Intraoperative Near-infrared Spectroscopy Correlates with Skin Flap Necrosis: A Prospective Cohort Study.

BACKGROUND: Skin flap necrosis (SFN) is a morbid complication that is disfiguring, leads to acute and chronic wound issues, often requires further surgery, and can delay adjuvant chemotherapy. Although most surgeons rely on the clinical examination, near-infrared (NIR) spectroscopy can extrapolate tissue oxygenation and may serve as an important tool to assess flap perfusion intraoperatively. This cohort study was undertaken to evaluate the capacity of NIR spectroscopy to detect clinically relevant differences in tissue perfusion intraoperatively. METHODS: Patients undergoing oncologic resection of breast cancer, sarcomas, and cutaneous tumors requiring flap reconstruction (local, regional, or free) between January 2018 and January 2019 were analyzed in this study. Clinicians were blinded to device tissue oxygen saturation (StO2) measurements taken intraoperatively after closure and at follow-up appointments in the first 30 days. Measurements were categorized as (1) control areas not affected by the procedure, (2) areas at risk, and (3) areas of necrosis. These areas were retrospectively demarcated by 2 blinded assessors on follow-up images and transposed onto anatomically correlated intraoperative StO2 measurements. Mean StO2 values were compared using a single-sample t test and analysis of variance (ANOVA) to determine differences in oxygenation. RESULTS: Forty-two patients were enrolled, and 51 images were included in the analysis. Oncologic procedures were predominantly breast (22), postextirpative melanoma (13), and sarcoma (3) reconstructions. Flap reconstruction involved 30 regional skin flaps, 3 pedicled flaps, and 3 free flaps. Nine patients (20.9%) and 11 surgical sites developed SFN. Mean intraoperative StO2 measurements for control areas, areas at risk, and areas of SFN were 74.9%, 71.1%, and 58.3%, respectively. Relative to control areas, mean intraoperative StO2 measurements were lower by 17.5% (P = 0.01) in ultimate areas of SFN and in areas at risk by 5.8% (P = 0.003). Relative to areas at risk, mean StO2 measurements from areas of ultimate SFN were lower by 8.3% (P = 0.04). CONCLUSION: These preliminary data suggest that measuring skin flap tissue oxygenation intraoperatively, with NIR spectroscopy, can differentiate objective variations in perfusion that are associated with clinical outcomes.

Secondary Effects of Radiation Therapy to the Hand for Benign Conditions.

Background: Emerging literature introduces radiation therapy for benign hand conditions. However, hand surgeons are wary recommending radiation therapy for nonmalignant conditions. In our practice, we have used radiation therapy for patients who present with infiltrative or recurrent giant cell tumor of the tendon sheath (GCTTS) since 1998. The purpose of this study is to examine the secondary effects of radiation to the hand through the critical lens of a hand surgeon. Methods: A case series of patients who received radiation therapy for GCTTS were reviewed. The Radiation Oncology/Toxicity Grading Late Radiation Morbidity Scoring Schema was used, and patients were questioned about symptoms and examined for physical findings involving their irradiated digits. Results: A total of 8 patients with GCTTS presented for follow-up. The average patient age was 59.1 years, and the average time since radiation therapy was 5.4 years. Patients had an average of 2.3 surgeries on the affected digit prior to receiving radiation therapy. The average Disabilities of the Arm, Shoulder, and Hand score was 8.1. The most common sign of radiation was nail changes. All patients complained of sensibility changes, although only 2 of the 8 patients had abnormal moving 2-point discrimination tests. There were no confirmed recurrences of GCTTS and no skin cancers. Conclusions: Patients who received radiation therapy to the hand report high levels of satisfaction with the therapy. Radiation therapy is tolerated well by these patients and has a low level of morbidity in our population.

Usability of the internal mammary recipient vessels in microvascular breast reconstruction.

BACKGROUND AND AIM: Although the internal mammary vessels are, for many surgeons, the recipient vessels of choice in microvascular breast reconstruction, there continues to be some debate regarding their use. The reliability of these vessels, particularly the vein, has been called into question, with high rates of conversion to alternative vessels being reported. This study investigates the true usability rate of the internal mammary vessels in a large series of consecutive patients without preselection. METHODS: A review of all patients who underwent microvascular breast reconstruction at the University Health Network between September 2007 and December 2013 was conducted, and the conversion rate to alternative vessels was determined. RESULTS: A total of 759 microvascular breast reconstructions were performed in 515 patients. The internal mammary vessels were explored in all cases and found to be suitable for anastomosis in 756 of 759 reconstructions. Conversion to the thoracodorsal vessels was required in three reconstructions (0.4%) due to unusable internal mammary arteries. There was no significant increase in unusable vessels with timing or laterality of reconstruction or other factors such as smoking, vascular co-morbidities and adjuvant chemotherapy or radiotherapy. Total flap failure occurred in four reconstructions (0.5%), whereas partial flap loss occurred in five (0.6%). CONCLUSION: The internal mammary vessels can be safely and reliably used in almost all patients undergoing microsurgical breast reconstruction with low rates of microvascular complications.

Current biopsy practices for suspected melanoma: A survey of family physicians in Southwestern Ontario.

BACKGROUND: Family physicians (FPs) have an opportunity to diagnose pigmented lesions early with a timely biopsy. OBJECTIVE: To assess current biopsy practices used by FPs in diagnosing melanoma. METHODS: A computer-generated random sample of 200 practicing FPs from large and small communities in Southwestern Ontario was identified from the College of Physicians and Surgeons of Ontario physician directory. Paper-based surveys exploring practice setting, basic melanoma knowledge, biopsy practices and referral wait times were mailed using a modified Dillman protocol. RESULTS: The response rate was 50% and respondents reflected the demographic characteristics of FPs nationwide as per the National Physician Survey. Knowledge testing revealed reasonable mean (± SD) scores (3.2±1.03 of 5). Twenty percent of respondents would always perform an excisional biopsy of skin lesions suspicious for melanoma. The remaining 80% would avoid an excisional biopsy in an aesthetically sensitive area and if there was risk of failure to close the defect primarily, among other reasons. If an excisional biopsy were not performed, one-half of respondents would perform an incisional biopsy (eg, punch biopsy). In large communities, 24% of patients were not seen by a surgeon within six months when referred without a tissue biopsy, leading to delayed diagnosis. DISCUSSION: Educating and supporting FPs to perform incisional biopsies in cases for which excisional biopsies are inappropriate should result in earlier diagnosis of melanoma. CONCLUSION: FPs appropriately recognize that excisional biopsies are ideal in melanoma management and one-half will move on to an incisional biopsy when excision is not appropriate.

HISTORIQUE: Les médecins de famille (M) peuvent diagnostiquer des lésions pigmentées rapidement grâce à une biopsie. OBJECTIF: Évaluer les pratiques de biopsie actuelles des MF pour diagnostiquer un mélanome. MÉTHODOLOGIE: Un échantillon aléatoire créé par ordinateur de 200 MF en exercice de grandes et petites collectivités du sud-ouest de l'Ontario a été extrait du répertoire de l'Ordre des médecins et chirurgiens de l'Ontario. On leur a posté des sondages papier au sujet de leur lieu de pratique, de leurs connaissances de base sur les mélanomes, de leurs pratiques de biopsie et des temps d'attente avant l'aiguillage, selon un protocole de Dillman modifié. RÉSULTATS: Le taux de réponse s'élevait à 50 % et les répondants reflétaient les caractéristiques démographiques des MF au pays, conformément au Sondage national des médecins. Les tests sur les connaissances ont révélé des indices moyens (± ÉT) raisonnables (3,2±1,03 sur 5). Vingt pour cent des répondants effectueraient toujours une biopsie-exérèse des lésions cutanées en cas de présomption de mélanome. Les 80 % restants éviteraient une biopsie-exérèse dans une zone esthétiquement fragile et en présence d'un risque de ne pas fermer l'anomalie primaire, entre autres. S'ils rejetaient la biopsie-exérèse, la moitié des répondants effectueraient une biopsie incisionnelle (p. ex., biopsie à l'emporte-pièce). Dans les grandes collectivités, 24 % des patients n'étaient pas vus par un chirurgien dans les six mois s'ils étaient aiguillés sans biopsie des tissus, ce qui s'associait à un retard de diagnostic. EXPOSÉ: L'enseignement et le soutien des MF à effectuer une biopsie incisionnelle lorsque la biopsie-exérèse ne convient pas devraient favoriser un diagnostic plus rapide des mélanomes. CONCLUSION: Le MF indiquait correctement que les biopsies-exérèses sont idéales pour prendre en charge les mélanomes et la moitié opterait pour une biopsie incisionnelle lorsque l'excision ne convient pas.