Faculty Bibliography

Large, traumatic wounds around the proximal third of the lower extremity may have disrupted local vasculature, potentially obviating local pedicled options. However, free-tissue transfer to this area is technically challenging given the resulting paucity of recipient options and the depth of principal blood vessels. We present an anatomic and radiographic study of the proximally based peroneal vascular bundle as a recipient option in the proximal leg. Optimal approach was prone, through an incision over the fibula with dissection between lateral and posterior compartments. Magnetic resonance angiography demonstrated consistent vascular anatomy between patients. A proximally based peroneal vascular bundle protected by a cuff of flexor hallucis longus was used as a recipient vessel in free flap reconstruction of an open knee wound. The bundle itself does not require coverage by virtue of its own local muscle cuff. Caveats for its use include the need for adequate leg inflow and foot outflow.

Large acquired intracranial defects can result from trauma or surgery. When reoperation is required because of infection or tumor recurrence, management of the intracranial dead space can be challenging. By providing well-vascularized bulky tissue, intracranial microvascular free flaps offer potential solutions to these life-threatening complications. A multi-institutional retrospective chart and radiographic review was performed of all patients who underwent microvascular free-flap surgery for salvage treatment of postoperative intracranial infections between 1998 and 2006. A total of six patients were identified with large intracranial defects and postoperative intracranial infections. Four patients had parenchymal resections for tumor or seizure and two patients had posttraumatic encephalomalacia. All patients underwent operative debridement and intracranial free-flap reconstruction using the latissimus dorsi muscle ( N = 2), rectus abdominis muscle ( N = 2), or omentum ( N = 2). All patients had titanium ( N = 4) or Medpor ( N = 2) cranioplasties. We concluded that surgery or trauma can result in significant intracranial dead space. Treatment of postoperative intracranial infection can be challenging. Vascularized free tissue transfer not only fills the void, but also provides a delivery system for immune cells, antibodies, and systemically administered antibiotics. The early use of this technique when intracranial dead space and infection coexist is beneficial

The success of lower extremity microsurgical reconstructions may be compromised postoperatively secondary to several factors, including thrombosis, infection, bleeding, and edema. To address edema, surgeons may use protocols for gradually dangling and/or wrapping the affected extremity. Such protocols vary widely among surgeons and are typically based on training and/or prior experience. To that end, we distributed surveys to five plastic surgeons who are experienced in microvascular lower extremity reconstruction at five different institutions. The surveys inquired about postoperative management protocols for lower extremity free flaps with regard to positioning, compression, initiation and progression of postoperative mobilization, nonweightbearing and weightbearing ambulation, assessment of flap viability, and flap success rate. These protocols were then evaluated for similarities to create a consensus of postoperative management guidelines. Progressive periods of leg dependency and compression therapy emerged as important elements. Although the consensus protocol developed in this study is considered safe by each participant, we do not intend for these recommendations to serve as a standard of care, nor do we suggest that any one particular protocol leads to improved outcomes. However, these recommendations may serve as a guide for less experienced surgeons or those without a protocol in place

BACKGROUND: Impaired diabetic wound healing is due, in part, to defects in mesenchymal progenitor cell tracking. Theoretically, these defects may be overcome by administering purified progenitor cells directly to the diabetic wound. The authors hypothesize that these progenitor cells will differentiate into endothelial cells, increase wound vascularity, and improve wound healing. METHODS: Lineage-negative progenitor cells were isolated from wild-type murine bone marrow by magnetic cell sorting, suspended in a collagen matrix, and applied topically to full-thickness excisional dorsal cutaneous wounds in diabetic mice. Application of lineage-positive hematopoietic cells or acellular collagen matrix served as comparative controls (n = 16 for each group; n = 48 total). Time to closure and percentage closure were calculated by morphometry. Wounds were harvested at 7, 14, 21, and 28 days and then processed, sectioned, stained (lectin/DiI and CD31), and vascularity was quantified. RESULTS:: Wounds treated with lineage-negative cells demonstrated a significantly decreased time to closure (14 days) compared with lineage-positive (21 days, p = 0.013) and collagen controls (28 days, p = 0.004), and a significant improvement in percentage closure at 14 days compared with the lineage-positive group (p < 0.01) and the collagen control (p < 0.01). Fluorescently tagged lineage-negative cells remained viable in the wound for 28 days, whereas lineage-positive cells were not present after 7 days. Lineage-negative, but not lineage-positive, cells differentiated into endothelial cells. Vascular density and vessel cross-sectional area were significantly higher in lineage-negative wounds. CONCLUSION: Topical progenitor-cell therapy successfully accelerates diabetic wound closure and improves wound vascularity

The hedgehog family of morphogens (sonic [Shh], Indian, and desert hedgehog) are central regulators of embryologic growth and tissue patterning. Although recent work implicates Shh in postnatal tissue repair and development, conclusive evidence is lacking. Here, we demonstrated the importance of Shh in wound repair, by examining the effects of cyclopamine, a specific inhibitor of the Shh signaling cascade, on tissue repair. Using a murine-splinted excisional wound model, which attenuates wound contraction in this loose-skinned rodent, we established that, by all measures (wound closure, epithelialization, granulation formation, vascularity, and proliferation), wound healing was profoundly impaired when Shh signaling was disrupted. Because embryonic disruption of Shh is associated with distinct phenotypic defects, our findings invite investigation of the potential role of Shh signaling under postnatal conditions associated with disregulated wound healing

Breast cancer often leads to significant alteration of body image and disfigurement of the breast. Reconstruction for breast cancer defects can provide the patient with a restored breast contour. The potential benefit of breast cancer reconstructive surgery is to increase the patient's post-surgical quality of life and alleviate the posttraumatic psychological sequelae of breast cancer surgery. Time of breast cancer diagnosis is an important point of access for patients to receive information on breast reconstruction. Access to this information and plastic surgeons in the early phases of diagnosis is critical to a patient's decision to undergo reconstructive surgery, but is currently underutilized in the United States. Breast cancer reconstruction is a complex process that should be treated in a multidisciplinary fashion. This process must begin with the identification and treatment of psychological issues preceding or accompanying breast cancer diagnosis. These psychological problems should be addressed immediately and can significantly influence a patient's decision toward and level of satisfaction with breast cancer reconstruction. Breast reconstruction continues to be an essential element in helping patients recover from the diagnosis and treatment for breast cancer.