Sami H. Tuffaha

Plastic surgery and smoking: a prospective analysis of incidence, compliance, and complications.

Background: Tobacco use remains a persistent risk factor in elective plastic surgery. Although nicotine is thought to increase complications, which procedures are affected and the reliability of patient-provided histories remain poorly defined. The authors sought to examine nicotine use and its impact on outcomes. Methods: All patients in a single-surgeon practice undergoing surgery with general anesthesia during a 2-year period were enrolled. Preoperative evaluation included a thorough smoking history. All patients had urine samples taken on the day of surgery to assess for nicotine metabolites. Patients were followed for a minimum of 3 months after surgery and monitored for complications. Results: Four hundred fifteen patients were enrolled. Of these, 139 (33.5 percent) stated that they had quit smoking and 39 (9.4 percent) were admitted active smokers. For the 362 patients with urine nicotine analysis available, 54 showed active smoking. Fifteen of these (4.1 percent) had denied current tobacco use. Patients stating that they had quit smoking were more likely to be deceitful than those stating they had never smoked (p < 0.001). Smokers had significantly higher overall complication rates (OR, 3.7; p < 0.001) and tissue necrosis rates (OR, 4.3; p = 0.02) and were likelier to require reoperation (OR, 3.7; p < 0.001). Conclusions: In a large cohort study examining the prevalence and impact of nicotine in the general plastic surgery population, substantial rates of deception regarding smoking status were found. Furthermore, active smoking was strongly correlated with complications. A methodologic approach to the detection and management of patients using tobacco products can help to optimize outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

A Critical Analysis of Rejection in Vascularized Composite Allotransplantation: Clinical, Cellular and Molecular Aspects, Current Challenges, and Novel Concepts

Advances in microsurgical techniques and immunomodulatory protocols have contributed to the expansion of vascularized composite allotransplantation (VCA) with very encouraging immunological, functional, and cosmetic results. Rejection remains however a major hurdle that portends serious threats to recipients. Rejection features in VCA have been described in a number of studies, and an international consensus on the classification of rejection was established. Unfortunately, current available diagnostic methods carry many shortcomings that, in certain cases, pose a great diagnostic challenge to physicians especially in borderline rejection cases. In this review, we revisit the features of acute skin rejection in hand and face transplantation at the clinical, cellular, and molecular levels. The multiple challenges in diagnosing rejection and in defining chronic and antibody-mediated rejection in VCA are then presented, and we finish by analyzing current research directions and novel concepts aiming at improving available diagnostic measures.

Using the dorsal, cavernosal, and external pudendal arteries for penile transplantation: technical considerations and perfusion territories.

Background: Penile transplantation may provide improved outcomes compared with autogenous phalloplastic reconstruction. The optimal approach to vascularizing penile allografts is unknown. In penile replantation, typically only the dorsal arteries are repaired, but using the cavernosal and external pudendal arteries may improve erectile function and shaft skin perfusion, respectively. The authors sought to demonstrate the technical feasibility of using the dorsal, cavernosal, and external pudendal vessels for penile transplantation and to assess differences in their perfusion territories. Methods: Cadaveric penile transplantation was performed. Different colored dyes were injected at physiologic pressure into the dorsal, cavernosal, and external pudendal arteries, and tissue perfusion territories were assessed visually. Results: Cavernosal artery exposure and repair required minimal dissection of the corpora cavernosa; extra length taken from the donor compensated for resultant shortening of the proximal shaft stump. The external pudendal system was easily accessed in the groin. Dye injected into the cavernosal artery strongly perfused the corpora cavernosa, with minimal communication to skin. The dorsal artery principally perfused the glans and corpus spongiosum. The external pudendal artery perfused the shaft and surrounding skin. Conclusions: Anastomosing the cavernosal arteries may augment corporal inflow, which is necessary for erection. Although the dorsal arteries are critical for distal penile skin perfusion, the external pudendal artery should be used in proximal transplantation to ensure adequate shaft skin perfusion. Each of these arteries has a distinct and seemingly important perfusion territory that should be considered in the setting of penile transplantation.

Pyoderma Gangrenosum After Breast Surgery: Diagnostic Pearls and Treatment Recommendations Based on a Systematic Literature Review.

BackgroundPyoderma gangrenosum (PG) is a rare cutaneous disorder that poses a diagnostic challenge in the postoperative period. A systematic literature review was performed to determine distinguishing characteristics of PG in the setting of breast surgery that can facilitate timely diagnosis and appropriate treatment. MethodsPubMed, EMBASE, Scopus, and Web of Science databases were systematically searched for articles with cases of PG occurring after breast surgery. Forty-three relevant articles, including 49 case reports, were identified. ResultsPG manifested bilaterally in 30 of 34 cases (88%) in which bilateral surgery was performed. Abdominal wounds were present in 6 of 7 cases in which an abdominal donor site was used for breast reconstruction. Nipples were spared from wound involvement in 33 of 37 cases (89%) in which nipples were present after surgery. Presence of fever was noted in 27 cases (55%) and leukocytosis in 21 cases (43%). A total of 33 patients (67%) underwent wound debridement. Successful medical treatment most commonly involved steroids (41 cases, 84%) and cyclosporine (10 cases, 20%). ConclusionsPertinent clinical features were identified that may aid in timely diagnosis and treatment of PG after breast surgery. Appearance of discrete wounds involving multiple surgical sites that surround but spare the nipples should raise suspicion for PG rather than infection or ischemia, even with concomitant fever and leukocytosis. Wound debridement should be minimized and skin grafting considered only after medical therapy is initiated. Cognizance of these features may enable prompt therapeutic intervention that minimizes morbidity and improves outcomes.

Growth Hormone Therapy Accelerates Axonal Regeneration, Promotes Motor Reinnervation, and Reduces Muscle Atrophy following Peripheral Nerve Injury.

Background: Therapies to improve outcomes following peripheral nerve injury are lacking. Prolonged denervation of muscle and Schwann cells contributes to poor outcomes. In this study, the authors assess the effects of growth hormone therapy on axonal regeneration, Schwann cell and muscle maintenance, and end-organ reinnervation in rats. Methods: Male Sprague-Dawley rats underwent sciatic nerve transection and repair and femoral nerve transection without repair and received either daily subcutaneous growth hormone (0.4 mg/day) or no treatment (n = 8 per group). At 5 weeks, the authors assessed axonal regeneration within the sciatic nerve, muscle atrophy within the gastrocnemius muscle, motor endplate reinnervation within the soleus muscle, and Schwann cell proliferation within the denervated distal femoral nerve. Results: Growth hormone–treated animals demonstrated greater percentage increase in body mass (12.2 ± 1.8 versus 8.5 ± 1.5; p = 0.0044), greater number of regenerating myelinated axons (13,876 ± 2036 versus 8645 ± 3279; p = 0.0018) and g-ratio (0.64 ± 0.11 versus 0.51 ± 0.06; p = 0.01), greater percentage reinnervation of motor endplates (75.8 ± 8.7 versus 38.2 ± 22.6; p = 0.0008), and greater muscle myofibril cross-sectional area (731.8 ± 157 &mgr;m versus 545.2 ± 144.3 &mgr;m; p = 0.027). Conclusions: In male rats, growth hormone therapy accelerates axonal regeneration, reduces muscle atrophy, and promotes muscle reinnervation. Growth hormone therapy may also maintain proliferating Schwann cells in the setting of prolonged denervation. These findings suggest potential for improved outcomes with growth hormone therapy after peripheral nerve injuries.

Reconstruction of Large Abdominal Wall Defects Using Neurotized Vascular Composite Allografts.

Background: Abdominal wall vascularized composite allotransplantation is the second most common form of vascularized composite allotransplantation. Sensory and functional recovery are expected in other forms but have never been demonstrated in abdominal wall vascularized composite allotransplantation. The authors hypothesize that coaptation of two thoracolumbar nerves will result in reinnervation of the alloflap and maintenance of the muscle component. Methods: Adult, male, 10-week-old Brown Norway and Lewis rats were used for experiments. The rat donor’s common iliac vessels were anastomosed to the recipient’s femoral vessels. Intercostal nerves T10/L1 were coapted. Four groups (n = 5 per group) were included for study: group 1, Lewis, intercostal nerves cut, not repaired; group 2, Lewis intercostal nerves cut, T10/L1 repaired; group 3, allogeneic Brown Norway–to-Lewis abdominal wall vascularized composite allotransplantation, T10/L1 repaired; and group 4, syngeneic Lewis-to-Lewis abdominal wall vascularized composite allotransplantation, T10/L1 repaired. Animals were killed on postoperative day 60. Nerve regeneration was assessed using muscle weight analysis, myofibril cross-sectional area, nerve histomorphometry, and neuromuscular junction percentage reinnervation. Results: Groups 2, 3, and 4 maintained a significantly greater percentage of postharvest weight compared with group 1 (p < 0.05). Group 1 had significantly decreased myofibril cross-sectional area compared with controls (p < 0.05). There was no significant difference in myofibril cross-sectional area in groups 2 through 4 compared with controls (p > 0.05). Group 1 had significantly decreased percentage reinnervation of the alloflap compared with controls (p < 0.05). There was no significant difference when comparing group 2 through 4 with internal, contralateral controls (p > 0.05). Conclusion: In a murine model for abdominal wall vascularized composite allotransplantation, coaptation of T10/L1 will allow for reinnervation of the alloflap and maintenance of the muscle component.

Pediatric Orbital Floor Fractures: Outcome Analysis of 72 Children with Orbital Floor Fractures.

Background: Orbital floor fractures are uncommon in the pediatric population. The aim of this study was to review the presentation, management, and outcomes for children with these injuries. Methods: A retrospective review was performed on 72 consecutive children with orbital floor fractures over a 21-year period. Results: Seventy-two patients with 76 fractures were identified. Mean follow-up time was 14.2 ± 4 months. The majority (50 percent) of patients suffered minimally displaced fractures, whereas 17 percent (13 of 76) suffered blowout fractures and 5 percent (four of 76) suffered trapdoor fractures. Nineteen percent of children (14 of 72) presented with decreased visual acuity and 8 percent (six of 72) had enophthalmos on presentation. Thirty-three percent (24 of 72) underwent surgery. The most common indications for surgery were size of the fracture, followed by muscle entrapment. Fracture width and the defect width–to–orbital width ratios were significantly greater in the operative cohort versus their conservatively managed counterparts (20.7 mm versus 7.7 mm, p < 0.05, and 0.54 versus 0.32, p < 0.05, respectively). Surgery was not associated with improved visual outcomes (p < 0.05). However, patients who underwent reconstruction had a significantly lower adjusted risk of enophthalmos on follow-up (relative risk, 0.02; 95 percent CI, 0.00 to 0.49; p < 0.05). Conclusions: Operative intervention prevents enophthalmos in pediatric patients with pediatric orbital floor fractures, and patients who present with decreased visual acuity should be cautioned that surgical intervention does not improve visual outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Chest Wall Reconstruction: Evolution over a Decade and Experience with a Novel Technique for Complex Defects

BackgroundChest wall reconstruction (CWR) with biologic matrices has gained popularity over the last decade; however, data on this topic remain sparse. The aim of this study is to review the different methods and materials used for CWR while reviewing and highlighting a novel approach using a biologic inlay and synthetic onlay technique for larger, complex high-risk defects. MethodsA retrospective review was performed of all patients who underwent full thickness chest wall resection and reconstruction during a 10-year period. Patient characteristics, comorbidities, operative data, as well as postoperative wound complications and outcomes were reviewed. Different reconstructive methods and materials were reviewed and compared. ResultsFrom December 2003 to January 2014, a total of 81 patients underwent CWR. The indications for resection/reconstruction included oncologic in 49 patients (60.5%), desmoids tumors in 10 (12.3%), bronchopleural fistula in 3 (3.7%), infection in 7 (8.6%), and anatomic deformity in 7 (8.6%) patients. Synthetic and/or acellular dermal matrices (ADM) reconstruction was used in 59 patients (10 biologic, 22 synthetic, and 27 biologic ADM inlay/synthetic onlay combination). On average, 2.5, 3.5, and 3.6 ribs were resected in the biologic, synthetic, and combination group, respectively (P = 0.1). A greater number of patients in the combination group had a history of chemotherapy and/or radiation therapy (P = 0.03) than the synthetic or biologic alone groups. Risk analysis demonstrated an association between the number of ribs resected and postoperative chest wall complications. The incidence of chest wall/wound complications in the synthetic, combination, and biologic groups was 31.8%, 22.2%, and 10%, respectively (P = 0.47). ConclusionsIn the largest single institution study comparing the use of different reconstructive materials, including ADM in CWR, the authors demonstrate that a biologic inlay/synthetic onlay may be used effectively for high-risk, large complex defects. Early outcomes with this technique are promising. The authors believe this combination highlights benefits from both materials because the ADM facilitates tissue ingrowth and revascularization, whereas the synthetic component provides structural durability. Additional studies with larger sample sizes are necessary to further explore the benefits of the combination technique to determine if outcomes are better than either material alone when used to reconstruct high-risk wounds after larger resections.

Functional abdominal wall reconstruction using an innervated abdominal wall vascularized composite tissue allograft: a cadaveric study and review of the literature.

BACKGROUND Large, composite abdominal wall defects represent complex problems requiring a multidisciplinary approach for reconstruction. Abdominal wall vascularized composite allotransplantation (AW-VCA) has been successfully performed in 21 patients, already receiving solid organ transplants, to provide immediate abdominal closure. The current study aims to establish a novel anatomic model for AW-VCA that retains motor and sensory function in an effort to preserve form and function while preventing complications. METHODS Three fresh cadaver torsos were obtained. Dissection was started in the midaxillary line bilaterally through the skin and subcutaneous fascia until the external oblique was encountered. The thoracolumbar nerves were identified and measurements were obtained. A peritoneal dissection from the costal margin to pubic symphysis was performed and the vascular pedicle was identified for subsequent microsurgical anastomosis. RESULTS The mean size of the abdominal wall graft harvested was 615 ± 120 cm(2). The mean time of abdominal wall procurement was ∼150 ± 12 minutes. The mean number of thoracolumbar nerves identified was 5 ± 1.4 on each side. The mean length of the skeletonized thoracolumbar nerves was 7.8 ± 1.7 cm. The cross-sectional diameter of all nerves as they entered the rectus abdominis was greater than 2 mm. CONCLUSIONS Motor function and sensory recovery is expected in other forms of vascularized composite allotransplantation, such as the hand or face; however, this has never been tested in AW-VCA. This study demonstrates feasibility for the transplantation of large, composite abdominal wall constructs that potentially retains movement, strength, and sensation through neurotization of both sensory and motor nerves.

Penile Transplantation: An Emerging Option for Genitourinary Reconstruction

Penile transplantation is an emerging option for patients with severe genital defects not amenable to traditional reconstructive options. In this article, we discuss the burgeoning problem of severe male genitourinary trauma in the military, the limitations of traditional reconstructive options in addressing these problems, and the potential for penile transplantation to provide improved outcomes. We also review the preclinical research and limited worldwide experience with penile transplantation to date, including lessons learned, and discuss the many important technical, logistical, and ethical considerations pertaining to penile transplantation that must be addressed to maximize the likelihood of successful implementation.