Patrick Basile

Current surgical practices in cleft care: cleft palate repair techniques and postoperative care.

Background: The purpose of this study was to objectively report practices commonly used in cleft palate repair in the United States. This study investigates current surgical techniques, postoperative care, and complication rates for cleft palate repair surgery. Methods: All 803 surgeon members of the American Cleft Palate-Craniofacial Association were sent online and/or paper surveys inquiring about their management of cleft palate patients. Results: Three-hundred six surveys were received, a 38 percent response rate. This represented responses of surgeons from 100 percent of American Cleft Palate-Craniofacial Association registered cleft teams. Ninety-six percent of respondents perform a one-stage repair. Eighty-five percent of surgeons perform palate surgery when the patient is between 6 and 12 months of age. The most common one-stage repair techniques are the Bardach style (two flaps) with intravelar veloplasty and the Furlow palatoplasty. After surgery, 39 percent of surgeons discharge patients within 24 hours. Another 43 percent discharge patients within 48 hours. During postoperative management, 92 percent of respondents implement feeding restrictions. Eighty-five percent of physicians use arm restraints. Surgeons’ self-reported complications rates are minimal: 54 percent report a fistula in less than 5 percent of cases. The reported need for secondary speech surgery varies widely. Conclusions: The majority of respondents repair clefts in one stage. The most frequently used repair techniques are the Furlow palatoplasty and the Bardach style with intravelar veloplasty. After surgery, the majority of surgeons discharge patients in 1 or 2 days, and nearly all surgeons implement feeding restrictions and the use of arm restraints. The varying feeding protocols are reviewed in this article.

Adhesions in a Murine Flexor Tendon Graft Model: Autograft versus Allograft Reconstruction

Reconstruction of flexor tendons often results in adhesions that compromise joint flexion. Little is known about the factors involved in the formation of flexor tendon graft adhesions. In this study, we developed and characterized a novel mouse model of flexor digitorum longus (FDL) tendon reconstruction with live autografts or reconstituted freeze‐dried allografts. Grafted tendons were evaluated at multiple time points up to 84 days post‐reconstruction. To assess the flexion range of the metatarsophalangeal joint, we developed a quantitative outcome measure proportional to the resistance to tendon gliding due to adhesions, which we termed the Gliding Coefficient. At 14 days post‐grafting, the Gliding Coefficient was 29‐ and 26‐fold greater than normal FDL tendon for both autografts and allografts, respectively (p < 0.001), and subsequently doubled for 28‐day autografts. Interestingly, there were no significant differences in maximum tensile force or stiffness between live autograft and freeze‐dried allograft repairs over time. Histologically, autograft healing was characterized by extensive remodeling and exuberant scarring around both the ends and the body of the graft, whereas allograft scarring was abundant only near the graft–host junctions. Gene expression of GDF‐5 and VEGF were significantly increased in 28‐day autografts compared to allografts and to normal tendons. These results suggest that the biomechanical advantages for tendon reconstruction using live autografts over devitalized allografts are minimal. This mouse model can be useful in elucidating the molecular mechanisms in tendon repair and can aid in preliminary screening of molecular treatments of flexor tendon adhesions.

Impact of Smad3 loss of function on scarring and adhesion formation during tendon healing.

Studies were performed evaluating the role of Smad3, a transcription factor mediating canonical TGF‐β signaling, on scarring and adhesion formation using an established flexor digitorum longus (FDL) tendon repair model. In unoperated animals the metatarsophalangeal (MTP) range of motion (ROM) was similar in Smad3−/− and wild‐type (WT) mice while the basal tensile strength of Smad3−/− tendons was significantly (39%) lower than in WT controls. At 14 and 21 days following repair Smad3−/− MTP ROM reached approximately 50% of the basal level and was twice that observed in WT tendon repairs, consistent with reduced adhesion formation. Smad3−/− and WT maximal tensile repair strength on post‐operative day 14 was similar. However, Smad3−/− tendon repairs maximal tensile strength on day 21 was 42% lower than observed in matched WT mice, mimicking the relative decrease in strength observed in Smad3−/− FDL tendons under basal conditions. Histology showed reduced “healing callus” in Smad3−/− tendons while quantitative PCR, in situ hybridization, and immunohistochemistry showed decreased col3a1 and col1a1 and increased MMP9 gene and protein expression in repaired Smad3−/− tendons. Thus, Smad3−/− mice have reduced collagen and increased MMP9 gene and protein expression and decreased scarring following tendon FDL tendon repair.

Soft tissue injury management with a continuous external tissue expander

BackgroundBlast exposure is a common cause of soft tissue injury within the battlefield setting, with the extremities often critically involved. The resulting injury pattern presents with massive soft tissue defects that may be further complicated by varying degrees of accompanying orthopedic and peripheral nerve damage. To address the severe soft tissue defect, various combinations of advanced reconstructive methods are typically required to achieve definitive wound coverage. Continuous external tissue expansion has been used by our institution to significantly reduce wound burden and provide for definitive wound closure in certain blast-injured patients. MethodsThe authors present an early series of 14 patients who suffered massive extremity soft tissue injuries and were treated with an external tissue expansion system (DermaClose RC). Outcome measurements included time to definitive closure and method of definitive wound closure. A 5-patient subset of this group was prospectively analyzed to determine measurements including initial wound surface area (WSA), percentage reduction in WSA, and related complications. ResultsOverall time to wound coverage ranged from 1 to 6 days, with mean time to wound coverage being 4.4 days. Of the 14 patients included in the series, 12 (85.7%) were able to undergo delayed primary closure, whereas 2 required split thickness skin grafting. In the 5-patient subgroup, WSA initially ranged from 20.25 to 1031.25 cm2. Mean wound size was 262.7 cm2. Decrease in WSA ranged from 44% to 93% of the initial WSA, with mean decrease being 74.3% (95% confidence interval, 57.33–91.3). ConclusionsIn the management of large complex wounds, external tissue expansion has proven to be a valuable adjunct in achieving definitive wound closure. It can often aid in successful delayed primary closure of certain soft tissue wounds, has low associated morbidities, and can reduce the need for more complex or morbid procedures when used properly. The authors propose an algorithm for the use of continuous external tissue expansion system to achieve effective and successful wound closure, while potentially reducing the need for increased donor-site morbidities associated with more complex or larger reconstruction measures.

Use of intraoperative fluorescent angiography to assess and optimize free tissue transfer in head and neck reconstruction.

PURPOSE Composite tissue defects in the head and neck region present unique challenges. Definitive head and neck reconstruction of these cases is often complicated by complex 3-dimensional defects that may require multiple flap or chimeric flap procedures. These advanced techniques can have serious repercussions should poor perfusion of the flap cause flap failure, which can be devastating. MATERIALS AND METHODS A retrospective review was completed for those complex reconstructions using free tissue transfers and fluorescent indocyanine green angiography (Lifecell SPY Elite imaging, Lifecell Corporation, Bridgewater, NJ) at Walter Reed National Military Medical Center over a 24-month period. Data analyzed included flap type (myocutaneous, osteocutaneous, or fasciocutaneous), flap success and failure rates, and complications. These also were compared with data from the institution before the study period and the incorporation of SPY technology. RESULTS Sixty-one free flaps, including 11 head and neck flaps, were performed. The head and neck flaps included 1 latissimus, 3 gracilis, 1 vastus lateralis, 4 anterior lateral thigh, and 2 fibular flaps. The overall success rate was 98.4%; 1 flap was lost (1.6%) and 2 flaps developed partial flap necrosis (3.3%). Where SPY Elite was used, there was no unpredicted partial flap necrosis. The only total flap loss was related to a hypercoagulable condition. CONCLUSIONS Free tissue transfer can be technically challenging, especially in complex head and neck reconstruction. An algorithmic approach using SPY Elite imaging aids in pedicle location, angiosomal assessment, anastomotic flow visualization, and cutaneous and osteocutaneous flap perfusion assessment. This objective tool can assist the reconstructive surgeon in avoiding perfusion-related complications and total and partial flap losses, thus improving patient outcomes.

The Use of Intraoperative Fluorescent Angiography To Maximize Fasciocutaneous Flap Coverage of Battle Field Extremity Injuries

concluSIon: The forearm fascial flap provides coverage of the upper extremity without sacrificing any major arteries to the hand. Donor site morbidity is minimal as the adipofascial nature of the flap allows primary closure of the donor site. Further benefits include a shorter operative time, no microsurgery requirements, aesthetically pleasing contour for the hand with out the need for secondary procedures and early range of motion for patients. It has become our flap of choice for upper extremity reconstruction. The use of Intraoperative Fluorescent Angiography To Maximize Fasciocutaneous Flap Coverage of Battle Field Extremity Injuries

The Changing Patterns of Extremity War Trauma and Microsurgical Challenges: The Afghanistan Experience

IntroductIon: Extremity traumatic war injuries are complex. As aggressive forward resuscitative care and stabilization measures in the war theater have advanced, the survival rates of the war wounded continue to improve. Additionally, the latest war transport systems have enabled the provision of complex medical care to our wounded personnel in an abbreviated timeframe, with transfer from initial battlefield injury to a definitive stateside care setting typically within 5 days.