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An oncoplastic breast reduction may disrupt normal lymphatic drainage and make subsequent identification of the sentinel lymph nodes (SLNs) unreliable. There are little data on the success rate of sentinel lymph node biopsy (SLNB) after recent oncoplastic breast reduction, and there is no agreement on whether SLNB should be done at the time of the partial mastectomy and reduction for ductal carcinoma in situ (DCIS). The primary goals of this study were to evaluate the identification rate of SLNB after recent oncoplastic or functional breast reduction and to examine recurrence rates in this setting. Results reveal SLNB is feasible in this setting. At least one SLN was found in all patients, and there were no recurrences with an average follow-up of 34 months.

Background:. The AeroForm System, a needle-free, patient-controlled carbon dioxide-filled tissue expander, represents a novel option for tissue expansion in 2-stage breast reconstruction. This technology has previously been found to decrease time to expansion, health-care utilization, and infection rates. The purpose of this study was to determine the economic impact of the reduced infection rate observed with the AeroForm tissue expander as compared with saline tissue expansion. Methods:. A decision model incorporating costs, quality-adjusted life years, and clinical outcomes of infection was designed to evaluate the cost-efficacy of AeroForm tissue expanders versus conventional saline expanders. All statistical calculations were performed in the R statistical computing environment. Results:. Pooled infection rates from the published literature following saline and AeroForm tissue expander placement were 5.83% and 2.62%, respectively. Cost-utility analysis resulted in a baseline expected savings of $253.29 and an expected gain of 0.00122 quality-adjusted life years with AeroForm tissue expanders. One-way sensitivity analysis revealed that AeroForm tissue expanders were dominant when the surgical site infection rate was greater than 4.56% with traditional saline expanders. Conclusions:. Clinical benefits of an innovation are no longer sufficient to justify its acquisition costs. Novel technologies must also demonstrate favorable economic outcomes. This cost-utility analysis demonstrates that the use of AeroForm expanders is likely a cost-saving technology for 2-stage breast reconstruction.

Background:. The AeroForm tissue expander is a carbon dioxide-filled breast tissue expander that allows gradual, needle-free expansion using a hand-held remote controller. This study evaluates 2-stage, prepectoral tissue expander-to-implant breast reconstruction with the carbon-dioxide tissue expanders and compares the outcomes to our recent experience with saline tissue expanders. Methods:. This was a retrospective study of consecutive patients from a single institution. The subjects consisted of women who underwent mastectomy and either immediate or delayed breast reconstruction with AeroForm or saline tissue expanders. Outcomes encompassed postoperative complications including mastectomy flap necrosis, infection requiring readmission and/or intravenous antibiotics, capsular contracture, hematoma, seroma, skin dehiscence, extrusion, premature explant, and loss of communication with the device (AeroForm) or rupture of the device (saline). Results:. This study evaluated 115 patients with 185 breast reconstructions. Of the 185 breast reconstructions, 74 (40%) utilized AeroForm tissue expanders and 111 (60%) utilized traditional saline tissue expanders. Treatment was successful in 100% and 94% in the AeroForm and saline groups, respectively (P = 0.025). The incidence of adverse events was greater in the saline group (45.9% versus 32.4%). Surgical-site infection occurred more commonly in the saline group (5.4% versus 0%). Full-thickness skin necrosis occurred at a significantly higher rate in the saline cohort as compared with AeroForm (5.4% versus 0%). Conclusions:. The use of AeroForm tissue expanders offers notable advantages for breast reconstruction. This device when employed in the prepectoral space may be associated with reduced infection rates and decreased utilization of healthcare and patient resources.

Full-thickness defects of the chest wall are managed based on the principle of restoring structure and function. Characteristics of the lesion, such as size, location and etiology, as well as its resultant effects on pulmonary mechanics govern the surgical approach to reconstruction. Defects of intermediate size, however, occupy a gray area in thoracic wall reconstruction, with no clear consensus on management. The authors describe a novel method of providing bony coverage for a moderate-size thoracic wall defect in a patient with a complex intrathoracic, extrapleural hernia by crossing osteotomies in addition to transposition and fixation of ribs. Osseous rib Z-plasty is a novel surgical technique that may be considered to be a valid alternative for reconstruction of selected moderate-size, full-thickness defects of the lateral rib cage. Knowledge of this technique is recommended for thoracic, trauma and plastic surgeons who are likely to encounter and manage such defects.

Nipple-sparing mastectomy (NSM) is more technically challenging than skin-sparing mastectomy (SSM) but offers quality-of-life and cosmetic advantages. However, surgeon physical symptoms related to NSM workload have not been documented. This was a prospective study using questionnaires to compare surgeon-reported physical symptoms before, during, and after NSM versus SSM. Surgeons also answered general questions about each mastectomy. Bilateral cases were performed simultaneously by two surgeons, who completed independent questionnaires. Questionnaires were completed after 82 SSMs and 44 NSMs. On a 0–10 scale, surgeons reported NSM was more physically demanding than SSM (7.0 vs. 4.5, p

About 5%-11% of all abdominal surgery results in incisional hernia. This rate can be even higher among high-risk populations such as transplant patients. Lifetime incidence of incisional hernia following liver transplant is as high as 43% in recent studies. The transplant population is at higher risk for incisional hernia precisely because of their immunosuppressive therapy. Thus, it is imperative to understand the risk factors for incisional hernia in this unique patient population. This article focuses on understanding preoperative, intraoperative, and postoperative risk factors for failure of hernia repair in the transplant population in addition to discussing risk stratification for incisional hernia in this population. Furthermore, we discuss the utility of panniculectomy in abdominal organ transplantation. Additionally, we discuss the value of mesh placement in abdominal wall closure. Finally, we review the concept of vascularized composite allograft as a method for achieving abdominal wall closure for patients who have failed more traditional repairs and who are left with inadequate tissue for successful repair.

Improvements in surgical techniques have allowed us to achieve primary closure in a high percentage of large abdominal hernia repairs. However, postoperative wound complications remain common. The benefits of negative-pressure wound therapy (NPWT) in the management of open abdominal wounds are well described in the literature. Our study investigates the effects of incisional NPWT after primary closure of the abdominal wall.A retrospective chart review was performed for the period between September 2008 and May 2011 to analyze the outcomes of patients treated postoperatively with incisional NPWT versus conventional dry gauze dressings. Patient information collected included history of abdominal surgeries, smoking status, and body mass index. Postoperative complications were analyzed using χ exact test and logistic regression analysis.Fifty-six patients were included in this study; of them, 23 were treated with incisional NPWT, whereas 33 received conventional dressings. The rates of overall wound complications in groups I and II were 22% and 63.6%, respectively (P = 0.020). The rates of skin dehiscence were 9% and 39%, respectively (P = 0.014). Both outcomes achieved statistical significance. Rates of infection, skin and fat necrosis, seroma, and hernia recurrence were 4%, 9%, 0%, and 4% for group I and 6%, 18%, 12%, 9% for group II, respectively.This study suggests that incisional NPWT following abdominal wall reconstruction significantly improves rates of wound complication and skin dehiscence when compared with conventional dressings. Prospective, randomized, controlled studies are needed to further characterize the potential benefits of this therapy on wound healing after abdominal wall reconstruction.

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.

Background We compared the efficacy of pectoralis turnover versus advancement technique for sternal wound reconstruction. Methods A retrospective chart review was performed, December 1989 to December 2010, to compare postoperative complication rates between pectoralis major turnover versus pectoralis major advancement reconstruction techniques. Complications included hematomas, wound infections, tissue necrosis, dehiscence, and need for reoperation. Pearson χ and logistic regression were used and significance was P Results Sixty-seven patients received 91 tissue flaps. Eleven patients (16%) required reoperation due to complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Four patients (6%) were treated conservatively for minor complications. Overall, complication rates were significantly higher after pectoralis major advancement reconstruction (32.5% vs. 3.7%, P = 0.004). Conclusions When feasible, pectoralis major turnover flap offers a superior reconstructive technique for complex sternal wounds, with diminished complications compared with the pectoralis advancement flap.

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.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.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.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.

The current indications for reduction mammoplasty include the relief of painful physical symptoms of macromastia. Numerous studies have demonstrated not only improvement in physical symptoms following reduction mammoplasty, but postoperative psychological benefits as well, including increased ability to participate in physical activity as a result of pain relief and decreased breast mass. Reduction mammoplasty may have additional effects on the patient's ability to breast-feed and perform breast self-exam. The present study is a retrospective study of the effects of reduction mammoplasty on breast-feeding, breast self-exam, physical symptoms, and physical activity. One-hundred and forty-one patients who underwent reduction mammoplasty at our institution between the years 1996-2005 agreed to participate in the study. Each was asked a series of questions in order to assess changes in symptoms and behaviors including breast-feeding and breast self-exam practices before and after the surgery. Patients were also asked questions regarding their pain symptoms and physical activity profiles. Ninety-seven percent of the participants claimed to have back, neck, and/or shoulder pain that was either significantly improved or completely resolved. Moreover, 100% of patients report that physical activity such as exercise was easier following reduction mammoplasty. Ninety-three percent of participants reported that performing breast self-exam following surgery was either the same (68%) or easier (25%) as a result of having less breast tissue. Eighty-nine percent of participants had no children following surgery, therefore effects on breast-feeding practices following reduction mammoplasty were not statistically significant. However, we suggest that when patients are seen in consultation or in the perioperative period, there is an opportunity to teach patients about the benefits of breast-feeding, and to assure patients that a pedicle flap reduction will likely allow breastfeeding. This is also a chance for physicians to teach patients how to perform breast self-examination and explain the importance of early breast mass detection.

Complex abdominal wall reconstruction is beset by postoperative complications. A recent meta-analysis comparing the use of closed-incision negative-pressure therapy to standard dressings found a statistically significant reduction in surgical-site infection. The use of closed-incision negative-pressure therapy is gaining acceptance in this population; however, the economic impact of this innovative dressing remains unknown. In this study, a cost-utility analysis was performed assessing closed-incision negative-pressure therapy and standard dressings following closure of abdominal incisions in high-risk patients.Cost-utility methodology involved reviewing literature related to closed-incision negative-pressure therapy in abdominal wall surgery, obtaining utility estimates to calculate quality-adjusted life-year scores for successful surgery and surgery complicated by surgical-site infection, summing costs using Medicare Current Procedural Terminology codes, and creating a decision tree illuminating the most cost-effective dressing strategy. One-way sensitivity analysis was performed to assess the robustness of the results.The aforementioned meta-analysis comparing closed-incision negative-pressure therapy to standard dressings included a subset of five studies assessing abdominal wall surgery in 829 patients (260 closed-incision negative-pressure therapy and 569 standard dressings). Decision tree analysis revealed an estimated savings of $1546.52 and a gain of 0.0024 quality-adjusted life-year with closed-incision negative-pressure therapy compared with standard dressings; therefore, closed-incision negative-pressure therapy is a dominant treatment strategy. One-way sensitivity analysis revealed that closed-incision negative-pressure therapy is a cost-effective option when the surgical-site infection rate is greater than 16.39 percent.The use of closed-incision negative-pressure therapy is cost-saving following closure of abdominal incisions in high-risk patients.

Synthetic mesh is used for chest wall reconstruction, but infection or exposure can occur and necessitate removal. Human acellular dermal matrix (AlloDerm) has been used to reconstruct musculofascial defects in the trunk with low infection and herniation rates. AlloDerm may have advantages over synthetic mesh for chest wall reconstruction. This study compared outcomes and repair strengths of AlloDerm to expanded polytetrafluoroethylene mesh used for repair of rib cage defects.A 3 x 3-cm, full-thickness, lateral rib cage defect was created in each rabbit and repaired with expanded polytetrafluoroethylene (n = 8) or acellular dermal matrix (n = 9). At 4 weeks, the animals were euthanized and evaluated for lung herniation/dehiscence, strength of adhesions between the implant and intrapleural structures, and breaking strength of the implant materials and the implant-fascia interface. Tissue sections were analyzed with histologic and immunohistochemical staining to evaluate cellular infiltration and vascularization.No herniation or dehiscence occurred with either material. The incidence and strength of adhesions was similar between materials. The mean breaking strength of the AlloDerm-fascia interface (14.5 +/- 8.9 N) was greater than the expanded polytetrafluoroethylene-fascia interface (8.7 +/- 4.4 N; p = 0.027) and similar to the rib-intercostal-rib interface of the contralateral native chest wall (14.0 +/- 5.6 N). The AlloDerm grafts became infiltrated with cells and vascularized after implantation.AlloDerm used for chest wall reconstruction results in greater implant-defect interface strength than expanded polytetrafluoroethylene. The ability of AlloDerm to become vascularized and remodeled by autologous cells and to resist infection may be advantageous for chest wall reconstruction.

Biological alternatives to synthetic meshes are increasingly utilised in complex abdominal wall reconstruction. There is a lack of evidence demonstrating that non‐cross‐linked porcine acellular dermal matrix vascularizes and integrates with human tissue in suboptimal wound conditions. We aimed to evaluate these properties in Strattice™ (Life Cell Inc., Branchburg, NJ) following ventral hernia repair. A retrospective review of patients with high‐risk ventral hernia repair utilising Strattice™ as an onlay after open component separation was conducted. Patients with postoperative wound exploration and exposure of the onlay were included in this review. One patient underwent punch biopsy for histological analysis. Eleven patients with wound complications necessitating postoperative debridement and exposure of Strattice™ onlay were identified. The onlay was partially debrided in two cases, and one case required complete excision. Vascularisation was clinically evident in 10 of 11 cases (91%) as demonstrated by the presence of granulation tissue and/or the ability to support a skin graft. Histological analysis of one onlay 3 months postoperatively showed neovascularisation and collagen remodelling with minimal inflammatory response. Strattice™ demonstrated resistance to rejection, ability to undergo vascularisation and incorporation into host tissues in sub‐optimal wound conditions following ventral hernia repair.

Seroma formation is common following mastectomy and autologous breast reconstruction and is a potential cause of significant morbidity in patients. For this reason, many methods have been investigated to prevent this complication. BD Cell-Tak is a tissue adhesive formulated from the proteins excreted by the marine mussel Mytilus edulis. The purpose of this study was to determine if Cell-Tak is able to prevent seroma formation in a rat mastectomy seroma model. Twenty Sprague-Dawley rats underwent unilateral radical mastectomy, partial axillary lymph node dissection, and disruption of the dermal lymphatics. The animals were randomly assigned to either control (n = 10) or experimental groups (n = 10). The experimental animals received 0.3 ml of the topical adhesive in the wound prior to closure, whereas control animals received no treatment. On postoperative day 7, seroma collections were aspirated and quantified and the tissue flaps were sent for histologic analysis. The control rats had a mean seroma volume of 5.3 +/- 2.6 ml, whereas the rats treated with Cell-Tak tissue adhesive had a mean seroma volume of 1.8 +/- 1.5 ml (p < 0.004). Histologic analysis revealed mild inflammation consistent with postoperative changes in both groups and no evidence of foreign body reaction to the adhesive. BD Cell-Tak tissue adhesive significantly reduces seroma formation in the rat mastectomy model. This tissue adhesive may prove beneficial in patients undergoing mastectomy with or without breast reconstruction.

Background: This cadaver study investigates the efficacy and safety of the Biomet knife and technique for percutaneous Al pulley release. We also evaluate the anatomic relationship between specific palmar surface landmarks and relevant underlying structures and identify differences between genders. Methods: Eighty percutaneous Al pulley releases, excluding the thumb, were performed on 20 fresh human cadaver hands (10 male, 10 female). Results: Complete release was obtained in 60 of 80 fingers. Success rates for each surgeon improved markedly as the study progressed. There were no significant differences between males and females regarding the distance between a standardized incision site and the proximal edge of the Al pulley. Conclusions: A learning curve exists for percutaneous Al pulley release using the Biomet knife and technique. The extended distal palmar crease is a reasonable incision site for percutaneous release of the index, middle, and ring Al pulleys in both men and women as the Al pulley begins just distal to this surface landmark.

Reconstructed nipples rapidly lose projection. We describe the use of human acellular dermal matrix (ADM) to improve long-term projection of nipple flaps. Athymic rats were randomized to 3 groups; each received 2 nipples: bell flap (control, n = 16 nipples), bell flap with a cylinder of implanted ADM (n = 24), or bell flap with intraflap injection of micronized ADM (MADM) (n = 10). Seven of 24 ADM nipples extruded (30%). By 12 weeks, the control nipples maintained 44% of initial projection compared with 70% for ADM nipples (P = 0.000025). The MADM nipples maintained 49% of initial projection after 12 weeks (P = 0.55 compared with control). No MADM nipples extruded. ADM grafts maintain long-term projection better than local tissue flaps alone. We hypothesize that MADM may limit extrusion and allow for serial injection of nipples. Based on the promising results of this study, clinical trials are warranted using human ADM and/or human MADM for nipple reconstruction.

Microsurgeons currently employ the internal mammary artery and vein as recipient vessels for microvascular reconstruction of the breast with increasing frequency. Recent reports have demonstrated that the perforating branches of the internal mammary artery and vein can also be used as recipient vessels. The purpose of the following cadaver study was to determine the location and diameter of these internal mammary perforators and whether they are suitable as recipient vessels. Ten fresh cadavers were obtained for this project. Using a micrometer under loupe magnification, bilateral measurements were taken of the perforators from the first five interspaces. The largest arterial perforator averaged 1.74 mm in diameter and the largest venous perforator averaged 1.78 mm in diameter. The largest perforators were most commonly found in the second interspace. Based on the results of this study, the internal mammary perforators appear to have suitable diameter for microvascular anastomosis and should be considered.

This article presents the first known case of pneumorrhachis (spinal air), pneumomediastinum, pneumopericardium, pneumoretroperitoneum, and subcutaneous emphysema after proctocolectomy for ulcerative colitis. We review the patient's medical history, clinical and laboratory findings, radiographic data, and operative records, as well as the relevant literature. We describe the case of a young male with ulcerative colitis who developed pneumorrhachis, subcutaneous emphysema, pneumoretroperitoneum, pneumomediastinum, and pneumopericardium after a proctocolectomy with ileal pouch-anal anastomosis. Unlike the case we report, previously described episodes of pneumomediastinum and subcutaneous emphysema in patients with ulcerative colitis developed before operative intervention. We offer possible explanations for these unusual complications based on analysis of this case and thorough review of the literature.

Surgical manipulation of the groin can lead to persistent lymphorrhea or lymphoceles with a reported incidence of 1.8%–18.9%.1 The wound complications associated with such leaks lymphatic leak can lead to prolonged hospital stays, additional operations, and increased healthcare costs for the patient and society.2 Initial management with pressure dressings and immobilization can progress to include aspiration, drain placement, sclerosant, radiotherapy, negative pressure wound therapy, lymphovenous anastomosis, surgical tissue transfer, and exploration with lymphatic ligation.2–5 Up to half of all patients with lymphatic leak develop an associated infection which can be catastrophic in the setting of a vascular graft.4 Vital dyes, such as isosulfan blue (Lymphazurin, Tyco Healthcare, Norwalk, Conn.), are commonly used for intraoperative identification of lymphatic leaks, thereby reducing time to resolution, complications, and need for reoperation.6 Indocyanine green (ICG) imaging is an emerging modality for lymphatic vessel visualization. We report the utility of laser-assisted ICG lymphography for intraoperative identification of lymphatic leaks presenting after surgical groin manipulation.

Background. Components separation has been proposed as a means to close large ventral hernia without undue tension. We report a modification on open components separation that allows for the incorporation of onlaid noncrosslinked porcine acellular dermal matrix (Strattice, LifeCell Corp, Branchburg, NJ) as a load-sharing structure. Methods. This was a retrospective case series including all cases using Strattice from July 2008 through December 2009. Data evaluated included patient demographics, comorbidities associated with risk of recurrence, hernia grade, and postoperative complications. The primary outcomes were hernia recurrence and surgical site occurrences. Results. There were 58 patients; 60.8% presented with a recurrent incisional hernia. Average length of follow-up was 384 days. There were 4 hernia recurrences (7.9%). Complications included surgical site infection (20.7%), seroma (15.5%), and hematoma (5%) requiring intervention. Four deaths occurred in the series due to causes unrelated to the hernia repair, only 1 within 30 days of operation. Conclusions. This series demonstrates that components separation reinforced with noncrosslinked porcine acellular dermal matrix onlay is an efficacious, single-stage repair with a low rate of recurrence and surgical site occurrences.

Massive localized lymphedema (MLL) is a rising and potentially fatal complication of the obesity epidemic. Described as a benign lymphoproliferative overgrowth of obese patients, MLL is a form of secondary lymphedema, caused by the obstruction of lymphatic flow, with characteristic clinical and histological presentation. Patients have a large mass with classic skin changes often accompanied by lymphatic weeping that require complex reconstruction. Although oftentimes benign, if left untreated, MLL can progress to angiosarcoma, further supporting the need for more research into MLL and its sequelae. We present a unique case of MLL of the mons pubis in a 52-year-old man with a body mass index of 75.7 kg/m. The literature was comprehensively reviewed with a total of 65 cases of MLL being described, 9 of which resulted in angiosarcoma (10.3% of all cases), 6 of which resulted in death (9.2% of all cases). We found a female predominance of 1.24 to 1, an average weight of 183 kg, and a 48.5% majority of cases in the thigh.

Objective: Phosphodiesterase-5 inhibitors, used to increase penile blood flow in erectile dysfunction patients, have recently been postulated to increase blood flow and flap survival in cutaneous flaps based on random blood supply. This study aims to investigate the phosphodiesterase-5 inhibitor tadalafil, administered orally, on random flap survival. Methods: Modified McFarlane flaps measuring 8 cm × 2.5 cm were raised on the backs of 37 male Sprague-Dawley rats. Rats received were divided into a control group, a low-dose group (10 mg/kg tadalafil), and a high-dose group (20 mg/kg tadalafil). Treatment doses were administered once preoperatively and every 24 hours postoperatively for a total of 7 doses. On postoperative day 7 and 14, the area of flap survival was calculated and compared. Results: All rats survived and thrived throughout the experimental period. Control group rats showed an average flap survival of 77% ± 11% at 7 days and 77% ± 9% at 14 days. Low-dose-group rats showed an average flap survival of 82% ± 10% at 7 days (P=0.21), and 81% ± 12% at 14 days (P=0.41). High-dose group rats showed an average flap survival of 81% ± 11% at 7 days (P = 0.45) and 80% ± 12% at 14 days (P = 0.53). Statistical analysis was performed using the Mann-Whitney test. Conclusions: Our results indicate a trend toward increased random-pattern flap survival with both high- and low-dose oral tadalafil in a rat model. Because this trend did not achieve statistical significance, further studies are warranted.

Millions of patients require implantable cardiac devices for management of cardiac dysrhythmias. These devices are susceptible to erosion, exposure, or infection and plastic surgeons are consulted when salvage is required. As of yet, an anterior muscle-splitting approach to effectively and safely relocate the device into the subpectoral position has not been described in the plastic surgery literature. The authors retrospectively reviewed the charts of 7 patients who required repositioning of cardiac devices. Indications for repositioning included exposure, erosion, infection, hematoma at the time of primary placement (3), and one cosmetic revision. All patients were treated with subpectoral repositioning of the device into the subpectoral space via an anterior muscle-splitting approach. Six of 7 patients (86%) achieved successful long-term repositioning in the subpectoral position without recurrent exposure or hematoma and with good cosmetic results. One patient who had a prior history of multiple failed device placements required reoperation due to recurrent infection. The anterior muscle-splitting technique proposed by the authors for defibrillator or pacemaker salvage is a feasible technique with promising results. Plastic surgeons should be aware of this simple and effective approach.

BACKGROUND We sought to identify patient comorbidities that predict complications after tissue flap sternal reconstruction. METHODS A retrospective study, December 1989 to December 2010, analyzed numerous comorbidities, including diabetes mellitus (DM), hypertension (HTN), coronary artery disease, congestive heart failure (CHF), and renal insufficiency, as independent risk factors for postoperative complications. Pearson χ2 test, Fisher exact test, 2-sample t test, and median-unbiased estimation were used for data analysis. Significance was P≤0.05. RESULTS In all, 106 patients received 161 sternal tissue flap repairs. Nineteen patients (18%) required reoperation because of complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Our analysis found DM, HTN, and CHF as significant predictors of complications after sternal reconstruction (P=0.014, 0.012, and 0.006). CONCLUSIONS Results suggest DM, HTN, and CHF may contribute to complications after tissue flap repair of sternal wounds, possibly through impaired perfusion and healing of repairs.

Implant infection is a common clinical complication of abdominal hernia repair. Our objectives were to determine if acellular dermal matrix (ADM) grafts resisted Staphylococcus aureus infection better (as measured by ability to reduce or clear bacterial counts) than synthetic (polytetrafluoroethylene [PTFE]) mesh when used in abdominal wall reconstruction, and to determine whether vascularization of the implant occurred. We hypothesized that the ability of the ADM grafts to vascularize and allow cellular ingrowth would allow the immune system to clear the infection better in these animals.In New Zealand White rabbits (average weight, 3.0 kg), a full-thickness 3 x 3 cm(2) abdominal defect was created, then repaired with an interpositional implant (ADM, n = 62; PTFE, n = 57). Before skin closure, the epidermal surface of each implant was inoculated with 1 mL of S. aureus at various concentrations (10(4) colony-forming units [CFU]/mL, n = 82; 10(6) CFU/mL, n = 27; 10(9) CFU/mL, n = 10), and the rabbits were harvested at either day 7 or day 21.At day 7, ADM grafts inoculated with 10(4) CFU had lower counts or no bacteria (p = 0.006), fewer adhesions (p = 0.005), and fewer abscesses (p = 0.008) than PTFE grafts. By day 21, more ADM (n = 12) than PTFE (n = 0) grafts were free of bacteria (p = 0.002). Fewer rabbits with ADM grafts formed abscesses (13 vs. 19; p = 0.03). When evaluating the 7- and 21-day 10(4) CFU groups combined, a total of 15 rabbits with ADM cleared the bacteria completely vs. none of those with PTFE grafts (p0.001). There was no significant difference in bacterial counts or wound complications at days 7 or 21 between PTFE and ADM implants when inoculated with 10(6) CFU. All rabbits inoculated with 10(9) CFU died of sepsis within 48 h. Herniation did not occur in any of the animals.Our study demonstrates that ADM resists surgical site infection caused by S. aureus in an animal model without compromising the ventral hernia repair. This ability of ADM grafts to perform well in the setting of infection is most likely attributable to their capacity to vascularize and aid clearance of bacteria.

The purpose of this study was to develop a nonhuman primate model for heterotopic composite tissue facial transplantation in which to study the natural history of facial transplantation and evaluate immunosuppressive regimens.A composite oromandibular facial segment transplant based on the common carotid artery was evaluated. Flaps from 7 cynomolgus monkeys were transplanted to the groins of 7 recipients at the superficial femoral artery and vein. The immunosuppressive regimen consisted of thymoglobulin, rapamycin, and tacrolimus. Allograft survival ranged from 6 to 129 days. Histology performed in the long-term survivor at the time of necropsy revealed extensive inflammation and necrosis of the allograft skin; however, muscle and bone elements were viable, with minimal inflammation. This heterotopic facial transplantation model avoids the potential morbidity of mandibular resection and orthotopic facial transplantation. Our work also concurs with the work of other groups who found that the skin component is the most antigenic.

Background: Recent clinical trials involving patients with acute coronary syndromes have demonstrated significant reduction in the progression of coronary artery thrombosis using a regimen of aspirin, heparin, and the glycoprotein IIb/IIIa inhibitor tirofiban. Acute coronary syndromes and free tissue transfer are similar pathophysiologically in that they both involve endothelial injury, thrombosis, and ischemia. In this study, the authors investigate tirofiban, combined with aspirin and heparin, for the prevention of microsurgical anastomotic thrombosis in a thrombogenic rat model. Methods: Using a randomized, controlled, double-blind experimental design, 80 thrombogenic anastomoses were performed on rat femoral arteries (n = 40) and veins (n = 40). Preoperatively, each rat received one of four treatment regimens: aspirin and heparin (regimen 1), aspirin and heparin plus tirofiban (regimen 2), tirofiban alone (regimen 3), or isotonic saline (control) (regimen 4). Vessels were assessed for patency at 5, 15, 30, and 120 minutes after reperfusion and then harvested for microscopic analysis. Results: At 120 minutes after reperfusion, regimen 1 had an arterial and venous patency rate of 80 percent and 70 percent, respectively, whereas the vessel patency rate for regimen 2 was 100 percent. The difference between regimens 1 and 2 was not statistically significant. Regimens 3 and 4 had vessel patency rates of 40 percent or less. The aspirin/heparin and aspirin/heparin/tirofiban groups both demonstrated significantly improved vessel patency and significantly less thrombotic occlusion compared with controls. Conclusions: Combination therapy with aspirin, heparin, and tirofiban significantly increases arterial and venous patency and decreases anastomotic thrombus formation in thrombogenic anastomoses in rats. The role of glycoprotein IIb/IIIa inhibitors in microsurgery warrants further investigation.

Background: The purpose of this study was to evaluate the effects of fondaparinux, a selective antithrombin III agonist, in comparison to the low-molecular-weight heparin enoxaparin in the survival of a congested skin flap. Materials and Methods: Eighteen axial-pattern auricular flaps were performed on rabbits using a well-described congested flap model. Animals were randomized into 2 treatment groups, enoxaparin (n = 6) and fondaparinux (n = 6), and a control group (n = 6) that received no treatment. Skin flap survival area was measured postoperatively at 7 and 14 days. Results: The groups that received fondaparinux and enoxaparin had similar mean flap survival areas and were not statistically different. However, both treatment groups significantly increased flap survival compared with controls (P < 0.014). Conclusions: Fondaparinux, like enoxaparin, significantly improves survival of congested flaps in rabbits. Its use instead of enoxaparin may be warranted, given that it eliminates the risk of heparin-induced thrombocytopenia. Further study in humans is warranted.

Various local and distant flaps have been used to repair pelvic defects, including sartorius, rectus abdominis, rectus femoris, tensor fascia lata, vastus lateralis, gracilis, and omentum, each with benefits and disadvantages. The pedicled internal oblique rotational muscle flap has been described to cover pelvic wounds but may be underutilized. We present our experience with 5 pedicled internal oblique flaps in 4 patients (3 male, 1 female). The mean patient age was 32 years (23-47 years), and the mean follow-up was 8 months. All patients required coverage of the lateral pelvis after failure of conservative measures. There were no major complications. One patient experienced decreased sensation in the lateral femoral cutaneous nerve distribution, which resolved fully within 3 months. The internal oblique muscle provides local soft-tissue coverage with a predictable blood supply, and its proximity to the pelvis offers an alternative for reconstruction of lateral pelvic defects, with minimal associated morbidity.

Th e use of prosthetic mesh for the tension-free repair of incisional hernias has been shown to be more eff ective than primary suture repair. Unfortunately, prosthetic materi- als can be a suboptimal choice in a variety of clinical scenarios. In general, prosthetic materials should not be implanted into sites with known contamination or infection because they lack an endogenous vascular network and are thus incapable of clearing bacteria. Th is is of particu- lar relevance to the repair of recurrent hernias, which are often refractory to repair because of indolent bacterial colonization that weakens the site and retards appropriate healing. Although fascia lata grafts and muscle fl aps can be employed for tension-free hernia repairs, they carry the potential for signifi cant donor site morbidity. Recently, a growing number of clinicians have used human acellular dermal matrix as a graft material for the tension-free repair of ventral hernias. Th is material has been shown to become revascularized in both animal and human subjects. Once repopulated with a vascular network, this graft material is theoretically capable of clearing bacteria, a property not found in prosthetic graft materials. Unlike autologous materials such as fascial grafts and muscle fl aps, acellular dermal matrix can be used without subjecting the patient to additional morbidity in the form of donor site complications. Th is article presents a thorough review of the current literature, describing the properties of human acellular dermal matrix and discussing both animal and human studies of its clinical performance. In addition to the review of previously published clinical experiences, we discuss our own preliminary results with the use of acellular dermal matrix for ventral hernia repair in 46 patients.

This study was designed to assess the long-term efficacy of allogenic acellular dermal matrix (ADM) used as an interpositional graft for ventral hernia repair in a swine model.We created 12x4-cm full-thickness abdominal wall defects in 22 Yucatan miniature pigs. The defect was repaired with either two 6x4-cm pieces of AlloDerm (acellular dermal matrix processed from pig skin in order to avoid a xenogenic response, LifeCell Corporation, Branchburg, NJ USA) (n = 12), or expanded polytetrafluoroethylene mesh (ePTFE) (Gore-Tex, W.L. GoreAssociates, Inc., Newark, DE USA) (n = 10). In six pigs, a separate 3-cm fascial incision was made, which was then suture repaired as a control for tensiometry testing. The surgical sites were evaluated at either 3 months or 9 months for the presence of a hernia, stretching of the implant, adhesions, vascularity, and biomechanical strength.Two hernias occurred in both the ADM and the ePTFE groups. There was minimal stretching of the implants and minimal adhesions in both groups. Fluorescein testing and histology indicated vascular ingrowth into the ADM. There was no statistical difference between the mean breaking strengths of the ADM-fascial interface (106.5 N +/- SD 40.1), the interface between two pieces of ADM (149.1 N +/- SD 76.7), and the primary fascial repair (108.1 N +/- SD 20.9) at 9 months. The ADM-fascial interface had a significantly higher breaking strength than that of the ePTFE-fascia interface (66.1 N +/- SD 30.1) (P = 0.017, t-test, P = 0.043 Wilcoxon rank sum test).In this study, we were unable to demonstrate a difference between ADM and ePTFE in their ability to repair ventral hernias at 9 months in a swine model. The ADM additionally supports vascular ingrowth and exhibits increased breaking strength at the fascia-implant interface.