Summary: Injectable drug use in the upper extremity often leads to chronic wounds complicated by osteomyelitis. Conventional reconstructive options are often not feasible and/or are contraindicated in this patient population. We have started using a synthetic, biodegradable temporizing matrix (BTM) for the treatment of these patients. We hypothesize that BTM is a safe, low-risk, and low-morbidity alternative reconstructive option. We report outcomes after staged debridement and BTM application followed by split-thickness skin grafting for two patients with large, chronic bilateral forearm wounds with concomitant osteomyelitis confirmed by MRI and biopsy. No acute surgical complications were encountered and at a mean follow-up of 13 months, both patients had maintained stable soft-tissue coverage. Reconstruction using BTM is a novel treatment option that can simplify the reconstruction, reduce donor-site morbidity, and optimize success for patients with chronic wounds resulting from injectable drug use. Initial outcomes are promising; however, further comparative studies are needed to better evaluate long-term outcomes of this technique.
PURPOSE: Vascularized lymph node (VLN) transfer is a promising treatment option for patients suffering from lymphedema.1 Despite positive preliminary outcomes, several questions remain unanswered, including mechanism of action and optimal flap design.2–4 The purpose of this study was to: 1) evaluate the mechanism of lymph drainage through the VLN flap, and 2) investigate if the number of VLNs impacts lymph transit time through the flap. MATERIALS AND METHODS: Twenty-seven axillary VLN flaps were elevated in 14 male Sprague-Dawley rats (450- 500g) and divided into 3 groups (n=9 each) based on the number of lymph nodes present: Group 1 (0 VLNs), Group 2 (2 VLNs), and Group 3 (4 VLNs). Indocyanine green (n=8/group) and Alexa680-albumin (n=1/group) were injected into the edge of flaps and latency period between injection and fluorescence in the axillary vein was recorded. Stereomicroscopic fluorescent lymphography was performed to directly visualize lymphatic transit through the VLNs (Figure 1).Figure 1: Stereomicroscopic lymphography displaying lymphatic fluid drainage through the rat axillary VLN flap. * – Alexa680-albumin injection site; Arrows: afferent lymphatics; Green dashed line – flap contour; Yellow dashed line – VLN contour.RESULTS: Fluorescence was detected in the axillary vein after 197±188, 109±97, and 73±57 seconds in Groups 1, 2, and 3, respectively. Increased lymph node number decreased lymph transit time as shown by the negative correlation between the number of VLNs in the flap and the latency period (r =-0.39; p=0.03). Mean flap weights were comparable in Group 1, 2, and 3 (275±54, 298±74, 309±60 mg; ANOVA p=0.54). Stereoscopic lymphography allowed direct visualization of lymphatic fluid transit first through afferent lymphatics into the lymph nodes, followed by movement through the hilum into vessels draining toward the flap pedicle vein (Figure 2).Figure 2: Stereomicroscopic lymphography showing high magnification view of lymph node.CONCLUSION: Our results suggest that lymphatic fluid in VLN flaps drains into the venous system mainly by passing through the afferent lymphatics and lymph nodes. A secondary mechanism is the diffusion of fluid directly into the venous system via flap capillary lymphatics. This is shown by the delayed presence of fluorescence in the pedicle vein in flaps without VLNs. Increasing the number of lymph nodes in the flap directly improves flap lymphatic drainage capacity.
AMERICAN SOCIETY OF PLASTIC SURGEONS PLASTIC & RECONSTRUCTIVE SURGERY PRS GLOBAL OPEN ASPS EDUCATION NETWORK AMERICAN SOCIETY OF PLASTIC SURGEONS PLASTIC & RECONSTRUCTIVE SURGERY PRS GLOBAL OPEN ASPS EDUCATION NETWORK
Sir: We read with interest a recent article by Mosharrafa et al. entitled “Direct-to-Implant Breast Reconstruction with Simultaneous Nipple-Sparing Mastopexy Utilizing an Inferiorly Based Adipodermal Flap: Our Experience with Prepectoral and Subpectoral Techniques.”1 The authors describe their experience with a single-stage, nipple-sparing, direct-to-implant reconstruction with simultaneous mastopexy. We have also utilized this single-stage technique and agree that excellent results can be obtained in a selected group of patients without the disadvantage of performing multiple operations.2 However, we have noted some limitations of this approach. First, we found this technique to be unreliable in patients with a nipple-areola complex–to–inframammary fold distance greater than double the inframammary fold width. Thus, patients with narrow breasts or those with moderate to severe ptosis may not be good candidates. Second, this technique requires a team approach with an experienced breast surgeon. At our institution, for example, the breast surgeon usually elevates the inferior flap off of the breast parenchyma. Careful nipple-areola complex dissection at this point in the operation is a critical step to optimally preserve vascularity. If the flap is too thin, viability of the nipple-areola complex will be jeopardized. For patients deemed suboptimal candidates for this technique, such as those mentioned above, we have developed two alternative modifications that can be utilized reliably and successfully. The first is based on an inferiorly based adipodermal flap. If the pedicle is too long or too thin or if the nipple-areola complex needs to be resected for oncological safety, a round skin paddle can be designed closer to the inframammary fold to serve as a neoareola. [See Figure, Supplemental Digital Content 1, which shows single-stage direct-to-implant reconstruction of a ptotic breast combined with a mastopexy-like procedure. In this case, the nipple-areola complex was not able to be preserved given oncologic safety. Areola reconstructions were performed using wide, inferiorly based adipodermal flaps. (Above) Preoperative markings. (Below, left) Elevated inferiorly based adipodermal flaps with preserved round skin paddle to serve as a neoareola. (Below, right) Intraoperative appearance of reconstructed breasts after closure, https://links.lww.com/PRS/E494.] Then the flap distal to this neoareola is amputated and prepectoral direct-to-implant reconstruction is completed in a fashion similar to that described by Mosharrafa et al.1 This is a modification of a technique previously described for lumpectomy defects and breast reductions.3,4 We have performed multiple bilateral reconstructions using this technique with favorable outcomes. The majority of our patients were pleased with results and did not wish to undergo further nipple reconstruction. The second technique allows preservation of the nipple-areola complex even if the nipple-areola complex–to–inframammary fold distance exceeds the breast width by twofold.5 In this technique, a superior adipodermal pedicle is utilized as opposed to the inferior pedicle. [See Figure, Supplemental Digital Content 2, which shows single-stage direct-to-implant prepectoral reconstruction of a ptotic breast combined with a mastopexy-like procedure. The nipple-areola complex is based on a superior adipodermal flap. (Above, left) Preoperative markings. (Below) Mastectomy flap with a superior adipodermal pedicle. (Above, right) Intraoperative appearance of reconstructed breasts after closure, https://links.lww.com/PRS/E495.] Wise-pattern markings are made, and the skin is deepithelialized. A nipple-sparing mastectomy is then performed through the inframammary incision. Acellular dermal matrix is sutured in a prepectoral position and an implant sizer is placed. Then the breast is closed in a mastopexy-like fashion, followed by exchange of the sizer to a permanent implant. As of this writing, we have performed 38 bilateral reconstructions of this type, with a favorable complication profile and a high level of patient-reported satisfaction.5 In conclusion, we find the single-stage technique described by Mosharrafa et al. very useful in selected patients. If, for the reasons mentioned above, it cannot be utilized, we present additional single-stage alternatives that in our experience can yield excellent outcomes and satisfied patients. DISCLOSURE Dr. Moreira is a compensated speaker for Acelity. All other authors have no commercial associations or financial disclosures to report. Grzegorz J. Kwiecien, M.D.Demetrius M. Coombs, M.D.Cagri Cakmakoglu, M.D.Steven Bernard, M.D.Department of Plastic and Reconstructive Surgery Alicia Fanning, M.D.Department of General SurgerySection of Breast Surgery Andrea Moreira, M.D.Department of Plastic and Reconstructive SurgeryCleveland ClinicCleveland, Ohio
PURPOSE: Extremity lymphedema is a feared sequela of axillary or ilioinguinal lymph node dissection (LND). In traditional LND, no effort is made to preserve or restore upper or lower extremity lymphatic flow. We hypothesized that prophylactic lymphaticovenous bypass (LVB) could be a reproducible technique to preserve functional lymphatic flow following axillary and ilioinguinal LND in melanoma patients. This study reports the first prophylactic LVB in melanoma patients undergoing complete LND for gross metastatic disease. METHODS: We present a case series of 15 patients with malignant melanoma who had axillary or ilioinguinal LND for bulky regional involvement and who underwent prophylactic LVB. Details of the surgical procedure, common pitfalls, and indications are discussed. Five milliliters of indocyanine green (ICG) dye is injected into the hand or foot web spaces. Meticulous complete LND is then started using loupe magnification, minimal cautery dissection, and sharp lymphatic and venous transection. During lymphadenectomy, the lymphatics are assessed using ICG lymphangiography and a fluorescent surgical microscope. Using the multispectrum platform with its rainbow color on-lay software, smaller lymphatic vessels are classified based on their signal intensity, with red indicating the highest intensity and blue the lowest. Those lymphatics that need to be transected and are red on the rainbow color on-lay scale are selected for anastomosis. RESULTS: During this study period, 15 patients underwent lymphatic preservation surgery. Multiple subdermal ICG dye injections allowed for visualization of 1–3 transected lymphatics after LND. An average of 1.8 LVBs (range, 1–2) was performed per patient. All the anastomosis were patent as shown by ICG lymphangiography. End-to-end anastomosis was employed in 4 patients, and intussusception anastomosis was performed in 11 patients. LVB operative time varied from 40 to 150 minutes. Drain period ranged from 6 to 18 days. CONCLUSIONS: Performing LVB in prophylactic setting with gross metastatic disease in melanoma patients distinguishes our study from others. In our study, using ICG angiography, we identified lymphatic vessels under up to 42× magnification, including those with high flow based on a gradient scale via rainbow color on-lay software system. Traditionally, isosulfan and methylene blue are used for lymphatic visualization. However, they have a risk of severe hypersensitivity reactions, isosulfan blue might interfere with oxygen saturation, and their use is associated with increased incidence of tissue necrosis. Using ICG eliminates these risks. In 2017, Multicenter Selective Lymphadenectomy Trial II showed no survival difference in patients with intermediate-thickness, node-positive melanoma who underwent immediate CLND. Thus, most patients undergoing lymphadenectomy currently have gross, many times bulky metastatic disease. Despite more extirpative surgery as compared to CLND for positive sentinel lymph node biopsy, we were still able to easily identify lymphatics and appropriate recipient veins in all our patients. Expensive and time-consuming radioactive tracer studies were not needed. This technique is reproducible as we have successfully completed this procedure in all 15 consecutive cases. Restoration of lymphatic flow following axillary or ilioinguinal LND in melanoma patients represents a new approach that may decrease the burden of iatrogenic extremity lymphedema.
Vapocoolant sprays are commonly used to minimize pain following minor interventions such as venipuncture, shave biopsy or needle insertion. Although these sprays have been widely used in clinical practice, little is known about their effect on microcirculation or cutaneous blood flow.To evaluate the real-time effect of a topical vapocoolant using a well-established, rat cremaster muscle microcirculatory model, allowing direct measurement of changes in vessel diameter, capillary density and leukocyte behaviour.Fifty rats were divided into a control and four experimental groups: group 1: 4 s spray with vapocoolant at 18 cm distance; group 2: 10 s spray at 18 cm distance; group 3: 4 s spray at 8 cm distance; and group 4: 10 s spray at 8 cm distance. Vessel diameters, capillary density and leukocyte behaviour were monitored for 1 h thereafter. Muscle was harvested for immunohistochemistry analysis of proangiogenic markers (vascular endothelial growth factor and von Willebrand factor), leukocyte behaviour markers (E-selectin, vascular cell adhesion molecule, intercellular adhesion molecule), pimonidazole-hypoxia staining and ApopTag (Millipore, USA) staining for apoptosis. Gene expression for inflammatory markers (interleukin [IL]-1β, IL-2, IL-4, IL-6, IL-10, tumour necrosis factor-alpha and interferon-gamma) was evaluated using polymerase chain reaction and myeloperoxidase assay for inflammation was performed.The use of refrigerant spray decreased vessel diameter and capillary density initially, although none of these decreases were statistically significant. Polymerase chain reaction showed no significant changes. The myeloperoxidase assay showed statistically significant increase in myeloperoxidase activity in groups 2, 3 and 4. Immunohistochemistry was negative for angiogenic and proinflammatory markers.The lack of statistically significant changes in vessel diameter and inflammatory markers corroborated the safety on microcirculation.Les pulvérisateurs à froid sont couramment utilisés pour réduire la douleur après des interventions mineures comme les ponctions veineuses, les biopsies par rasage ou l’insertion d’aiguilles. Même si ces vaporisateurs sont largement utilisés en pratique clinique, on ne sait pas grand-chose de leur effet sur la microcirculation ou la circulation cutanée.Évaluer l’effet en temps réel d’un pulvérisateur à froid topique au moyen d’un modèle microcirculatoire bien établi du muscle crémaster de rats, afin de mesurer directement les modifications au diamètre, à la densité capillaire et au comportement leucocytaire des vaisseaux.Les chercheurs ont réparti 50 rats en un groupe témoin et quatre groupes expérimentaux (groupe 1 : pulvérisation à froid de quatre secondes à une distance de 18 cm; groupe 2 : pulvérisation à froid de dix secondes à une distance de 18 cm; groupe 3 : pulvérisation à froid de quatre secondes à une distance de 8 cm; groupe 4 : pulvérisation à froid de dix secondes à une distance de 8 cm). Ils ont ensuite surveillé le diamètre, la densité capillaire et le comportement leucocytaire des vaisseaux pendant une heure. Ils ont prélevé le muscle pour effectuer une analyse immunohistochimique des marqueurs proangiogéniques (facteur de croissance de l’endothélium vasculaire et facteur de von Willebrand), des marqueurs de comportement leucocytaire (E-sélectine, molécule d’adhésion des cellules vasculaires, molécule d’adhésion intercellulaire), du pimonidazole, marqueur d’hypoxie, et de la trousse ApopTag (Millipore, États-Unis) pour déceler l’apoptose. Ils ont évalué l’expression génique des marqueurs inflammatoires (interleukine [IL]-1β, IL-2, IL-4, IL-6, IL-10, facteur de nécrose tumorale alpha et interféron gamma) au moyen de la réaction en chaîne de la polymérase et du dosage de myéloperoxydase pour déterminer l’inflammation.Au départ, l’utilisation d’un pulvérisateur à froid a réduit le diamètre et la densité capillaire des vaisseaux, mais pas de manière statistiquement significative. La réaction en chaîne de la polymérase n’a pas changé de manière significative. Le dosage de myéloperoxydase a révélé une augmentation statistiquement significative de l’activité de la myéloperoxydase dans les groupes 2, 3 et 4. L’immunohistochimie était négative aux marqueurs angiogéniques et pro-inflammatoires.L’absence de changements statistiquement significatifs du diamètre des vaisseaux et des marqueurs inflammatoires en ont corroboré l’innocuité sur la microcirculation.
Summary: Cerebrospinal fluid (CSF) drainage catheters have been associated with numerous complications in various anatomic locations, because of migration, infection, and obstruction. However, breast-related CSF shunt complications tend to occur infrequently or have seldom been reported in the empirical literature. Therefore, a case is presented detailing a breast pseudocyst caused by migration and subsequent coiling of a ventriculoperitoneal shunt in the right breast pocket. To the best of the authors’ knowledge, this is the first case that has been reported in the peer-reviewed literature of a pseudocyst resulting from a CSF drainage catheter coiling around the breast implant post pancreaticoduodenectomy. Moreover, this case highlights the importance of cross-disciplinary procedural awareness, particularly in regards to breast, ventriculoperitoneal shunt, and pancreatic procedures.
AMERICAN SOCIETY OF PLASTIC SURGEONS PLASTIC & RECONSTRUCTIVE SURGERY PRS GLOBAL OPEN ASPS EDUCATION NETWORK AMERICAN SOCIETY OF PLASTIC SURGEONS PLASTIC & RECONSTRUCTIVE SURGERY PRS GLOBAL OPEN ASPS EDUCATION NETWORK
