Rebecca Knackstedt

The Anterolateral Thigh Flap as the Flap of Choice for Scalp Reconstruction

Introduction: Large scalp soft tissue defects can present difficulties with reconstruction. The ideal flap for scalp reconstruction has yet to be described although the latissimus dorsi flap is frequently referred to as the first choice in this setting. Patients and Methods: Following institutional review board approval, the authors reviewed their experience in scalp reconstruction for the past 4 years. Patient demographics, reconstruction indication, flap choice, complications, and outcomes were recorded. Results: Thirteen patients underwent scalp reconstruction with an anterolateral thigh (ALT) free flap. In most patients, the indication was resection of a cutaneous malignancy. In all but 1 patient the facial or more proximal vessels were used for anastomosis. None of the patients required vein grafts to increase pedicle length. The median flap surface area was 156u200acm2. One flap had vascular compromise. All donor sites healed without complications. Discussion: The ALT flap can emerge as the flap of choice for scalp reconstruction, even when proximal neck vessels are used as the recipient targets. Using a suprafascial dissection and extending the vascular pedicle to the profunda femoris artery can optimize its role in this setting. The ALT flap provides excellent cosmesis and durable scalp coverage with minimal donor site morbidity.

Reconstructive Options of Abdominal Wounds in the Setting of Abdominal Wall Defects and Hernias

The abdominal wall is an integral, yet often ignored, functional unit that, while performing an important aesthetic role, is required to protect vital internal organs and allow for physical activity. Thus, the goals of abdominal wall reconstruction (AWR) are to restore these crucial functions. Understanding and appreciating the abdominal wall anatomy is critical for successful reconstruction. When surgical intervention is required, preoperative nutrition optimization and glucose control are imperative to permit desired wound healing. From a reconstructive standpoint, repair can be done via an open or closed approach. However, most defects that a plastic surgeon encounters are large, requiring an open approach, likely with mesh utilization. Numerous strategies for mesh placement are addressed in this chapter, and options for soft tissue coverage are addressed by location. Abdominal wall defects require a logical, multidisciplinary, individualized approach to permit successful reconstruction. However, with a solid foundation of anatomy and familiarity with options for soft tissue coverage, successful reconstruction can be achieved.

A literature review and meta-analysis of outcomes in microsurgical reconstruction using vasopressors

There is a hesitancy to utilize vasopressors in microsurgical reconstruction due to fear of vessel spasm and subsequent flap compromise. Although there are large literature reviews analyzing vasopressor usage in head and neck reconstruction, this has not been extrapolated to all regions of the body. The goal of this study was to perform a meta‐analysis examining vasopressor usage and risk of complications in microsurgical reconstruction for all recipient sites.

Single-stage versus two-stage arteriovenous loop microsurgical reconstruction: A meta-analysis of the literature

Arteriovenous (AV) loops can be utilized in a single‐ or two‐stage approach in free flap reconstruction when proper vessels are not available. However, there exists no consensus on which method leads to superior microsurgical and patient outcomes. The purpose of this article was to review single‐ versus two‐stage AV loops utilized in free flap reconstruction with a focus on complications and overall outcomes.

Utilization of indocyanine green to aid in identifying sentinel lymph nodes in Merkel cell cancer

BACKGROUNDnMerkel cell carcinoma (MCC) is a relatively rare skin cancer with high rates of regional lymph node involvement and metastatic spread. National Comprehensive Cancer Network guidelines recommend sentinel lymph node biopsy (SLNB) for staging purposes. The goal of this study is to report our experience utilizing indocyanine green (ICG) fluorescence-based technology to aid in SLNB detection in MCC.nnnMETHODSnConsecutive MCC patients who underwent SLNB with radioisotope lymphoscintigraphy, with intraoperative handheld gamma probe, and ICG-based fluorescence imaging from 2012 to 2017 were prospectively studied (Cohort A). A group of historical controls that underwent SLNB for MCC with radioisotope lymphoscintigraphy and vital blue dye (VBD) (lymphazurin or methylene blue dye) was also analyzed (Cohort B).nnnRESULTSnTwenty-four consecutive patients underwent SLNB with lymphoscintigraphy and ICG-based fluorescence and 11 controls underwent SLNB with lymphoscintigraphy and VBD. The localization rate by node with VBD was 63.6% and ICG-based fluorescence was 94.8%. For two patients, a positive sentinel lymph node (SLN) was detected only by ICG-based fluorescence and the nodes were not detected by gamma probe and one patients only positive node was identified via ICG fluorescence only. VBD or gamma probe did not identify any unique positive SLNs in either cohort B or either cohort, respectively.nnnCONCLUSIONSnIn this study, we indicate that ICG-based fluorescence is not only feasible to augment SLN identification, but it has a higher node localization rate as compared to blue dye and it was able to identify positive SLNs otherwise missed by gamma probe. This study suggests the importance of utilizing two modalities to augment SLN identification and that ICG-based fluorescence may be able to identify nodes that would have been otherwise missed by gamma probe. We will continue to follow these patients and enroll more patients in this prospective study to further determine the role that ICG-based fluorescence has in identifying sentinel lymph nodes in MCC.

Indocyanine green fluorescence imaging with lymphoscintigraphy for sentinel node biopsy in head and neck melanoma

BACKGROUNDnHead and neck melanoma is associated with a high false negative (FN) sentinel lymph node biopsy (SLNB) rate. If techniques are developed that can decrease FN SLNBs, better prognostic information will be obtained, and it may be possible to improve overall survival as patients are assigned to the appropriate adjuvant management. Our group previously demonstrated that the combination of lymphoscintigraphy and indocyanine green (ICG) fluorescence-based technology was feasible for SLNB in primary melanoma.nnnMETHODSnConsecutive head and neck cutaneous melanoma patients who underwent radioisotope lymphoscintigraphy and ICG-based fluorescence imaging by the senior author (B.G.) from 2012 to 2015 were prospectively enrolled for analysis. Patients were followed postoperatively by the multidisciplinary melanoma team. Main outcome variables were FN rate of SLNB. Length of follow-up was date of surgery to the date of last follow-up/death.nnnRESULTSnThere were 10 positive SLNBs, 51 true negative SLNBs, and one FN SLNB. False negative rate was 9.1%, false negative incidence was 1.6%, sensitivity was 91%, and specificity was 100%. Mean follow-up was 27.6, 17.6, and 16.5xa0mo for true negative, true positive, and FN patients, respectively.nnnCONCLUSIONSnWe report the largest cohort of patients with head and neck cutaneous melanoma undergoing SLNB using both a combination of radioactive tracer, gamma probe, and ICG-based fluorescence identification. Our results demonstrate that using concomitant gamma probe-based radioactivity detection and ICG-based fluorescence for SLN identification in head and neck melanoma is reliable, reproducible and, thus far, has produced a low rate of FN SLNB.

Treatment of dopplerable nummular headache with minimally invasive arterectomy under local anesthesia

OBJECTIVEnThe objective of the current study is to elucidate the potential role of surgery in the treatment of nummular headache (NH).nnnBACKGROUNDnNH is a disorder in which pain is localized to a specific area. Treatment has traditionally been medical, with the recent addition of nerve blocks and botox injection with equivocal results.nnnDESIGNnForty-nine patients were identified using the International Classification of Headache Disorders, third edition, beta version. Patients were asked to identify the area of maximal pain. Patients who had an associated Doppler signal within the area of pain underwent surgical arterectomy using local anesthesia. Preoperative and postoperative headache frequency, severity, duration, and headache-free days were analyzed.nnnRESULTSnThere were a total of 49 patients included in the study (42F:7M) with an average age of 45 years (21-65 years). The average follow-up period was 16 months with a range of 8-33 months. There was a significant reduction in the frequency (-10.7 days; pu2009<u20090.001), severity (-3.5; pu2009<u20090.001), and duration (-0.3 hours; pu2009=u20090.4) of the headache. There was a significant increase in the number of headache-free days per month (10 vs. 21; pu2009<u20090.001). Headache index decreased by 39.6%, from an average of 378.6 to 228.4 (pu2009<u20090.05). Twelve patients (24.5%) were free from NH and able to discontinue their medications. There were no complications identified during the follow-up period.nnnCONCLUSIONnNH, although rare, can be associated with significant disability despite current treatment modalities. In select patients, surgical arterectomy is a safe, minimally invasive, and effective treatment for NH.

Variations in the origins and absence of the common digital arteries of the hand: a cadaveric study:

We studied anomalies of the common digital arteries by dissecting 33 fresh cadaver hands under magnification. In the majority of the dissected hands (25 hands), common digital arteries took off from the superficial palmar arch and ran superficial and parallel to the flexor tendons. Variations were found in eight out of 33 hands. In four hands the common digital artery to the second web space was replaced by an atypical vessel, originating from the deep palmar arch, that crossed posterior to the index flexor tendons proximal to the A1 pulley. In eight hands, the common digital artery to the fourth web space was replaced by an atypical deeper vessel, originating from the superficial palmar arch and crossing posterior to the little finger flexors. No nerve anomalies were identified. Unrecognized, these atypical arteries to the second and/or fourth web spaces could lead to vascular complications during surgery, especially pollicization.

Comparison of Liposomal Bupivacaine for Pain Management after Immediate and Delayed Deep Inferior Epigastric Perforator Free Flap Reconstruction

Patient analgesia can be addressed pre, intra and post-operatively. The utilization of local anesthetics administered intra-operatively is limited by the medication’s short duration of action. However, an intraoperative transversus abdominis plane (TAP) block can be utilized to anesthetize the T6-L1 intercostal nerves that supply the anterior abdominal wall. This provides analgesia to the abdominal wall, which has been identified as the largest source of post-operative pain following abdominally-based autologous tissue breast reconstruction.

Novel algorithm in decision making process for implant-based breast reconstruction

There has been a renewed interest in the pre-pectoral placement of tissue expanders and implants due to possibility of decreased animation deformity, pain, and hospital stays with similar aesthetic and complication profiles compared to sub-pectoral placement. However, for surgeons who are beginning to offer pre-pectoral device placement, or whom work with breast surgeons who are unfamiliar with this approach, pre-pectoral reconstruction can be daunting. The senior author has developed a step-wise algorithm from the initial consultation to the operating room in an attempt to optimize patient satisfaction, aesthetic outcomes, and minimize complications for pre-pectoral and direct-to-implant (DTI) device placement. We present this algorithm for determining which patients are pre-pectoral candidates and we have identified patient factors that are amenable to a DTI approach as opposed to a two-stage reconstruction with a tissue expander. Finally, considerations for patients undergoing pocket conversion from a sub-pectoral to a pre-pectoral plane are discussed. The pre-pectoral technique is an exciting avenue with numerous potential patient benefits. However, reconstruction failure remains a devastating complication and this proposed algorithm allows physicians to maximize their results while minimizing potential complications.