Faculty Bibliography

BACKGROUND: Traditional nonoperative management of stenosing tenosynovitis is limited to one corticosteroid injection, followed by surgery in the case of failure. Recently, nonoperative strategies have been extended to include two or three injections despite the absence of large prospective studies supporting this practice. METHODS: A prospective study was performed of all patients presenting with stenosing tenosynovitis to a single surgeon (R.S.R.) over a 22-year period. Patients with potentially confounding comorbidities were excluded. All digits received one to three injections of triamcinolone acetonide plus local anesthetic into the tendon sheath. Data were analyzed by digit. RESULTS: Five hundred seventy-one digits (401 patients) were included. Digits that were symptomatic for 3 months or less were more likely to resolve after one injection than those that were symptomatic for more than 3 months (OR, 2.6; 95 percent CI, 1.67 to 4.0; p < 0.01). For the digits that failed to resolve after the first injection, those that were symptomatic for 5 months or less before one injection were more likely to respond to a second injection than those that were symptomatic for more than 5 months (OR, 9.4; 95 percent CI, 3.0 to 29.7; p < 0.01). Eight digits received three injections, after which six (75 percent) achieved remission. There were no instances of tendon/pulley rupture, infection, or soft-tissue atrophy. CONCLUSIONS: Stenosing tenosynovitis is more likely to respond to nonoperative therapy when treated before 3 months. It is safe and effective to administer more than one corticosteroid injection, as second and third doses increase the overall remission rate without increasing morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

BACKGROUND: Autologous breast reconstruction has been shown to have fewer complications and superior outcomes. In the elderly patient population, a paucity of literature on the subject may render the surgeon reluctant to recommend or perform such a procedure. The objective of this study was to compare complications and satisfaction after abdominally based breast reconstruction in patients older than versus younger than 65 years. METHODS: A retrospective study was performed with data from 5 North American centers from 2002 to 2012. Patients who underwent autologous reconstruction were identified retrospectively, and chart review was performed. The BREAST-Q questionnaire was sent to these patients via mail. Patient variables, operative outcomes and BREASTQ results were analyzed. The Pearson chi and analysis of variance tests were used. Given the number of analyses, a more conservative alpha of 0.01 was used for each comparison. RESULTS: A total of 1809 patients were included with 1751 patients younger than 65 years and 58 patients aged 65 years or older. Analysis of postoperative complications showed no significant differences between the age groups, though there was a trend toward higher seroma development (17.2% vs 8.1%; P = 0.013) and infection (19.0% vs 10.0%; P = 0.028) in the older group with statistical significance set at P less than 0.01 to account for multiple comparisons. A total of 1809 BREAST-Q surveys were sent with a response rate of 52.5%. Patient satisfaction results were equally high between the 2 age groups. CONCLUSIONS: This is the largest study to compare patients undergoing autologous breast reconstruction older than and younger than 65 years within the same cohort. Women older than 65 years represent a minority and constituted only 3% of patients in this multicenter 10-year review. We have shown that with careful patient selection, abdominally based autologous reconstruction should be considered in the elderly patient population because it is well tolerated and achieves high patient satisfaction.

BACKGROUND:Current data addressing the role of robotic surgery for the management of colorectal disease are primarily from single-institution and case-matched comparative studies as well as administrative database analyses. The purpose of this study was to compare minimally invasive surgery outcomes using a large regional protocol-driven database devoted to surgical quality, improvement in patient outcomes, and cost-effectiveness. METHODS:This is a retrospective cohort study from the prospectively collected Michigan Surgical Quality Collaborative registry designed to compare outcomes of patients who underwent elective laparoscopic, hand-assisted laparoscopic, and robotic colon and rectal operations between July 1, 2012 and October 7, 2014. We adjusted for differences in baseline covariates between cases with different surgical approaches using propensity score quintiles modeled on patient demographics, general health factors, diagnosis, and preoperative co-morbidities. The primary outcomes were conversion rates and hospital length of stay. Secondary outcomes included operative time, and postoperative morbidity and mortality. RESULTS:A total of 2735 minimally invasive colorectal operations met inclusion criteria. Conversion rates were lower with robotic as compared to laparoscopic operations, and this was statistically significant for rectal resections (colon 9.0 vs. 16.9%, p < 0.06; rectum 7.8 vs. 21.2%, p < 0.001). The adjusted length of stay for robotic colon operations (4.00 days, 95% CI 3.63-4.40) was significantly shorter compared to laparoscopic (4.41 days, 95% CI 4.17-4.66; p = 0.04) and hand-assisted laparoscopic cases (4.44 days, 95% CI 4.13-4.78; p = 0.008). There were no significant differences in overall postoperative complications among groups. CONCLUSIONS:When compared to conventional laparoscopy, the robotic platform is associated with significantly fewer conversions to open for rectal operations, and significantly shorter length of hospital stay for colon operations, without increasing overall postoperative morbidity. These findings and the recent upgrades in minimally invasive technology warrant continued evaluation of the role of the robotic platform in colorectal surgery.

Surface topography modifications have become a key strategy for hastening the host-to-implant response to implantable materials. The present study evaluated the effect of three different carefully controlled surface texture patterns achieved through microrobotized blasting (controlled to high, medium and low roughness) relative to a larger scale blasting procedure (control) in early osseointegration in a canine model. Four commercially pure grade 2 titanium alloy implants (one of each surface) were bilaterally placed in the radii of six beagle dogs and allowed end points of 1 and 6 weeks in vivo. Following sacrifice, implants in bone were non-decalcified processed for bone morphologic and histometric (bone-to-implant contact; bone area fraction occupancy) evaluation. Surface topography was characterized by scanning electron microscopy and optical interferometry. Results showed initial osteogenic tissue interaction at one week and new bone in intimate contact with all implant surfaces at 6 weeks. At 1 and 6 weeks in vivo, higher bone-to-implant and bone area fraction occupancy were observed for the high texture pattern microrobotized blasted surface relative to others.

BACKGROUND: This article presents a real-time surgical simulator for teaching three- dimensional local flap concepts. Mass-spring based simulators are interactive, but they compromise accuracy and realism. Accurate finite element approaches have traditionally been too slow to permit development of a real-time simulator. METHODS: A new computational formulation of the finite element method has been applied to a simulated surgical environment. The surgical operators of retraction, incision, excision, and suturing are provided for three-dimensional operation on skin sheets and scalp flaps. A history mechanism records a user's surgical sequence. Numerical simulation was accomplished by a single small-form-factor computer attached to eight inexpensive Web-based terminals at a total cost of $2100. A local flaps workshop was held for the plastic surgery residents at the University of Wisconsin hospitals. RESULTS: Various flap designs of Z-plasty, rotation, rhomboid flaps, S-plasty, and related techniques were demonstrated in three dimensions. Angle and incision segment length alteration advantages were demonstrated (e.g., opening the angle of a Z-plasty in a three-dimensional web contracture). These principles were then combined in a scalp flap model demonstrating rotation flaps, dual S-plasty, and the Dufourmentel Mouly quad rhomboid flap procedure to demonstrate optimal distribution of secondary defect closure stresses. CONCLUSIONS: A preliminary skin flap simulator has been demonstrated to be an effective teaching platform for the real-time elucidation of local flap principles. Future work will involve adaptation of the system to facial flaps, breast surgery, cleft lip, and other problems in plastic surgery as well as surgery in general.

Immune suppression following major thermal injury directly impacts the recovery potential. Limited data from past reports indicate that natural killer cells might be suppressed due to a putative soluble factor that has remained elusive up to date. Here we comparatively study cohorts of patients with Major and Non-Major Burns as well as healthy donors. MICB and ULBP1 are stress ligands of NKG2D that can be induced by heat stress. Remarkably, serum concentration levels of MICB and ULBP1 are increased by 3-fold and 20-fold, respectively, already within 24h post major thermal injury, and are maintained high for 28 days. In contrast, milder thermal injuries do not similarly enhance the serum levels of MICB and ULBP1. This kinetics coincides with a significant downregulation of NKG2D expression among peripheral blood NK cells. Downregulation of NKG2D by high concentration of soluble MICB occurs in cancer patients and during normal pregnancy due to over production by cancer cells or extravillous trophoblasts, respectively, as an active immune-evasion mechanism. In burn patients this seems an incidental outcome of extensive thermal injury, leading to reduced NKG2D expression. Enhanced susceptibility of these patients to opportunistic viral infections, particularly herpes viruses, could be explained by the reduced NKG2D expression. Further studies are warranted for translation into innovative diagnostic or therapeutic technologies.

Ionizing radiation is a common therapeutic modality and following irradiation dermal changes, including fibrosis and atrophy, may lead to permanent changes. We have previously demonstrated that occupancy of A2A receptor (A2AR) stimulates collagen production, so we determined whether blockade or deletion of A2AR could prevent radiation-induced fibrosis. After targeted irradiation (40 Gy) of the skin of wild-type (WT) or A2AR knockout (A2ARKO) mice, the A2AR antagonist ZM241385 was applied daily for 28 d. In irradiated WT mice treated with the A2AR antagonist, there was a marked reduction in collagen content and skin thickness, and ZM241385 treatment reduced the number of myofibroblasts and angiogenesis. After irradiation, there is an increase in loosely packed collagen fibrils, which is significantly diminished by ZM241385. Irradiation also induced an increase in epidermal thickness, prevented by ZM241385, by increasing the number of proliferating keratinocytes. Similarly, in A2ARKO mice, the changes in collagen alignment, skin thickness, myofibroblast content, angiogenesis, and epidermal hyperplasia were markedly reduced following irradiation. Radiation-induced changes in the dermis and epidermis were accompanied by an infiltrate of T cells, which was prevented in both ZM241385-treated and A2ARKO mice. Radiation therapy is administered to a significant number of patients with cancer, and radiation reactions may limit this therapeutic modality. Our findings suggest that topical application of an A2AR antagonist prevents radiation dermatitis and may be useful in the prevention or amelioration of radiation changes in the skin.-Perez-Aso, M., Mediero, A., Low, Y. C., Levine, J., Cronstein, B. N. Adenosine A2A receptor plays an important role in radiation-induced dermal injury.

INTRODUCTION: Long-term oncologic outcomes in nipple-sparing mastectomy (NSM) continue to be defined. Rates of locoregional recurrence for skin-sparing mastectomy (SSM) and NSM in the literature range from 0% to 14.3%. We investigated the outcomes of NSM at our institution. METHODS: Patients undergoing NSM at our institution from 2006 to 2014 were identified and outcomes were analyzed. RESULTS: From 2006 to 2014, 319 patients (555 breasts) underwent NSM. One-hundered and fourty-one patients (237 breasts) had long-term follow-up available. Average patient age and BMI were 47.78 and 24.63. Eighty-four percent of patients underwent mastectomy primarily for a therapeutic indication. Average tumor size was 1.50 cm with the most common histologic type being invasive ductal carcinoma (62.7%) followed by DCIS (23.7%). Average patient follow-up was 30.73 months. There was one (0.8%) incidence of ipsilateral chest-wall recurrence. There were 0.37 complications per patient. CONCLUSIONS: We examined our institutional outcomes with NSM and found a locoregional recurrence rate of 0.8% with no nipple-areolar complex recurrence. This rate is lower than published rates for both NSM and SSM. J. Surg. Oncol. (c) 2015 Wiley Periodicals, Inc.

BACKGROUND AND AIM: The increased media attention to shark attacks has led to a heightened fear and public awareness. Although few sharks are considered dangerous, attacks on humans can result in large soft tissue defects necessitating the intervention of reconstructive surgeons. This study aims to evaluate and describe the characteristics of shark-related injuries in order to improve treatment. METHODS: The Global Shark Accident File, maintained by the Shark Research Institute (Princeton, NJ, USA), is a compilation of all known worldwide shark attacks. Database records since the 1900s were reviewed to identify differences between fatal and nonfatal attacks, including: geography, injury pattern, shark species, and victim activity. RESULTS: Since the 1900s, there have been 5034 reported shark attacks, of which 1205 (22.7%) were fatal. Although the incidence of attacks per decade has increased, the percentage of fatalities has decreased. Characteristics of fatal attacks included swimming (p = 0.001), boating (p = 0.001), three or more bite sites (p = 0.03), limb loss (p = 0.001), or tiger shark attack (p = 0.002). The most common attacks were bites to the legs (41.8%) or arms (18.4%), with limb loss occurring in 7% of attacks. Geographically, the majority of attacks occurred in North America (36.7%) and Australia (26.5%). Most attacks in the USA occurred in Florida (49.1%) and California (13.6%). CONCLUSIONS: Although rare, shark attacks result in devastating injuries to patients. As these injuries often involve multiple sites and limb loss, this creates a significant challenge for reconstructive surgeons. Proper identification of the characteristics of the attack can aid in providing optimal care for those affected.