Nontopical Nitrates in Flap Perfusion and Delay Phenomenon.

Background: Topical nitrates have demonstrated efficacy in improving flap perfusion. However, evidence for nontopical nitrates in modulation of flap perfusion dynamics has yet to be consolidated. Here, we review evidence regarding the use of intravascular, sublingual, and oral nitrates in modulating flap perfusion. Methods: We performed a review of the literature for evidence linking nontopical nitrates and flap perfusion, and included clinical studies, animal studies, and in vitro studies. Results: Evidence suggests that intravascular, sublingual, and oral nitrates exert vasodilatory properties, which may be harnessed for identification of perforators and improved flap perfusion. We also found evidence suggesting nitrates may facilitate ischemic preconditioning while reducing ischemia-reperfusion injury. Conclusions: Nitrates delivered intravascularly, sublingually, or orally may increase flap perfusion and serve as a method for ischemic preconditioning, particularly in the intraoperative setting.

Local Infiltration Anesthesia Versus Ultrasound-Guided Pectoralis (PEC1) + Serratus Anterior Plane (SAP) Blocks on Postanesthetic Care Unit Pain Control in Patients Undergoing Primary Submuscular Augmentation Mammoplasty.

BACKGROUND: Ultrasound-guided regional field blocks are not widely used in outpatient plastic surgeries. The efficacy of truncal blocks (PEC1 + SAP) has not been established in plastic surgery. The purpose of this study was to analyze the outcomes of these newer anesthetic techniques compared with traditional blind local anesthetic infiltration in patients undergoing breast augmentation. METHODS: This retrospective institutional review board-approved cohort study compared the outcomes of the different practices of 2 plastic surgeons at the same accredited outpatient surgery center between 2018 and 2022. Group 1 received an intraoperative blind local infiltration anesthetic. Group 2 underwent surgeon-led, intraoperative, ultrasound-guided PEC1 (Pectoralis 1) + SAP (serratus anterior plane) blocks. Patients who underwent any procedure other than primary submuscular augmentation mammoplasty were excluded from the study. The outcomes measured included operative time, opioid utilization in morphine milligram equivalents (MME), pain level at discharge, and time spent in the post anesthetic care unit (PACU). RESULTS: Sixty patients met the inclusion criteria for each group for a total of 120 patients. The study groups were similar to each other. Patients receiving PEC1 + SAP blocks (group 2) had significantly lower average MME requirements in the PACU (3.04 MME vs 4.52 MME, P = 0.041) and required a shorter average PACU stay (70.13 minutes vs 80.38 minutes, P = 0.008). There were no significant differences in the pain level at discharge, operative time, or implant size between the 2 groups. CONCLUSIONS: Surgeon-led, intraoperative, ultrasound-guided PEC1 + SAP blocks significantly decreased opioid utilization in the PACU by 33% and patient time in the PACU by 13%, while achieving similar patient pain scores and operating times.

Modulation of Cellular Stemness for Enhanced Fat Grafting.

Low volumetric retention limits the utility of fat grafting. Although inclusion of stem cells and platelet-rich plasma have been proposed to enhance graft retention, accumulating evidence has failed to show a clear benefit. Here, we propose a strategy to pharmacologically enhance stemness of stem and progenitor cell populations in fat grafts to promote increased volume retention and tissue health. We also propose how to integrate stemness-promoting and differentiation-promoting therapies such as platelet-rich plasma, and viability promoting therapies within the common fat grafting workflow to achieve optimal fat grafting results.

Use of Suprapubic Panniculus for Split-Thickness Skin Graft in Buried Penis Repair.

Background: In the United States, acquired buried penis deformity is an increasingly more common condition. Management of the buried penis deformity is accomplished with removal of macerated skin and subcutaneous tissue from the panniculus and prepubic region, and replacement of denuded penile skin. If local tissue advancement is insufficient to cover the defect, a skin graft may be required. Though the anterior thigh is commonly used, this creates a second defect. Here we describe 2 cases of split-thickness skin grafts harvested from the panniculus to cover buried penis deformities. Methods: Two patients with a buried penis deformity were identified. The denuded suprapubic tissue was elevated. Using inferior traction, split-thickness skin grafts were harvested and placed onto the shaft of the penis. The remaining excess tissue was resected. Results: One patient had a fungal rash that resolved with topical treatment. The other patient had a hematoma requiring surgical evacuation. Neither patient had any other complications, and both had over 95% take of the split-thickness skin grafts. Conclusions: These cases demonstrate the successful use of pannicular skin grafts for buried penis deformity correction. This donor site avoids creation of a second defect. As demonstrated here, the grafts are a durable option, even in the setting of local infection and hematoma.

Ultrasound-Guided Transversus Abdominis Plane Blocks Versus Local Infiltration Anesthesia on Postanesthesia Care Unit Pain Control in Patients Undergoing Abdominoplasty.

GOALS/PURPOSE: The goal of this study was to compare ultrasound-guided transversus abdominis plane (TAP) blocks to local infiltration anesthesia with or without blind rectus sheath blocks in patients who underwent abdominoplasty at an outpatient surgery center. METHODS/TECHNIQUE: A retrospective review was conducted of patients who underwent outpatient abdominoplasty performed by the senior surgeon (J.T.L.). Group 1 received local infiltration anesthesia with or without blind rectus sheath blocks between April 2009 and December 2013. Group 2 received surgeon-led, intraoperative, ultrasound-guided, 4-quadrant TAP blocks between January 2014 and December 2021. Outcomes measured were opioid utilization (morphine milligram equivalents), pain level at discharge, and time spent in postanesthesia care unit (PACU). RESULTS: Sixty patients in each of the 2 study groups met the study criteria for a total of 120 patients. The study groups were similar except for a lower average age in group 1. Patients who received TAP blocks (group 2) had significantly lower morphine milligram equivalent requirements in the PACU (3.07 vs 8.93, P = 0.0001) and required a shorter stay in PACU (95.4 vs 117.18 minutes, P = 0.0001). There were no significant differences in pain level at discharge. CONCLUSIONS: Surgeon-led, intraoperative, ultrasound-guided, 4-quadrant TAP blocks statistically significantly reduced opioid utilization in PACU by 65.6% and average patient time in the PACU by 18.5% (21.8 minutes).

Tissue Is the Issue: Use of 2 Bipedicled "Bucket-Handle" Local Advancement Flaps to Close a Nonhealing Wound.

Introduction: Soft tissue loss following total knee arthroplasty can result in catastrophic complications. Defects can be covered using various flaps and grafts, including fasciocutaneous flaps. Here, we discuss one case of double bipedicled "bucket-handle" local advancement flaps used for a nonhealing midline knee dehiscence wound following total knee arthroplasty. Methods: Flaps were planned using perforators identified with forward-looking infrared (FLIR) thermal imaging. Two bucket-handle bipedicled flaps were used for repair. Autologous split-thickness skin grafts were used for the donor sites. Results: FLIR imaging was used for flap monitoring. Apart from one site of superficial epidermolysis that healed with local wound care, there were no postoperative complications. Discussion: This case demonstrates the successful use of double bipedicled local advancement flaps to reconstruct a defect following a total knee arthroplasty. These flaps minimize donor site morbidity, provide adequate coverage, allow for tension-free closures, and have reliable vascular supplies. FLIR thermal imaging is an accessible and useful tool in designing and monitoring flaps.

Soft Tissue Reconstruction With Ovine Forestomach Matrix After Wide Excision of Plantar Fibromatosis.

Background. Plantar fibromatosis, or Ledderhose disease, presents as plantar fascia nodules caused by hyperactive proliferating fibroblasts. These benign tumorous growths can persist causing pain as well as reduced mobility and quality of life. Plantar fibromatosis may not respond to conservative nonsurgical treatment resulting in surgical intervention, including wide excision of the affected tissue and subsequent reconstruction. Reconstruction of the full-thickness plantar defect is challenging given the location, and recurrence rates are relatively high. Here we present a staged reconstruction of plantar fibromatosis following wide excision using a biologic graft to regenerate the neodermis and subsequent skin grafting. This reconstructive approach provided an alternative to free flap transfer, with excellent functional outcomes.

Surgical Reconstruction of Stage 3 and 4 Pressure Injuries: A Literature Review and Proposed Algorithm from an Interprofessional Working Group.

OBJECTIVE: Stage 3 and 4 pressure injuries (PIs) present an enormous societal burden with no clearly defined interventions for surgical reconstruction. The authors sought to assess, via literature review and a reflection/evaluation of their own clinical practice experience (where applicable), the current limitations to the surgical intervention of stage 3 or 4 PIs and propose an algorithm for surgical reconstruction. METHODS: An interprofessional working group convened to review and assess the scientific literature and propose an algorithm for clinical practice. Data compiled from the literature and a comparison of institutional management were used to develop an algorithm for the surgical reconstruction of stage 3 and 4 PIs with adjunctive use of negative-pressure wound therapy and bioscaffolds. RESULTS: Surgical reconstruction of PI has relatively high complication rates. The use of negative-pressure wound therapy as adjunctive therapy is beneficial and widespread, leading to reduced dressing change frequency. The evidence for the use of bioscaffolds both in standard wound care and as an adjunct to surgical reconstruction of PI is limited. The proposed algorithm aims to reduce complications typically seen with this patient cohort and improve patient outcomes from surgical intervention. CONCLUSIONS: The working group has proposed a surgical algorithm for stage 3 and 4 PI reconstruction. The algorithm will be validated and refined through additional clinical research.

Investigation of Hospital Pricing Information for Plastic Surgery Procedures Reveals Widespread Violation of the CMS Price Transparency Act.

BACKGROUND: Price transparency allows patients to estimate surgical procedure costs, which can affect where they elect to receive care and should theoretically result in hospitals setting lower and more uniform prices. To elucidate the traditionally opaque nature of health care pricing, the U.S. Centers for Medicare & Medicaid Services has mandated that hospitals publicly release their pricing information. The authors sought to investigate the utility of price transparency for plastic surgery patients, who are uniquely situated to benefit because of the dominance of elective procedures. METHODS: This study included 54 randomly chosen public and private hospitals. Pricing information for 15 common plastic surgery-related procedures was compiled from their websites. RESULTS: One year after the ruling went into effect, only 13% of hospitals were fully compliant with Centers for Medicare & Medicaid Services requirements for reporting standard charges. The most commonly reported plastic surgery procedures were adjacent tissue transfers (CPT codes 14000, 14001, 14301, and 14302), with an average of 32.4% of hospitals listing pricing data. The 25.9% of hospitals reporting the immediate insertion of breast implants (CPT code 19340) pricing presented a wide range of gross prices, from $2346.09 to $29,969.35. Free and pedicled flaps (CPT codes 19364, 19361, 19367, 19368, and 19369) were less commonly reported than autologous tissue transfer or nonflap breast procedures ( P = 0.00). CONCLUSIONS: A comparative analysis of published prices provides a starting point for surgeons to recommend facilities to patients based on price. However, significant variability was observed in data presentation, reported procedures, and listed prices. These inconsistencies in reporting and unrealistic ranges in price render the comparison of plastic surgery prices among hospitals impractical.

Smoking as a Risk Factor for Forehead Flap Wound Outcomes: An Analysis of 1030 Patients.

Background: The forehead flap is a local transposition flap based on a pedicled vessel commonly used to reconstruct facial defects. Often patients requiring reconstructions are smokers, yet the effects of smoking on forehead flaps are not well defined. Our study is aimed to examine smoking as a preoperative risk factor for complications following forehead flaps. Methods: This retrospective cohort study used data collected from the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2019. Multivariate logistic regression models were fitted to evaluate the association between smoking and development of wound complications. Results: A total of 1030 forehead flaps cases were analyzed and separated into 2 cohorts based on current smoking status: 789 (76.6%) nonsmokers versus 241 (23.4%) smokers. No significant differences in rates of wound complications were found for nonsmokers versus smokers (2.7% vs 4.1%; P = .0807), including when adjusted for comorbidities in a multivariate logistic regression model (adjusted odds ratio, 1.297 [95% confidence interval, 0.55-2.9]; P = .5174). Conclusions: Smoking has been demonstrated to be a risk factor for plastic surgery procedures. However, in our review of 1030 forehead flaps, smokers did not have worse outcomes compared with nonsmokers. Although it is still advised to recommend smoking cessation given multiple health benefits, smoking status should not preclude candidacy for facial reconstruction with a forehead flap based on complication risk.

Surgical Management of Hidradenitis Suppurativa: A Two-Center Retrospective Study.

BACKGROUND: Hidradenitis suppurativa is a chronic inflammatory condition that presents a challenging reconstructive problem for plastic surgeons. METHODS: The authors performed a retrospective chart review of hidradenitis suppurativa patients managed with surgical excision between 2005 and 2020 at Brigham and Women's Hospital and Tulane University Medical Center. Operative cases associated with the same hospitalization were organized into treatment episodes and assessed for patient demographics, operative techniques, and outcomes. RESULTS: A total of 181 patients, 435 cases and 316 treatment episodes (Brigham and Women's Hospital, n = 269; Tulane University Medical Center, n = 47), were identified across two diverse institutions. Their respective series showed comparable patient demographics, and 94 percent of the combined episodes achieved wound closure and healing during the study period. Several techniques of closure were identified, including immediate closure and site-specific methods, such as an expedited staged closure using internal negative-pressure wound therapy as a temporary bridge, "recycled" skin grafting, and repurposing iodoform wicks as an adjunct wound healing therapy to immediate closure. CONCLUSIONS: This large multi-institutional retrospective chart review on the plastic surgical management of hidradenitis suppurativa demonstrates that surgery is an effective therapy for hidradenitis suppurativa and captures a diversity of site-specific techniques that may serve as a foundation for future prospective studies and evidence-based guidelines for the use of various techniques to optimize patients' surgical outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Immediate Lymphatic Reconstruction for Prevention of Secondary Lymphedema: A Meta-Analysis.

BACKGROUND: Secondary lymphedema remains one of the most notorious complications of axillary and pelvic lymph node surgery following mastectomy. There is a lack of high-level evidence found on the effectiveness of immediate lymphatic reconstruction (ILR) in preventing secondary lymphedema. This meta-analysis evaluates the outcomes of ILR for prevention of secondary lymphedema in patients undergoing different surgeries, and provides suggestions for lymphatic microsurgical preventive healing approach (LYMPHA). METHODS: A review of PubMed, Embase, and Web of Science was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. All English-language studies published from January 1, 2009 to June 1, 2020 were included. We excluded non-ILR interventions, literature reviews/letters/commentaries, and nonhuman or cadaver studies. A total of 789 patients that were enrolled in 13 studies were included in our one-arm meta-analysis. RESULTS: A total of 13 studies (n=789) met inclusion criteria: upper extremity ILR (n=665) and lower extremity ILR (n=124). The overall incidence of lymphedema for upper extremity ILR was 2.7% (95%CI: 1.1%-4.4%) and lower extremity ILR was 3.6% (95%CI: 0.3%-10.1%). For upper extremity ILR, the average follow-up time was 11.6 ± 7.8 months and the LE incidence appeared to be the highest approximately 1 to 2 years postoperation. CONCLUSIONS: Lymphedema is a common complication in cancer treatment. ILR, especially LYMPHA, may be an effective technique to facilitate lymphatic drainage at the time of the index procedure but future studies will be required to show its short-term efficacy and long-term outcomes.

Retrospective real-world comparative effectiveness of ovine forestomach matrix and collagen/ORC in the treatment of diabetic foot ulcers.

The retrospective pragmatic real-world data (RWD) study compared the healing outcomes of diabetic foot ulcers (DFUs) treated with either ovine forestomach matrix (OFM) (n = 1150) or collagen/oxidised regenerated cellulose (ORC) (n = 1072) in out-patient wound care centres. Median time to wound closure was significantly (P = .0015) faster in the OFM group (14.6 ± 0.5 weeks) relative to the collagen/ORC group (16.4 ± 0.7). A sub-group analysis was performed to understand the relative efficacy in DFUs requiring longer periods of treatment and showed that DFUs treated with OFM healed up to 5.3 weeks faster in these challenging wounds. The percentage of wounds closed at 36 weeks was significantly improved in OFM treated DFUs relative to the collagen/ORC. A Cox proportional hazards analysis showed OFM-treated wounds had a 18% greater probability of healing versus wounds managed with collagen/ORC, and the probability increased to 21% when the analysis was adjusted for multiple variables. This study represents the first large retrospective RWD analysis comparing OFM and collagen/ORC and supports the clinical efficacy of OFM in the treatment of DFUs.

Patient Perspective on Post-Breast Reconstruction Exercise and Physical Therapy.

BACKGROUND: Breast reconstruction may result in significant functional compromise and pain. Postoperative exercise and physical therapy can mitigate these morbidities, but it is infrequently recommended by healthcare providers. This study asked how many breast reconstruction patients are instructed to perform postoperative at-home exercises or physical therapy, how many reported following through with these instructions, and what timeline they were given for these activities. METHODS: A 16-question multiple-choice anonymous online survey was distributed to a private breast cancer survivor Facebook group (Diep C. Foundation). RESULTS: A total of 150 breast reconstruction patients responded to our survey. The majority of respondents in our sample were not provided with specific instructions regarding postoperative at-home exercises (N = 70, 54.3%) or physical therapy (N = 77, 63.6%). Approximately 13 of 59 respondents (22%) who had been instructed to participate in postoperative at-home exercises were directed to begin at 2-3 weeks. Approximately 15 of 44 respondents (34.1%) who had been instructed to participate in physical therapy were directed to begin these at 4-5 weeks. CONCLUSIONS: To the best of our knowledge, this is the first study of how often postoperative at-home exercises and physical therapy are recommended to breast reconstruction patients. Despite robust evidence of these activities' benefits, most women are not instructed to participate in postoperative at-home exercises or physical therapy. This is likely to impede breast reconstruction patients' recovery and delay their return to activities of daily living. More studies are needed of how to actively engage breast reconstruction patients in postoperative at-home exercises and physical therapy.

Viability of acellular biologic graft for nipple-areolar complex reconstruction in a non-human primate model.

Many of the > 3.5 million breast cancer survivors in the US have undergone breast reconstruction following mastectomy. Patients report that nipple-areolar complex (NAC) reconstruction is psychologically important, yet current reconstruction techniques commonly result in inadequate shape, symmetry, and nipple projection. Our team has developed an allogeneic acellular graft for NAC reconstruction (dcl-NAC) designed to be easy to engraft, lasting, and aesthetically pleasing. Here, dcl-NAC safety and host-mediated re-cellularization was assessed in a 6-week study in rhesus macaque non-human primates (NHPs). Human-derived dcl-NACs (n = 30) were engrafted on the dorsum of two adult male NHPs with each animal's own nipples as controls (n = 4). Weight, complete blood counts, and metabolites were collected weekly. Grafts were removed at weeks 1, 3, or 6 post-engraftment for histology. The primary analysis evaluated health, re-epithelialization, and re-vascularization. Secondary analysis evaluated re-innervation. Weight, complete blood counts, and metabolites remained mostly within normal ranges. A new epidermal layer was observed to completely cover the dcl-NAC surface at week 6 (13-100% coverage, median 93.3%) with new vasculature comparable to controls at week 3 (p = 0.10). Nerves were identified in 75% of dcl-NACs (n = 9/12) at week 6. These data suggest that dcl-NAC is safe and supports host-mediated re-cellularization.

Surgical reconstruction of pilonidal sinus disease with concomitant extracellular matrix graft placement: a case series.

BACKGROUND: Pilonidal sinus disease (PSD) is a chronic inflammatory disease affecting the soft tissue of the sacrococcygeal region and remains a challenging disease for clinicians to treat. The optimal treatment for PSD remains controversial and recent reports describe several different surgical approaches offering different benefits. Approximately 40% of initial incision and drainage cases require subsequent surgery. Due to high recurrence rates and postoperative complications, a more complex revision surgery involving a flap reconstruction may be required. We hypothesised that the combination of an extracellular matrix (ECM) graft with tissue flap reconstruction may decrease the postoperative complications and recurrence rates for PSD. METHOD: We report a retrospective case series using a surgical flap reconstruction with concomitant implantation of an ovine forestomach ECM graft under a fasciocutaneous flap with an off-midline closure for recurrent PSD, where previously surgical intervention had failed due to wound dehiscence and/or recurrent disease. RESULTS: The case series included six patients. After three weeks, all patients except one were fully healed, and the sixth was fully healed by week 4; all wounds remained fully healed at 12 weeks. All patients achieved good cosmesis and were able to return to normal function without any residual symptoms. CONCLUSION: This pilot case series explored augmenting a flap reconstruction for complex PSD with advanced ECM graft materials, demonstrating that it may improve outcomes and minimise typical complications seen in flap closure, such as inflammation, infection, haematoma/seroma and hypoperfusion. Although the study had a limited number of participants, long-term outcomes were promising and suggest that further studies are warranted.

Extracellular matrix graft for reconstruction over exposed structures: a pilot case series.

OBJECTIVE: Soft tissue defects, especially those involving exposed vital structures, present a reconstructive challenge because poor vascularity of such defects typically makes immediate skin grafting unviable. Where flap procedures are inappropriate or not possible, dermal matrices represent an alternative reconstructive option for defects with denuded vital structures. With dermal matrices becoming increasingly available and technologically advanced, we evaluated an ovine-derived extracellular matrix graft in the reconstruction of complex soft tissue defects involving exposed vital structures. METHOD: Six cases of soft tissue defects exhibiting denuded vital structures underwent reconstruction using an ovine forestomach matrix graft as a dermal matrix. Grafts were fixed directly into defects for immediate coverage and subsequently temporised defects via granulation tissue formation for later skin graft or secondary closure. Defect granulation and epithelialisation were monitored until closure and the final aesthetic and functional outcomes were evaluated. RESULTS: Complete healing was achieved in all cases, with defect granulation becoming observable within one to two weeks and complete granulation occurring within one to six weeks. Granulation tissue resulting from the graft was suitable for skin grafting, with 100% take of skin grafts after one week and complete re-epithelialisation in two to three weeks in the four cases that received a skin graft. Good cosmetic, functional and patient satisfaction outcomes were achieved in all cases. CONCLUSION: The present series demonstrates our initial use of an extracellular matrix-based dermal matrix in reconstructing defects with exposed vital structures. While such dermal matrices do not supersede or replace flap procedures, they represent an alternative option on the reconstructive ladder in cases where flap procedures are not appropriate or possible.

Extracellular matrix graft for the surgical management of Hurley stage III hidradenitis suppurativa: a pilot case series.

OBJECTIVE: Surgical management of Hurley stage III hidradenitis suppurativa (HS) typically involves the excision of diseased tissue and subsequent reconstruction, potentially leading to complications or recurrence of the disease. This pilot case series sought to evaluate a decellularised ovine forestomach matrix (OFM) extracellular matrix (ECM) graft for soft tissue regeneration as part of surgical reconstruction of stage III HS of the axilla. METHOD: The prospective pilot case series involved six participants and a total of eight defects. The ECM graft was used either as a dermal substitute for a staged reconstruction (n=3 defects) or as an implant under a fasciocutaneous flap (n=5 defects) following wide excision of the diseased tissue. RESULTS: In all cases complete healing was achieved, with no major surgical complications. When used as a dermal substitute the OFM graft was completely granulated within 2-4 weeks, with defects closing by secondary intention or following placement of a split-thickness skin graft. When used as an implant beneath a fasciocutaneous flap, healing of the surgical sites was observed after 1-3 months. At the long-term follow-up (3-12 months), all participants had excellent range of motion and none had reported disease recurrences. CONCLUSION: This pilot case series explored the implementation of an ECM graft as part of the surgical management of axilla Hurley stage III HS. Although the study had a limited number of participants, long-term outcomes were promising and suggest further studies are warranted.