Faculty Bibliography

Background: The reconstruction of major skull base, scalp and calvarial defects with microvascular free flaps has revolutionized the predictable and safe conduct of multidisciplinary oncologic surgery of this region. While extended resections can be more confidently completed, this has not necessarily been accompanied by increased local control or cure. This is due to limitations of radiation tolerance of surrounding tissues, necessary acceptance of involved microscopically close or involved margins, tolerable morbidity, and the lack of specific medical oncologic agents for benign and malignant CNS tumors. Use of coupler devices in routine head and neck defects evolved into use in skull base, calvarial, and intracranial settings where flap loss can be catastrophic.
Method(s): Mechanical microvascular anastomosis became increasingly widely used in head and neck reconstruction in the late 1980s and 1990s as a method to speed the process, and perhaps patency over hand-sewn anastomoses. These have been incorporated primarily in venous interposition graft and end-to-end, and end-to side venous configurations facilitated by vessel pliability and the ability to evert vessel walls over coupler pins. The coupler itself is constructed of 2 polyethylene rings and staggered ferromagnetic pins which match holes on the opposing ring through a friction fit, thus joining the vessels. Because of its construction, and the increased use and preference of MRI for perioperative evaluation early concern for heating and/or rotation, torquing or disruption of new anastomoses, it was studied in a relevant model and found in clinical experience, to be irrelevant.[1]
Conclusion(s): The use of the superficial temporal vessels for recipients is often preferred to save pedicle length, minimize the need for interposition vein grafts (doubling the number of anastomoses and thrombotic opportunity/risk), and often influenced by prior treatment (bicoronal flaps) in which ligation and scar may limit suitability. Additionally, the vein is often thin-walled and technically unusable. The incision for access to these vessels is usually placed immediately in the junctional creases of the ear and cheek, and thus several millimeters removed from the actual course of the vessels. In a broad and significant experience spanning 25 years including 40 skull base microvascular reconstructions, 15 of which used temporal recipient vessels, there have been 2 cases (one calvarial, one intracranial) where the coupler rings have eroded through the temporal skin, and self-ejected, without flap loss, and implying the acquisition of adequate venous supply to support flap survival. Given this observation, unique to this region, hand-sewn anastomoses are specifically recommended when using these vessels so as to minimize potentially catastrophic flap loss. Our experience in microvascular skull base reconstruction in this context is reviewed in support of this recommendation

BACKGROUND:Widespread adoption of bariatric surgery in the treatment of obesity has led to greater numbers of patients seeking panniculectomy, including aged patients, who represent a rapidly growing proportion of the U.S population. Although the quality of life and functional benefits of abdominal panniculectomy have been established, its safety in patients 65 years and older has not been evaluated. METHODS:The American College of Surgeons National Surgical Quality Improvements (ACS-NSQIP) database was used to identify patients undergoing panniculectomy between 2010 and 2015. Age 65 years and older was the risk factor of interest, and primary outcomes included 30-day wound complications, overall complications, reoperation, readmission, and mortality. Multivariate regression was performed to control for confounders. RESULTS:Review of the database identified 7030 patients who underwent abdominal panniculectomy. When stratified by age, 6455 (91.8%) of patients were younger than 65, and 575 (8.2%) were 65 or older. Multivariate regression analysis demonstrated that age over 65 was a significant independent risk factor for wound complications (OR = 1.81; 95% CI 1.35-2.42; p < 0.001) and all complications (OR = 1.46; 95% CI 1.15-1.87; p = 0.002). BMI, smoking, diabetes, and partial or total dependence were also identified as significant independent risk factors for wound and all complications. CONCLUSION/CONCLUSIONS:Our analysis demonstrates that advanced age is an independent risk factor for wound and overall complications following abdominal panniculectomy. These results highlight the importance of preoperative evaluation and optimization of modifiable preoperative risk factors as well as close postoperative follow-up for safe outcomes in patients 65 and older.

We retrospectively reviewed 201 digit replantations or revascularizations that were performed between August 2007 and June 2015. Leeching therapy was used in 48 digits and was more commonly required in replanted digits. In revascularized digits, leeching was used significantly more frequently in avulsion injuries and injuries associated with fractures. Digits that were leeched for more than 4.5 days had significantly higher rates of survival of digits after replantation or revascularization. Leeching was associated with higher incidence of transfusion, higher mean number of transfusions, and longer length of stay. We conclude from this study that leeching is used more frequently after digital replantation than revascularizaion, and in revascularized digits, leeching is used more often in avulsion injury and in patients with fractures. In patients requiring leeching therapy, leaching for more than 4.5 days leads to higher rate of digital survival. Level of evidence: IV.

Background/UNASSIGNED:Recurrent platysma bands remain a common problem in neck rejuvenation. Objectives/UNASSIGNED:The goals of this cadaver study were to document the course of the cervical branches of the facial nerve and investigate the pattern of platysma muscle innervation before and after various platysmaplasty maneuvers. Methods/UNASSIGNED:A total of 8 fresh cadaver specimens were dissected for a total of 16 hemifaces/necks. After subcutaneous undermining and identification of the main trunk of the facial nerve, the cervical branch was dissected as distally/anteriorly as possible under loupe magnification. The following 4 platysmaplasty maneuvers were each performed on 4 hemifaces/necks: platysma window, extended SMAS with platysma flap, full width platysma transection, and lateral skin-platysma displacement (LSD). Upon completion of the techniques, the integrity of the cervical branches was evaluated. Results/UNASSIGNED:Contrary to some reports, all specimens in this study had only 1 main cervical branch. There were no branches detectable under 3.2× magnification until branches were given off to the platysma muscle at approximately the location of the facial vessels. The main cervical branch continued distally/anteriorly to the medial edge of the muscle below the thyroid cartilage. After performing the various platysma techniques, all cervical branches were in continuity in all specimens. Specifically, the main cervical branch was in continuity to the medial border of the muscle caudal to all platysmaplasty maneuvers. Conclusion/UNASSIGNED:Undermining the platysma muscle results in no injury to platysmal innervation unless continued beyond the facial vessels. Recurrent bands are likely related to persistent innervation of the medial platysma, which remains intact cranial and caudal to any described platysmal transection maneuvers.