Faculty Bibliography

BACKGROUND:Simultaneous ventral hernia repair and panniculectomy (SVHRP) is a procedure that is more commonly being offered to patients with excess skin and subcutaneous tissue in need of a ventral hernia repair; however, there are concerns about surgical-site complications and uncertainty regarding the durability of repair. SVHRP outcomes vary within the literature. This study assessed the durability, complication profile, and safety of SVHRP through a large data-driven repository of SVHRP cases.360 METHODS:: The current SVHRP literature was queried using the MEDLINE, PubMed, and Cochrane databases. Predefined selection criteria resulted in 76 relevant titles yielding 16 articles for analysis. Meta-analysis was used to analyze primary outcomes, identified as surgical-site occurrence and hernia recurrence. Secondary outcomes included review of techniques used and systemic complications, which were analyzed with pooled weighted mean analysis from the collected data. RESULTS:There were 917 patients who underwent an SVHRP (mean age, 52.2 ± 7.0 years; mean body mass index, 36.1 ± 5.8 kg/m; mean pannus weight, 3.2 kg). The mean surgical-site occurrence rate was 27.9 percent (95 percent CI, 15.6 to 40.2 percent; I = 70.9 percent) and the mean hernia recurrence rate was 4.9 percent (95 percent CI, 2.4 to 7.3 percent; I = 70.1 percent). Mean follow-up was 17.8 ± 7.7 months. The most common complications were superficial surgical-site infection (15.8 percent) and seroma formation (11.2 percent). Systemic complications were less common (7.8 percent), with a thromboembolic event rate of 1.2 percent. The overall mortality rate was 0.4 percent. CONCLUSIONS:SVHRP is associated with a high rate of surgical-site occurrence, but surgical-site infection seems to be less prominent than previously anticipated. The low hernia recurrence rate and the safety of this procedure support its current implementation in abdominal wall reconstruction.

BACKGROUND: The lateral femoral circumflex artery (LFCA) system, which supplies the anterolateral thigh (ALT) flap territory, offers a plethora of tissue types for composite, functional reconstruction. However, the ability to include a reliable and flexible osseous component is limited. Based on cadaveric dissections, we describe an isolated LFCA branch to the femur separate from the vastus intermedius that can be included in ALT flap harvest in cases requiring bony reconstruction. METHODS: Cadaveric dissection was undertaken to define the LFCA vascular system with specific dissection of the proximal branches of the descending branch of the LFCA (db-LFCA) to define any muscular, periosteal, and/or osseous branches to the femur. RESULTS: Six thighs in four cadavers were dissected. Consistent in all specimens, there was an isolated branch extending distally, medially, and posteriorly from the proximal LFCA and entering the periosteum of the femur. In five specimens, the identified branch to the femur was located approximately 1-cm distal to the rectus femoris branch of the LFCA and approximately 1-cm proximal to a separate branch entering and supplying the vastus intermedius. In one specimen, there was a common trunk. The length of this branch from the origin at the LFCA to insertion into the femoral periosteum was approximately 6 to 8 cm. CONCLUSION/CONCLUSIONS: There appears to be a consistent and reliable branch to the femur based on the proximal LFCA that may be included in ALT flap harvest, adding even more versatility, as another option in complex cases requiring composite reconstruction, including bone.

BACKGROUND/UNASSIGNED:The Alexis retractor is a device that provides simultaneous radial retraction and wound protection during surgical procedures. Although typically used in abdominal and pelvic surgeries, there has been increased development of novel operative techniques utilizing the Alexis retractors in head and neck surgeries. METHODS/UNASSIGNED:We describe 2 cases of utilizing the Alexis retractor to attain transoral exposure in the setting of free flap reconstruction of intraoral defects. RESULTS/UNASSIGNED:In both cases, the Alexis retractor provided improved retraction, decreasing the number of instruments required for adequate exposure. Additionally, the polyurethane sheath component acted as a protective membrane over the lips and mucosa. CONCLUSIONS/UNASSIGNED:The Alexis retractor can be a powerful retraction tool for certain surgical procedures involving the head and neck regions.

BACKGROUND:Microsurgical free tissue transfer is an important treatment option for nonhealing lower extremity diabetic wounds. The purpose of this study was to identify factors that affect flap survival and wound complications. METHODS:A retrospective review was conducted of 806 lower extremity free-flap reconstructions performed from 1979 to 2016. A total of 33 free flaps were used for coverage of nonhealing lower-extremity diabetic ulcers. Primary outcome measures were perioperative complications and long-term wound breakdown. RESULTS:The average age was 54 ± 12.3 y. 15.2% of patients were smokers, 12.1% had coronary artery disease and 12.1% had end-stage renal disease. Muscle flaps predominated (75.8%) compared to fasciocutaneous flaps (24.2%). There were 7 patients (21.2%) that underwent a revascularization procedure before (71.4%) or at the same time (28.6%) as the free flap. Immediate complications occurred in 7 flaps (21.2%) with 4 partial losses (12.1%) and 3 total flap failures (9.1%). Major wound complications occurred in 18.2% of patients. An end-to-side (E-S) anastomosis for the artery was used in 63.6% (n = 22) of flaps compared with an end-to-end (E-E) anastomosis. E-S anastomosis was associated with a significantly lower risk of wound complications compared with an arterial E-E anastomosis (0% versus 45.5%, P = 0.001). CONCLUSIONS:The use of microvascular free flaps can be used successfully to cover lower-extremity diabetic wounds. E-E arterial anastomosis should be avoided if possible as it is associated with higher rates of wound breakdown, likely by impairing perfusion to a distal limb with an already compromised vasculature. LEVEL OF EVIDENCE/METHODS:Level III.

PURPOSE/OBJECTIVE:There is a dearth of literature dedicated to specifically evaluating the use of free flap reconstruction in pediatric lower extremity traumas. This study aims to identify specific risk factors for flap failure in pediatric lower extremity trauma reconstruction. METHODS:Retrospective review of 53 free flaps in our lower extremity database (1979-2017) identified all free flaps performed for traumatic reconstruction in children <18 years of age at our institution. RESULTS:analysis (P = 0.041). CONCLUSION/CONCLUSIONS:Free flap reconstruction in the pediatric trauma population is safe with similar survival outcomes when compared to the adult population. Arterial injury and vessel size mismatch were associated with significantly higher flap failure rates in this population. LEVEL OF EVIDENCE/METHODS:Level III.

BACKGROUND:Although the surgical microscope remains the most common tool used for visual magnification for microsurgical anastomoses in free tissue transfer, loupe-only magnification for free flap breast reconstruction has been demonstrated to be safe and effective. To evaluate the loupe-only technique in lower extremity free flap reconstruction, the authors compared perioperative outcomes between microsurgical anastomoses performed with loupe magnification versus a surgical microscope. METHODS:The authors conducted a two-institution retrospective study of soft-tissue free flaps for traumatic below-knee reconstruction. Optimal subgroup matching was performed using patient age, defect location, flap type (muscle versus fasciocutaneous), and time from injury (acute, <30 days; remote, >30 days) for conditional logistic regression analysis of perioperative outcomes. RESULTS:A total of 373 flaps met inclusion criteria for direct matched comparison of anastomoses performed with loupe magnification (n = 150) versus a surgical microscope (n = 223). Overall major complication rates were 15.3 percent: take-back for vascular compromise, 7.8 percent; partial flap failure, 7.8 percent; and total flap loss, 5.4 percent. No differences were observed between the loupe and microscope groups regarding major complications (14.0 percent versus 16.1 percent; OR, 0.78; 95 percent CI, 0.38 to 1.59), take-back for vascular compromise (5.3 percent versus 9.4 percent; OR, 0.51; 95 percent CI, 0.19 to 1.39), any flap failure (13.3 percent versus 13.0 percent; OR, 1.21; 95 percent CI, 0.56 to 2.64), partial flap failure (7.3 percent versus 8.1 percent; OR, 1.04; 95 percent CI, 0.43 to 2.54), and total flap loss (6.0 percent versus 4.9 percent; OR, 1.63; 95 percent CI, 0.42 to 6.35). CONCLUSIONS:Perioperative complication rates, take-backs for vascular compromise, partial flap losses, and total flap failure rates were not significantly different between the matched loupe and microscope groups. Overall microsurgical success rates in traumatic lower extremity free flap reconstruction appear to be independent of the microsurgical technique used for visual magnification. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

BACKGROUND: The distal lower extremity poses unique reconstructive challenges due to its requirements for durability of the load-bearing plantar surface and for thin, pliable contour in the dorsal foot and ankle region. This study compares outcomes between muscle and fasciocutaneous flaps in patients with foot and ankle defects. METHODS: A retrospective review of soft tissue free flaps used for traumatic foot and ankle defects was performed. Outcomes included takebacks, partial flap failure, total flap failure, and wound complications. RESULTS: = 0.004). CONCLUSION/CONCLUSIONS: Compared with fasciocutaneous flaps, muscle flaps demonstrated higher rates of wound complications. While the flap selection in foot and ankle reconstruction depends on the nature of the defect, our findings support the use of fasciocutaneous over muscle flaps in this region.

BACKGROUND:Gustilo type IIIC open tibia fractures are characterized by an ischemic limb requiring immediate arterial repair. In this patient population, the decision between primary amputation and limb salvage can be challenging. This study aims to evaluate the reconstructive outcomes of patients with Gustilo type IIIC injuries. METHODS:A single-center retrospective review of 806 lower extremity free flaps from 1976 to 2016 was performed. Flap loss and salvage rates for patients with Gustilo type IIIC injuries were determined. To determine the utility of performing salvage in this group, outcomes of the IIIC reconstructions were compared to those of similar patients with Gustilo I type IIB injuries with only a single patent vessel. RESULTS:A total of 32 patients with Gustilo type IIIC injuries underwent reconstruction after traumatic injury. Ten patients (31.3 percent) experienced a perioperative complication, including seven unplanned returns to the operating room (21.9 percent), three partial flap losses (9.4 percent), and five complete flap losses (15.6 percent). When type IIIC injuries were compared with single-vessel Gustilo type IIIB injuries, no statistically significant differences were noted with respect to major perioperative complications (p = 0.527), unplanned return to the operating room (p = 0.06), partial flap loss (p = 0.209), complete flap loss (p = 0.596), or salvage rate (p = 0.368). Although this result was not statistically significant, Gustilo type IIIC injuries trended toward lower take-back rates and higher salvage rates compared with single-vessel Gustilo type IIIB injuries. CONCLUSION/CONCLUSIONS:Patients with Gustilo type IIIC open tibia fractures should be considered candidates for limb salvage, as flap loss and reconstruction of these injuries are comparable to those of the routinely reconstructed single-vessel runoff type IIIB injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.