Sheri Slezak

Restoring abdominal wall integrity in contaminated tissue-deficient wounds using autologous fascia grafts

&NA; Necrotizing abdominal wall infections, enteric fistulae, or exposed prosthetic material after ventral hernia repair often results in a loss of abdominal wall integrity. Further surgical reconstruction with prosthetic material is usually contraindicated in the contaminated wound because of the high infection rate necessitating prosthetic removal and further abdominal wall debridement. Consequently, for the past 9 years, we have been using free grafts of autologous fascia lata to replace deficient abdominal wall fascia and muscle in situations where prosthetic material is contraindicated and local tissue rearrangement (i.e., component separation) would be inadequate. Thirty‐two patients (mean age 59 years) underwent abdominal wall reconstruction with autologous fascia lata grafts. Indications included exposed mesh (31 percent), enteric fistulae (28 percent), enteric contamination (22 percent), wound infection (13 percent), and immunosuppression alone (6 percent); 31 percent of all patients were immunosuppressed secondary to either a solid organ transplant or a systemic inflammatory disorder. Fascia grafts (mean size 10 × 17 cm) were sutured to the surrounding abdominal wall and covered by local skin flap advancement and/or myocutaneous flap rotation. All abdominal reconstructions were initially successful. Subsequent local abdominal wall complications included cellulitis (n = 3), seroma (n = 2), and skin dehiscence with exposed fascia grafts (n = 7). Five of seven patients with skin dehiscence healed by secondary intention, whereas two had split‐thickness skin grafts successfully applied to the granulating fascia. Thigh donor site complications included hematoma (n = 1), skin dehiscence (n = 1), and seroma (n = 2). There have been no cases of lateral knee instability. The average follow‐up period is 27 months (range 3 to 106 months). Recurrent hernia has been seen in three patients (9 percent). Interestingly, laparotomy has been performed through an intact fascia lata patch in three patients for unrelated intra‐abdominal conditions. In each case, the graft was intact and revascularized, confirming experimental animal data performed in our laboratory. Recurrent hernia has not been observed through the laparotomy site. Our 9‐year experience has demonstrated that in the face of large, contaminated abdominal wounds where prosthetic material is contraindicated and local tissue rearrangement would be inadequate, fascia lata autografts are a reliable adjuvant to abdominal wall reconstruction.

The use of acellular dermal matrix to prevent capsule formation around implants in a primate model.

Background: Implant-based breast reconstruction is a popular option after mastectomy, but capsular contracture may detract from long-term outcomes. The authors have observed that breast implants covered with acellular dermal matrix (AlloDerm) are less likely to develop a capsule in the area where the implant is in direct contact with the acellular matrix. The authors tested this observation experimentally by comparing capsular formation around implants in the presence and absence of AlloDerm in primates. Methods: Eight smooth-surfaced tissue expanders were implanted into eight African green monkeys. In four experimental animals, a sheet of AlloDerm was draped over the tissue expander so as to cover the implant. Four control animals underwent placement of a tissue expander only. Animals were killed after 10 weeks and specimens underwent histologic and immunohistochemical analysis. Results: Hematoxylin and eosin staining of control specimens revealed the presence of a distinct layer of wavy, parallel arrays of collagen fibers consistent with capsule formation. Immunostaining identified abundant myofibroblasts, a profibrotic cell found in breast capsules. In the AlloDerm-covered specimens, no capsule layer was visible, and specimens stained weakly for myofibroblasts. The difference in myofibroblast staining intensity was statistically significant. Conclusions: The use of AlloDerm to partially enclose implants effectively prevented formation of a capsule in areas where AlloDerm contacted the implant at 10 weeks. Long-term studies will be required to determine whether this is a durable result that can be reproduced in humans.

Surgical options for early-stage breast cancer : Factors associated with patient choice and postoperative quality of life

Patients with early-stage breast cancer have three surgical options: lumpectomy with radiotherapy, mastectomy alone, and mastectomy with breast reconstruction. Our objective was to compare women in these three groups with respect to demographics, preoperative counseling, postoperative body image, and quality of life. Women having undergone surgery for stage 1 or 2 breast cancer between 1990 and 1995 were selected by random sampling of hospital tumor registries and were mailed a self-administered questionnaire, which included the Medical Outcomes Survey Short Form 36. Patients were stratified into three mutually exclusive groups: lumpectomy with axillary node dissection and radiotherapy, modified radical mastectomy, and modified radical mastectomy with breast reconstruction. In total, 267 of 525 surveys were returned (50.9 percent). Compared with mastectomy patients, breast reconstruction patients were younger (p < 0.001), better educated (p = 0.001), and more likely Caucasian (p = 0.02). Among mastectomy patients, 54.9 percent recalled that lumpectomy had been discussed preoperatively and 39.7 percent recalled discussion of breast reconstruction. Post-operative comfort with appearance was significantly lower for mastectomy patients. The relationship between type of surgery and postoperative quality of life varied with age. Under 55, quality of life was lowest for mastectomy patients on all but two Medical Outcomes Survey Short Form 36 subscales. Over 55, quality of life was lowest for lumpectomy patients on all subscales (p < 0.05 for all subscales except social functioning and role-emotional). Treatment choice may be related to age, race, education, and preoperative counseling. Whereas the effect of breast cancer on a womans life is complex and individual, the type of surgery performed is a significant variable, whose impact may be related to patient age.

Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures.

The patterns of midface fractures were related to postoperative computed tomography scans and clinical results to assess the value of ordering fracture assembly in success of treatment methods. A total of 550 midface fractures were studied for their midface components and the presence of fractures in the adjacent frontal bone or mandible. Preoperative and postoperative computed tomography scans were analyzed to generate recommendations regarding exposure and postoperative stability related to fracture pattern and treatment sequence, both within the midface alone and when combined with frontal bone and mandibular fractures. Large segment (Le Fort I, II, and III) fractures were seen in 68 patients (12 percent); more comminuted midface fracture combinations were seen in 93 patients (17 percent). Midface and mandibular fractures were seen in 166 patients (30 percent). Midface, mandible, and nasoethmoid fractures were seen in 38 patients (7 percent). Frontal bone and midface fractures were seen in 131 patients (24 percent). Split-palate fractures accompanied 8 percent of midface fractures. Frontal bone, midface, and mandibular fractures were seen in 54 patients (10 percent). The midface, because of weak bone structure and comminuted fracture pattern, must therefore be considered a dependent, less stable structure. Its injuries more commonly occur with fractures of the frontal bone or mandible (two-thirds of cases) and, more often than not (>60 percent), are comminuted. Comminuted and pan-facial (multiple area) fractures deserve individualized consideration regarding the length of intermaxillary immobilization. Examples of common errors are described from this patient experience.

The sensational transverse rectus abdominis musculocutaneous (TRAM) flap : return of sensibility after TRAM breast reconstruction

Normal breast sensation was objectively quantitated with a biothesiometer, Semmes-Weinstein monofilaments, and two-point discrimination in 10 patients. Ten patients, 2 to 7 years after pedicled transverse rectus abdominis musculocutaneous flap (TRAM) breast reconstruction, were tested in a similar manner. The majority of these patients were found to have recovered measurable sensibility in the TRAM reconstruction. Recovered sensation was best in the medial and superior quadrants and improved with time. Although sensibility was present, it was still significantly different from normal sensory thresholds. A method to improve sensation by intercostal nerve repair is described. Three patients who have undergone this reconstruction have better sensibility in the reinnervated breast compared with the control breast. Sensory reeducation programs may also improve subsequent sensibility return.

Comparison of 3 techniques of fat grafting and cell-supplemented lipotransfer in athymic rats: a pilot study.

BACKGROUND Given the wide application of autologous fat grafting, a new emphasis on fat processing techniques has emerged in an effort to limit unpredictable degrees of resorption often seen with this procedure. With the growing interest in regenerative medicine, approaches to supplement fat grafts with adipose-derived stem cells are evolving in hopes of promoting vascularization and neoadipogenesis. OBJECTIVE The authors evaluated the outcomes of the most common processing techniques for fat grafting--decantation, washing, high-speed centrifugation--and stromal vascular cell-supplemented lipotransfer to determine which method yields a higher percentage of retention and better quality graft. METHODS A total of 32 subcutaneous injections of processed human lipoaspirate were carried out in 8 athymic rats. Each animal received all 4 processing conditions, with end points at 4, 8, and 12 weeks postinjection. Evaluation of graft survival included serial measurements of volume retention and histologic analysis. RESULTS At 12 weeks postinjection, cell-supplemented and centrifuged grafts showed the most consistent volume maintenance. Based on histologic analysis, cell-supplemented and washed grafts had higher scores of viability and vascularity, with the former presenting the least cystic necrosis and calcification as well as minimal inflammation. CONCLUSIONS Cell-supplemented lipotransfer had optimal outcomes for graft retention, viability, and vascularity, while washing resulted in high viability with a less intensive process. High-speed centrifugation resulted in consistent volume retention but lower viability. Each of these approaches is ideal under different circumstances and contributes to the versatility and reliability of fat grafting.

Occult carcinoma in 866 reduction mammaplasties: Preserving the choice of lumpectomy

Background: Occult breast carcinoma is occasionally found in reduction mammaplasty specimens. Historically, these patients were treated with mastectomy because the exact location of the tumor was unknown. Currently, breast conservation is the treatment of choice in 50 to 85 percent of breast cancers. The authors present a technique of routine specimen marking that allows localization of the tumor and preservation of the choice of lumpectomy. Methods: This is a retrospective review of 866 patients who underwent reduction mammaplasty performed by a single surgeon between 1990 and 2009. Data were collected for patients who had occult cancer found in their specimens, including age, cancer risk factors, abnormality, nodal status, selected treatment, and survival status. Specimens were marked and oriented and then sent in separate bags to the pathologist. Results: There were 10 cases of occult carcinoma among the 866 women (1.15 percent) who underwent reduction mammaplasty. Six cancers were found in patients undergoing reduction for symptomatic macromastia [n = 629 (0.95 percent)]. Four new cancers were found in the group of patients with a personal history of cancer [n = 237 (1.69 percent)]. All 10 patients had normal preoperative mammograms. Location, size, and margin status were easily identified and patients were offered the choice of lumpectomy or mastectomy. Conclusions: This article demonstrates that careful marking of reduction specimens in high-risk patients or in women older than 40 years allows the pathologist to orient, localize, and further section tissue for margin status. Communication among plastic surgeon, pathologist, oncologist, and radiation therapist preserves the choice of breast conserving therapy for early cancers.

Silicon tissue assays in nonaugmented cadaveric patients: Is there a baseline level?

Microscopic silicone in various tissues in the bodies of females with breast implants has led to the possible incrimination of these implants with connective-tissue disorders. Current technology precludes accurate silicone measurements, but all compounds containing the element silicon (which would include silicone) may be measured accurately. Direct positive correlations of silicon assays with silicone measured levels were confirmed by adding known amounts of silicone oil as a control With the ubiquitous nature of organosilicons (food containers, syringes, etc.), we hypothesized that baseline silicon levels could be detected in tissues of cadavers without silicone breast augmentation. Ten cadavers were examined. Tissue samples were derived from subcutaneous fat, nipple, breast tissue, liver, spleen, and axillary nodes. Nine of 10 cadavers had silicon levels in various tissues. Measurements were performed by direct current atomic emission spectroscopy. The baseline data were compared with those from four augmented patients who underwent capsulectomies and implant removal. Silicon levels were fivefold higher in the augmented patients than in the nonaugmented cadavers. No difference in levels was noted if the patient had an intact or ruptured implant and/or was symptomatic versus asymptomatic for immunologic disease. This study was designed to measure baseline silicon levels in the normal population. It also has established an accurate level of measurement of tissue silicone. (Plast. Reconstr. Surg. 93:1117, 1994.)

A novel reconstructive technique following central lumpectomy.

Breast conservation therapy is a wellestablished treatment method for subareolar breast cancers, provided that the nipple-areola complex is completely removed, adequate surgical margins are obtained following tumor resection, and adjuvant radiation therapy is received. After resection of the central breast and nipple-areola complex, the remaining surgical defect is commonly closed primarily. However, this frequently results in an unattractive deformity, especially with larger subareolar tumors. We describe an immediate reconstructive technique after central lumpectomy and nipple-areola complex resection that demonstrates excellent cosmesis following radiation therapy.

Omental transposition flap for sternal wound reconstruction in diabetic patients

In 2004, we published our 12-year experience with tissue transfer for deep sternal wound infection after median sternotomy, finding increased rates of reoperation for diabetic patients. Therefore, we decided to alter our treatment approach to diabetic patients to include sternal debridement followed by omental transposition. Eleven diabetic patients underwent omental transposition by our division during the study period. Hospital records were retrospectively reviewed to determine outcomes and complications. We found that diabetic patients treated after implementation of the new treatment approach were 5.4 times less likely to require reoperation for sternal wound management than were patients in the previous series, most of whom had been treated with pectoralis muscle flaps (95% confidence interval, 0.5–50.5). By altering our treatment approach to use omental transposition as the initial surgical therapy, we were able to demonstrate a trend toward decreased need for flap revision in diabetic patients.