Shareef Jandali

1000 consecutive venous anastomoses using the microvascular anastomotic coupler in breast reconstruction.

Background: Microvascular anastomosis is one of the more critical aspects of free flap surgery. A safe, effective, and expedient method for venous anastomosis minimizes flap ischemia time, is easier on the surgical team, and saves costly operating room time. The authors report on their experience using the Synovis microvascular anastomotic coupling device in 1000 consecutive venous anastomoses in free flap breast reconstruction. Methods: The authors retrospectively reviewed 1000 consecutive venous anastomoses that were performed using the microvascular anastomotic coupler between July of 2002 and July of 2008. Data were obtained on flap type, recipient vessel, coupler size, incidence of venous thrombosis, timing of venous thrombosis, and morbidity as a result of venous thrombosis. Results: All anastomoses were performed in an end-to-end fashion. There were 460 unilateral cases and 270 bilateral cases of breast reconstruction. Flap types included muscle-sparing free transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, superficial inferior epigastric artery, superior gluteal artery perforator, and inferior gluteal artery perforator. The vast majority of the recipient vessels were the internal mammary or thoracodorsal vessels. Most of the couplers that were used were either 3 or 2.5 mm in diameter. Overall, there were six instances of venous thrombosis (rate of 0.6 percent). There were no total flap losses due to venous thrombosis in this series, although two patients had partial flap necrosis. Conclusions: The patency rate for venous anastomoses performed with the microvascular coupler is excellent when compared with standard suture techniques and has the advantage of overall easier application.

Breast reconstruction with free tissue transfer from the abdomen in the morbidly obese.

Background: There are national trends of increasing incidence of morbid obesity and autologous breast reconstruction with free tissue transfer from the abdomen. The purpose of this study was to assess the safety and efficacy of free flap breast reconstruction in the morbidly obese population. Methods: A retrospective review was conducted on all patients who underwent transverse rectus abdominis myocutaneous, deep inferior epigastric perforator, or superficial inferior epigastric artery flap breast reconstructions between July of 2006 and October of 2008. Data from all patients with a body mass index greater than 40 were compared with those of patients with a body mass index less than 40. A p value less than 0.05 was considered significant. Significant findings were then analyzed in a post hoc fashion to examine trends with increasing body mass index. Results: Four hundred four patients underwent 612 free flap breast reconstructions during the study period. Twenty-five of these patients (6 percent) had a body mass index greater than 40. The morbidly obese group had significantly higher rate of total flap loss (p = 0.02), total major postoperative complications (p = 0.05), and delayed wound healing (p = 0.006). Conclusions: Free flap breast reconstruction in the morbidly obese is associated with a higher risk of total flap loss, total major postoperative complications, and delayed abdominal wound healing. However, the overall incidence of complications is low, making free tissue transfer from the abdomen an acceptable method of breast reconstruction in this patient population.

Current trends in vaginal labioplasty: a survey of plastic surgeons.

Background:Labioplasty serves to resolve an anatomic variation that results in aesthetic and functional difficulties for many women. To date, little effort has been made to compare the efficacy or prevalence of various techniques, and furthermore, evidence-based practice guidelines have not yet been established for this procedure. The purpose of this study is to elucidate the current armamentarium and practice guidelines for labia minora reduction, as well as to examine self-reported outcomes for this procedure. Methods:A 2009 web-based survey was sent to members of the American Society of Plastic Surgeons via electronic mail. The survey was used to assess surgeon demographics, practice guidelines for labioplasty, and self-reported outcomes measures. Results:A total of 750 surgeons responded to the survey (19.7% response rate), and 51.0% of surgeons currently offered labioplasty. The total number of procedures over the past 24 months for all respondents was 2255. Per surgeon over 24 months, the mean number of procedures was 7.37 (range, 0–300). Surgeons that directly advertised that they performed labioplasty performed a mean of 14.2 procedures over 24 months versus a mean of 5.01 for those who did not (P = 0.001). The mean time suggested to refrain from intercourse was 31.3 days. Redundancy or inadequate resection and wound dehiscence were the 2 most common reasons that caused surgeons to reoperate. Surgeons using plain gut suture material had the highest reported rates of reoperation. The prevalence of each technique was as follows: simple amputation (52.7%), W-SHAPED resection (9.5%), S-shaped resection (8.8%), central v-wedge (36.1%), central wedge with z-plasty (13.9%), and deepithelialization (1.2%). The mean perceived patient satisfaction rate reported by surgeons was greater than 95% for all techniques, and there was no statistically significant difference when comparing perceived patient satisfaction among the techniques (P = 0.337). Conclusions:This study provides data suggesting that labioplasty has been safely and effectively used by many plastic surgeons. However, there is great variation with regard to both techniques and practice guidelines. In establishing these discrepancies among surgeons, we hope to provide the impetus for further academic dialogue and prospective trials.

Closer to an understanding of fate: the role of vascular complications in free flap breast reconstruction.

Background: Flap loss in autologous breast reconstruction is almost invariably a result of a vascular event; however, not all events portend the same fate. The purpose of this study was to determine whether intraoperative vascular complications predict subsequent postoperative vascular thrombosis and flap loss. Methods: This was a retrospective review of all free flaps performed between 2005 and 2010 in the University of Pennsylvania Health System for breast reconstruction. Details of all vascular thromboses and intraoperative technical difficulties were recorded. Flaps with a routine intraoperative course were compared with those with an intraoperative complication. Results: Overall, 1173 free flaps were performed in 804 patients. In regression analysis, an intraoperative vascular complication was the only independent predictor of a subsequent delayed vascular complication (odds ratio, 3.11; 95 percent confidence interval, 1.25 to 7.73). In subanalysis, intraoperative arterial thrombosis was not associated with a subsequent delayed arterial thrombosis; however, intraoperative technical difficulties were associated with increased delayed arterial thrombosis (1.0 percent versus 4.2 percent, p = 0.05) and partial flap loss (0.6 percent versus 4.2 percent, p = 0.02). There was a trend toward increased delayed venous thromboses following intraoperative venous thromboses (1.1 percent versus 16.7 percent, p = 0.07). In aggregate, there was a higher rate of complete flap loss following any intraoperative vascular complication (0.9 percent versus 3.5 percent, p = 0.04). Conclusions: In free flap breast reconstruction, an intraoperative vascular problem leads to increased risk of a subsequent postoperative vascular complication and flap loss. Postoperative vascular complications do not appear to be overtly affected by specific surgical intervention or choice of anticoagulation in the setting of a preceding intraoperative problem. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Evaluating the Use of a Barbed Suture for Skin Closure during Autologous Breast Reconstruction

This study compared the use of barbed suture to a traditional skin closure method for incision closure in free flap breast reconstruction. A retrospective study compared the two closure methods in consecutive series of patients undergoing autologous breast reconstruction between January 2007 and January 2009. Outcomes included total duration of operation and wound complications. We also performed a cost analysis. Use of the barbed suture significantly decreased operative time for unilateral cases by an average of 45 minutes (405 versus 360 minutes, P = 0.02). For bilateral cases, the mean operative time was decreased by an average of 10 minutes (510 versus 500 minutes, P = 0.44). There were more episodes of delayed wound healing in the bilateral barbed suture group (33/46 [72%] versus 15/31 [48%], P = 0.04). No statistical difference was noted between the two groups with regard to dehiscence, infection, or suture extrusion. Use of the barbed suture was, however, more cost-effective. The use of a barbed suture in the closure of abdominal and breast incisions in free flap breast reconstruction may expedite wound closure and reduce the cost of the procedure but may increase wound complications.

Trials and tribulations with the inferior gluteal artery perforator flap in autologous breast reconstruction.

Background: Perforator free flaps from the buttock serve as an alternative to abdominally based flaps in autologous breast reconstruction. Microsurgeons often opt to harvest tissue from the gluteal donor site because of a lack of abdominal volume and/or quality. The authors examined the experience of a single surgeon with the inferior gluteal artery perforator (IGAP) flap and provide a quantitative outcomes comparison with the deep inferior epigastric perforator (DIEP) flap. Methods: A retrospective review was performed of patients who underwent IGAP flap surgery for autologous breast reconstruction from August of 2005 to October of 2010 performed by a single surgeon (J.M.S.). Results: Thirty-one inferior gluteal artery perforator flaps were performed on 24 patients. Mean follow-up time was 24.4 months (range, 6 to 65 months). The total flap loss rate was 6.5 percent, and the take-back rate was 13 percent (salvage rate, 75 percent). Vascular complication rates were as follows: intraoperative arterial thrombosis, 13 percent; intraoperative venous thrombosis, 3 percent; delayed arterial thrombosis, 3 percent; and delayed venous thrombosis, 13 percent. Nineteen percent of patients had sensory complaints at the donor site that persisted beyond 3 months postoperatively. In comparison to the DIEP flap, IGAP flaps had a higher rate of intraoperative arterial thrombosis (13 percent versus 2.6 percent, p = 0.024) and delayed venous thrombosis (13 percent versus 1.5 percent, p = 0.008). Conclusions: Review of the IGAP flap reveals some shortcomings of this flap even in the hands of an experienced microsurgeon. Surgeons should be aware of the difficulties and limitations when choosing this flap for reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Free transverse rectus abdominis myocutaneous flap for breast reconstruction in patients with prior abdominal contouring procedures.

With an increasing number of women undergoing abdominal liposuction and abdominoplasties, patients who have a history of an abdominal-contouring procedure are now presenting to plastic surgeons with breast cancer and are interested in autologous breast reconstruction. Based on the principle of vascular ingrowth and experience of seeing intact perforators arise from the rectus abdominis muscle in repeat abdominoplasty patients, it was hypothesized that these new perforators could adequately and safely supply the abdominal skin island as a flap in this patient population. A retrospective chart review was performed searching for cases of free transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flap breast reconstruction in patients with a prior history of either abdominal liposuction, abdominoplasty, or both. Three successful cases of free TRAM flap breast reconstruction were performed in patients who had undergone previous full abdominoplasties. Additionally, three successful cases of free TRAM or DIEP flaps were performed in patients after abdominal liposuction. Major complications included one anterial thrombosis in which the flap was salvaged. This study demonstrates the feasibility and viability of free TRAM flaps after previous abdominoplasty and DIEP flaps following prior abdominal liposuction. This is an important advance in the potential uses of the free TRAM flap.

Extended trimethoprim/sulfamethoxazole prophylaxis for implant reconstruction in the previously irradiated chest wall.

Background: Patients who have undergone prior chest wall irradiation can present as challenging candidates for implant reconstruction because of troublesome rates of infectious complications. The issue of antibiotic prophylaxis remains controversial, and evidence-based postoperative strategies to reduce implant infections have not been well described in the literature. The purpose of this study was to determine the efficacy of extended trimethoprim/sulfamethoxazole therapy in preventing implant infections in the irradiated chest wall. Methods: A retrospective chart review of hospital and office records was performed on all patients undergoing implant reconstruction performed by a single surgeon (J.M.S.) from August of 2005 to March of 2008. Before 2007, the senior author used 5 to 7 days of cephalosporin prophylaxis. Subsequent to this period, the prophylactic regimen was amended to provide patients with previous chest wall irradiation prophylactic trimethoprim/sulfamethoxazole for 30 days after implant insertion. Results: Fifty-one implant reconstructions, in the setting of prior ipsilateral chest wall irradiation, were performed. The mean follow-up time was 39 months. The infection rate for the routine cephalosporin group was 35 percent as compared with 8 percent for the extended trimethoprim/sulfamethoxazole group (p = 0.038). After multivariate analysis, extended trimethoprim/sulfamethoxazole remained the only significant factor that influenced the rate of infection (p = 0.05). The mean time to infection was 13 weeks for the routine cephalosporin group and 1.5 weeks for the extended trimethoprim/sulfamethoxazole group (p = 0.044). Conclusion: Extended trimethoprim/sulfamethoxazole therapy demonstrates preliminary evidence as an effective adjunctive measure for reducing the rate of implant infections in breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Use of the vascularized free fibula graft with an arteriovenous loop for fusion of cervical and thoracic spinal defects in previously irradiated pediatric patients.

Background: Extensive spinal neoplasms are difficult to manage. Following resection, arthrodesis of the spine can be performed with instrumentation, but this often fails in the setting of radiation therapy. Use of the free fibula flap for anterior spinal fusion to correct deformities has been described in multiple studies, but its use for posterior spinal fusion has been limited. In addition, its use in the pediatric population for this purpose has not been reported. Methods: A retrospective review was performed of three pediatric cases of cervical and thoracic spine tumor resection with posterior fusion of the spine with a microvascular fibula flap over a 2-year period. Data recorded included patient demographics, medical/surgical history, indications for surgery, length of free fibula flap, recipient vessels, ischemic time, number of osteotomies performed on the fibula, complications, and time to computed tomography–documented fusion of the fibula to the remaining spinal column. Results: All three microvascular anastomoses were successfully performed using an arteriovenous loop of saphenous vein graft to the anterior neck or subscapular vessels. The average length of fibula harvested was 23.7 cm, the average length of ischemic time was 220 minutes, the number of osteotomies in all cases was two, and there was bony fusion at an average of 15.7 weeks postoperatively. Conclusions: The free fibula flap is ideally suited for accelerated posterior spinal fusion after extensive resection of cervical or thoracic spinal neoplasms. An arteriovenous saphenous vein loop facilitates the microvascular anastomosis in this anatomical region that lacks suitable recipient vessels.

From Surgery to Pharmacology to Gene Therapy: The Past, Present, and Future of Hair Restoration

The hair follicle is a complex structure containing many cell types that produce highly specialized proteins. These proteins govern the continuous cycling of the follicle through its stages of anagen, catagen, telogen, and exogen. Most common forms of alopecia result from the changes in the follicular cycling pattern and the morphology of the hair follicle. Hair restoration has traditionally been performed using scalp reduction techniques and the rearrangement of local hair-bearing flaps. Over the recent decades, hair transplantation has been the mainstay of hair restoration, whereas the pharmacological treatment of androgenic alopecia has halted the progression of hair loss. Over recent years, significant advances in the understanding of the biology and the molecular mechanisms of the follicle and its cycling have been made. This understanding, combined with new techniques for delivering molecules to the follicle, has made gene therapy for alopecia a possibility.