Sergey Y. Turin

Postoperative Flank Defects, Hernias, and Bulges: A Reliable Method for Repair.

Background: Although there is a high incidence of flank defects after lateral abdominal access, there is a paucity of large studies discussing this problem. Most studies express nihilism regarding their surgical management. The goal of this study was to describe the authors’ conceptualization of flank defects, with a determination of the number of true hernias versus bulges, and outcomes of surgical repair in these patients. Methods: The authors carried out a 13-year retrospective review of 31 consecutive flank defects repaired by the senior author (G.A.D.). Patients were treated with a 7.5-cm-wide macroporous polypropylene mesh and reapproximation of the abdominal wall to achieve a direct supported repair. There were 19 intraperitoneal placements and 12 placements between the external and internal oblique muscles or preperitoneal space. The prevalence of true hernia versus bulge at the time of repair was noted. Results: There were no surgical-site infections. Two patients developed minor bulges at the prior hernia site: one of these was repaired with additional mesh, and the other one was observed. One small asymptomatic recurrent hernia was noted incidentally on a follow-up computed tomographic scan. Initially, 10 patients had a complete hernia through all layers of the lateral abdominal musculature, 17 patients had dehiscence of the internal oblique and transversus abdominis muscles with an intact external oblique muscle, and four patients had denervation with all layers of the abdominal wall intact. Conclusions: Most flank defects represent true hernias rather than denervation injuries. Direct supported repair of flank hernias using mesh is a safe and effective technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Labial Incompetence in Mobius Syndrome: LeFort I Impaction Case Report and Review of Management Strategies

Difficulty with speech intelligibility in Mobius syndrome patients due to bilabial incompetence is common yet rarely discussed. We present a patient with Mobius syndrome who underwent counterclockwise LeFort I impaction to improve her labial competence. In addition, we present a literature review of management strategies for labial incompetence correction in Mobius patients. At 7-year follow-up after LeFort 1 impaction, the patient reports improvement in speech intelligibility, specifically regarding the ability to pronounce bilabial consonants. This is the first published report of LeFort I impaction to improve labial competence and bilabial consonant pronunciation in a Mobius syndrome patient.

Decreasing ALT donor site morbidity with the keystone flap

The anterolateral thigh (ALT) flap is a workhorse flap for a variety of wounds. The primary disadvantage of ALT flaps is donor site morbidity associated with large skin paddle defects. We present a strategy of managing the donor site with the Keystone flap to avoid skin grafts in cases where primary closure is not possible.

Multi-view stereo in the operating room allows prediction of healing complications in a patient-specific model of reconstructive surgery

Excessive mechanical stress leads to wound healing complications following reconstructive surgery. However, this knowledge is not easily applicable in clinical scenarios due to the difficulty in measuring stress contours during complex tissue rearrangement procedures. Computational tools have been proposed as an alternative to address this need, but obtaining patient specific geometries with an affordable and flexible setup has remained a challenge. Here we present a methodology to determine the stress contours from a reconstructive procedure on a patient-specific finite element model based on multi-view stereo (MVS). MVS is a noninvasive technology that allows reconstruction of 3D geometries using a standard digital camera, making it ideal for the operating room. Finite element analysis can then be used on the patient-specific geometry to perform a virtual surgery and predict regions at risk of complications. We applied our approach to the case of a 7-year-old patient who was treated to correct a cranial contour deformity and resect two large areas of scalp scarring. The simulation showed several zones of high stress, particularly near the suture lines at the distal ends of the flaps. The patient did show delayed healing and partial flap tip necrosis at one of such predicted regions at the 30-day follow up visit. Our results further establish the application of computational tools in individualized medical scenarios to advance preoperative planing and anticipate regions of concern immediately after surgery.

Digital analysis yields more reliable and accurate measures of dermal and epidermal thickness in histologically processed specimens compared to traditional methods

Changes in the thickness of the dermis and epidermis have been described in the scenario of tissue expansion as well as inflammatory skin processes (psoriasis, contact hypersensitivity and so on). These changes have previously been quantified using ocular micrometers to obtain and then average a limited number of spot measurements, leading to suboptimal accuracy. We describe a rapid method of using freely available ImageJ software to analyze digitized images of fixed skin specimens. By determining the cross‐sectional area and surface length of a skin layer, a simple calculation produces more accurate and reproducible measurements of its thickness compared to historical methods, with excellent inter‐rater reliability.

Rates and Predictors of Readmission Following Body Contouring Procedures: An Analysis of 5100 Patients From The National Surgical Quality Improvement Program Database

Background Hospital readmissions can be a major contributor to increased healthcare costs and are a salient current topic in healthcare. There is a paucity of large, prospective studies that evaluate rates and risk factors of readmission within the aesthetic subset of plastic surgery. Objectives The authors propose to determine the rates of unplanned readmission following body contouring procedures and to analyze the predictors associated with it. Methods The 2011 and 2012 National Surgical Quality Improvement Program Database was queried for body contouring procedures using the appropriate Current Procedural Terminology codes. The rate of unplanned readmission, preoperative risk factors, comorbidities, and medical and surgical postoperative complications data were analyzed using multivariate regression models to determine predictors of readmission after these procedures. Results We identified 5100 patients who underwent body contouring procedures, of which 142 (2.8%) experienced an unplanned readmission. Forty-eight per cent of readmitted patients experienced at least one surgical complication, and 23.9% experienced at least one medical complication. Multivariate regression analyses identified several independent predictors of unplanned readmission: increasing age (odds ratio [OR] 1.018 per year, P = 0.039), bleeding disorders (OR 3.674, P = 0.039), increased operative time (each additional hour conferring a 20% increased risk), surgical complications (OR 19.179, P < 0.001), and medical complications (OR 10.240, P < 0.001). Conclusions The unplanned readmission rate for body contouring procedures is low overall (2.8%). We identified age, bleeding disorders, operative duration, and postoperative complication as independent risk factors for unplanned readmission. These data can help guide preoperative risk stratification and future interventions in high-risk patient populations. Level of Evidence 2.

The Greater Palatine “Notch”: Clinical Sequelae of an Incomplete Greater Palatine Foramen

The anatomy of the greater palatine foramen has variation with regard to location, but there have been no reports on the absence of a complete foramen. We present 2 cases of pediatric patients with cleft palates possessing a greater palatine “notch” as opposed to a bony foramen. Awareness of this anomaly is advantageous in preventing injury to the greater palatine vessels during palatoplasty.

Matrices and Dermal Substitutes for Wound Treatment

Advanced wound matrices are important adjuncts to standard wound care and surgery. An understanding of their mechanisms of action leads to rational device selection for difficult wounds. We discuss the various types of advanced biofunctional wound care products currently available for wound treatment and dermal reconstruction and their most commonly used applications. Prototypic products within the categories of dermal allografts, dermal regenerative scaffolds, cellular substrates, and decellularized ECM-based materials are discussed. Dermal regenerative scaffolds are useful for temporary wound coverage to quell inflammation and prevent desiccation and infection in acute burn injury and have been used increasingly for dermal reconstruction. Cellular products and decellularized tissue matrices contain bioactive compounds that augment or stimulate wound healing pathways known to be impaired in diabetic foot ulcers (DFUs) and venous leg ulcers (VLUs). Early DFU and VLU healing within the first 4 weeks of standard wound care can predict a need for adjunctive measures. Current data is culled from numerous randomized controlled trials and systematic reviews. Available evidence demonstrates that in the appropriate setting, biofunctional wound matrices increase rates of complete wound closure and accelerate the rate of healing.

Improving tissue expansion protocols through computational modeling

Tissue expansion is a common technique in reconstructive surgery used to grow skin in vivo for correction of large defects. Despite its popularity, there is a lack of quantitative understanding of how stretch leads to growth of new skin. This has resulted in several arbitrary expansion protocols that rely on the surgeons personal training and experience rather than on accurate predictive models. For example, choosing between slow or rapid expansion, or small or large inflation volumes remains controversial. Here we explore four tissue expansion protocols by systematically varying the inflation volume and the protocol duration in a porcine model. The quantitative analysis combines three-dimensional photography, isogeometric kinematics, and finite growth theory. Strikingly, all four protocols generate similar peak stretches, but different growth patterns: Smaller filling volumes of 30 ml per inflation did not result in notable expander-induced growth neither for the short nor for the long protocol; larger filling volumes of 60 ml per inflation trigger skin adaptation, with larger expander-induced growth in regions of larger stretch, and more expander-induced growth for the 14-day compared to the 10-day expansion protocol. Our results suggest that expander-induced growth is not triggered by the local stretch alone. While stretch is clearly a driver for growth, the local stretch at a given point is not enough to predict the expander-induced growth at that location. From a clinical perspective, our study suggests that longer expansion protocols are needed to ensure sufficient growth of sizable skin patches.

The expression of fgfr3 in the zebrafish head

Fibroblast growth factor (FGF) signaling is essential for many developmental processes and plays a pivotal role in skeletal homeostasis, regeneration and wound healing. FGF signals through one of five tyrosine kinase receptors: Fgfr1a, -1b, -2, -3, -4. To characterize the expression of zebrafish fgfr3 from the larval stage to adulthood, we used RNAscope in situ hybridization on paraffin sections of the zebrafish head. Our study revealed spatial and temporal distribution of fgfr3 transcript in chondrocytes of the head cartilages, osteoblasts involved in bone formation, ventricular zone of the brain, undifferentiated mesenchymal cells of the skin, and lens epithelium of the eye. In general, the expression pattern of zebrafish fgfr3 is similar to the expression observed in higher vertebrates.