or return to the operating room), and progression to chronic wounds were assessed. Results: The authors identified 214 patients who underwent this procedure from 1995 to 2013. Forty-seven patients received pedicled flaps and had higher rates of recurrence and reoperation, active smoking, Crohn disease, human immunodeficiency virus, and anal cancers, and had higher American Joint Committee on Cancer tumor stages. Thirty-day complication rates were equivalent in the two groups. There were no complete flap losses or reconstructive failures. Perineal wound complication rates were marginally but not significantly higher in the flap group (55 percent versus 41 percent; p = 0.088). Infectious complications, readmissions for antibiotics, and operative revision were more frequent in the flap cohort. A larger proportion of the primary closure cohort developed chronic draining perineal wounds (23.3 versus 8.5 percent; p = 0.025). Conclusions: Immediate flap coverage of the perineum was less likely to progress to a chronic draining wound, but had higher local infectious complication rates. The authors attribute this to increased comorbidity in the selected patient population, reflecting the surgical decision making in approaching these high-risk closures and ascertainment bias in diagnosis of infectious complications with multidisciplinary examination. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Comparison of native porcine skin and a dermal substitute using tensiometry and digital image speckle correlation.

AbstractDermal substitutes are currently used in plastic surgery to cover various soft tissue defects caused by trauma, burns, or ablative cancer surgery. Little information is available on the biomechanical properties of these dermal substitutes after adequate incorporation as compared to normal skin. Determining parameters such as tensile strength in these skin substitutes will help us further understand their wound healing properties and potential in developing artificial tissue constructs. We hypothesize that a dermal substitute has a lower stress-strain curve and altered stress-induced deformation quantified with tensiometry and digital image speckle correlation (DISC) analysis. Two separate 5 × 10-cm full-thickness wounds were created on the dorsum of 3 female swine. Fibrin glue was applied before either a full-thickness skin graft (FTSG) or application of artificial dermal matrix. On day 42, cultured autologous keratinocytes were applied as a cell sheet to the wound covered with Integra. On day 56, the wounds were fully excised and fresh tissue specimens, including normal skin, were stored in a physiological solution and prepared for analysis. Rectangular samples were excised from the center of each specimen measuring 4 × 4 × 30 mm. Using a tensiometer and DISC analysis, we evaluated the tensile strength of 3 different groups of skin, namely, normal, FTSG, and Integra. There is a significant difference between the Integra specimen when compared to normal skin and FTSG. We found a minimal difference in the stress-strain curves of the latter two. Integra alone shows plastic deformation with continued stretching before ultimate midline fracture. There is significant change between the Young’s moduli of the normal skin and the Integra, whereas there is little difference between the FTSG and the normal skin; DISC confirms this analysis. The normal skin and FTSG show a convergence of vectors to a linear plane, whereas Integra shows very little organization. Using 2 different methods of analysis, we have shown a dermal substitute does not display similar biomechanical properties after adequate incorporation. These major tensile strength differences are shown between normal, grafted, and Integra constructs under physiological conditions. These properties will lead to further understanding of artificial tissue and engineered constructs in laboratory and clinical applications.

Laser-assisted indocyanine green dye angiography accurately predicts the split-thickness graft timing of integra artificial dermis.

BackgroundThe use of an artificial dermal substitute such as Integra—a bilaminate combination of thin silicone and cross-linked bovine tendon collagen and chondroitin-6-sulfate—has become a popular method to address large surface area wounds or smaller, complex wounds devoid of a vascular bed. The incorporation of Integra depends on a vascular wound bed or periphery and can take 4 weeks or longer to occur. If the Integra has not fully incorporated at the time of placement of the split-thickness graft, complete graft loss may result. The availability of a minimally invasive method to assess the incorporation of Integra would be of great value. MethodsTwo 5 × 10-cm paraspinal full-thickness wounds were created on 3 female swine. Wounds were randomly assigned full-thickness skin graft or Integra (Plainsboro, NJ) treatment. Both types of grafts were placed after the application of fibrin glue (Tisseel, Deerfield, Ill) to the wound bed. Laser Doppler imaging (LDI) (Moor), indocyanine green dye (ICG) angiography (LifeCell SPY), and clinical scoring were performed weekly for a period of 8 weeks after grafting. At 4 weeks, the silicone layer of the Integra was removed, and a culture of autologous keratinocytes was applied. A 4-mm punch biopsy sample of each graft was taken 1, 2, 4, 6, 7, and 8 weeks postoperatively for histologic analysis. ResultsBoth ICG angiography and LDI perfusion measurements noted an increase in perfusion at the Integra graft site that peaked 3 weeks after grafting, corresponding with the start of neovascularization and the optimal time for the application of a split-thickness skin graft. indocyanine green dye angiography measurements exhibit greater reproducibility between animals at late time points as compared with LDI. This decrease in LDI precision is directly related to increases in scar tissue thickness of greater than 5 mm as determined via histologic analysis and corresponds with the accepted maximum penetration depth of the LDI laser. ConclusionsIndocyanine green dye angiography may provide valuable information as to graft integrity and split-thickness skin graft timing at late time points. Range of LDI seems to be insufficient for split-thickness graft timing or late time point accuracy. Future exploration of ICG angiography potential will involve tracking Integra graft delay in porcine models.

An in vivo analysis of the effect and duration of treatment with botulinum toxin type A using digital image speckle correlation

Use of Botulinum toxin type A (BTX‐A) for facial wrinkles is well‐documented, but current methods of subjective evaluation by clinicians and patients fail to objectively quantify the magnitude and duration of facial muscle paralysis.