Outcomes and complications of postoperative seroma cavities following soft-tissue sarcoma resection.

Introduction: Seroma development is a known complication following extremity and trunk soft-tissue sarcoma (STS) resection. The purpose of this study is to evaluate and characterize seroma outcomes and the development of associated complications. Methods: A retrospective review of 123 patients who developed postoperative seromas following STS resection at a single institution was performed. Various patient and surgical factors were analyzed to determine their effect on overall seroma outcomes. Results: 77/123 seromas (62.6%) were uncomplicated, 30/123 (24.4%) developed infection, and 16/123 (13.0%) were symptomatic and required aspiration or drainage for symptom relief at an average of 12.2 months postoperatively. 65/123 (52.8%) seromas resolved spontaneously at an average time of 12.41 months. Seromas in the lower extremity (p=0.028), surgical resection volume >864 cm3, (p=<0.001) and initial seroma volume >42 cm3 (p=<0.001) increased the likelihood of infection. 90% of infected seromas developed the infection within the first three months following initial resection. No seromas which were aspirated or drained ultimately developed an infection following these procedures, though 50% recurred. Discussion: Most seromas following STS resection are uncomplicated and do not require intervention, though a large resection cavity >864 cm3 and a large seroma volume >42 cm3 are risk factors for complications.

Microsurgical breast reconstruction and primary hypercoagulable disorders.

BACKGROUND: Primary hypercoagulable disorders pose a significant challenge to microsurgeons and have traditionally been regarded as a relative contraindication to free tissue transfer. Since free flaps offer numerous advantages in breast reconstruction, there is an effort to expand the population to whom these operations can be safely offered. The purpose of this study is to describe our chemoprophylaxis regimen in cases of primary hypercoagulability, as well as to compare flap outcomes and complications between women with and without hypercoagulability. PATIENTS AND METHODS: A single institution retrospective review identified 15 patients (25 flaps) with known primary hypercoagulability who underwent microsurgical breast reconstruction from 2010 through 2020. There were 785 patients (1268 flaps) without primary hypercoagulability who underwent microsurgical breast reconstruction, including 40 patients (73 flaps) with a history of venous thromboembolism (VTE), evaluated for comparison. Patient characteristics, thromboprophylaxis regimen, and surgical outcomes were collected. In carrying out this cohort study, we have adhered to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. RESULTS: Fifteen patients with primary hypercoagulability were identified, including heterozygous factor V Leiden mutation (n = 12), protein S deficiency (n = 1), prothrombin mutation (n = 1), and primary antiphospholipid syndrome (n = 1). Thirteen of these (87%) were discharged with an extended LMWH course. There was no postoperative VTE or mortality in this cohort, and no significant difference in hematoma or transfusion compared with the control group (p = .31, p = .87, respectively). The flap loss rate was 4% in the hypercoagulable group compared with 0.92% in the control group (p = .15). The salvage for arterial or venous compromise in the hypercoagulable group was poor (0% vs. 52%, p = .3). CONCLUSION: Microsurgical breast reconstruction in women with primary hypercoagulability disorders is feasible with acceptable risk of flap loss but poor salvage potential. Postoperative thromboprophylaxis with extended prophylactic LMWH in this population appears to be a safe regimen.

Heparin-induced thrombocytopenia in lower extremity free tissue transfers.

BACKGROUND: Heparin-induced thrombocytopenia (HIT) an immunologically mediated reaction to heparin products, can lead to severe thrombocytopenia and potentially life-threatening thrombotic events. In microsurgery, a missed or delayed diagnosis of HIT can cause complications requiring revision operations, flap loss, or limb loss. Surgeons must remain vigilant for this uncommon yet potentially devastating condition and keep abreast of management strategies. METHODS: CPT and ICD-10 codes in electronic medical records were used to collect demographic information, clinical courses, and outcomes for patients with a HIT diagnosis who underwent lower extremity free tissue transfer in one institution. RESULTS: The authors' institution performed 415 lower extremity free flaps in 411 patients during the 10-year study period. Flap salvage rate was 71% for compromised lower extremity flaps without HIT, and 25% in those with HIT. Four patients (four flaps) met study inclusion criteria during the study period. Three of the four flaps failed and were later debrided; one was rescued after a takeback for anastomosis revision. Two patients successfully underwent a delayed second free flap procedure after recovery, and one was salvaged with a pedicled muscle flap. CONCLUSIONS: Surgeons should monitor for HIT by establishing coagulation panel and platelet count baselines and trending these values in the early post-operative period for patients treated with heparin products. The 4T score can be used to screen for HIT with high clinical suspicion. Arterial thrombosis or poor flap perfusion despite sound microvascular technique could suggest HIT. Surgical and medical management including strict heparin avoidance can prevent adverse events for these patients.

Rates of major complications and flap loss for abdominally based breast reconstruction in obese patients are independent of WHO class of obesity.

INTRODUCTION: Obesity is a risk factor for complications following autologous breast reconstruction. Little is known regarding outcomes based on the degree of obesity. This study compares breast reconstruction outcomes and complication rates for the three classes defined by the body mass index (BMI)-based WHO classification. METHODS: The authors conducted a retrospective chart review identifying obese patients who underwent abdominally based breast reconstruction between January 2011 and January 2021. Patients were stratified by BMI class [class 1 (C1) = 30-34.99 kg/m2, class 2 (C2) = 35-39.99 kg/m2, and class 3 (C3) = 40 kg/m2 + ]. Outcomes were compared. RESULTS: A total of 232 patients (395 flaps) were included with 138 patients were classified as C1, 68 patients as C2, and 26 patients as C3. Rates of any complication (80%) and at least one major complication (31%) did not vary significantly (P = 0.057, 0.185). Individual rates of 30-day readmission (18%) or reoperation (26%) did not vary significantly (P = 0.588 and 0.059). Rates of seroma (C1 = 15%, C2 = 16%, and C3 = 35%), hernia (C1 = 0%, C2 = 4%, and C3 = 8%), and incisional dehiscence (C1 = 30%, C2 = 44%, and C3 = 62%) were associated with significantly increased risk with higher classes of obesity (P < 0.05). The rate of flap failure did not vary significantly (P = 0.573). CONCLUSION: The risk of major complications and total flap loss associated with abdominally based breast reconstruction does not differ between the classes of obesity. Although complication rates are high overall in the obese population, detrimental complications do not vary between the classes. Patients should be counseled regarding their individual risk without the need for arbitrary BMI cutoffs.

Outcome comparison between muscle and fasciocutaneous flaps after secondary orthopedic procedures.

Lower extremity wounds associated with fractures and bony defects often require secondary orthopedic procedures after flap coverage has been performed. In this study, we compare complications between muscle and fasciocutaneous flaps after secondary orthopedic procedures. A retrospective chart review study of all lower extremity soft tissue reconstructions by a single surgeon over seven years yielded a subgroup of patients who underwent secondary orthopedic procedures, including hardware removal, hardware revision, and bone grafting after flap reconstruction. Of 355 lower extremity, soft tissue reconstructions for orthopedic coverage performed in the time period studied, 102 patients underwent secondary orthopedic procedures after flap reconstruction. Of these, 54 received muscle flaps (52.94%), and 48 received fasciocutaneous flaps (47.06%). Using this subgroup of 102 patients, we compared muscle and fasciocutaneous flaps using three categories of wound complications following these secondary procedures: There were no superficial wounds requiring local wound care only in the muscle flap group (0%, n = 0) versus 4.17% (n = 2; p = 0.130) in the fasciocutaneous flap group. There were 2 lost flaps requiring surgical debridement and additional skin grafting in the muscle flaps group (3.70%) versus 2 (4.17%; p = 0.904) in the fasciocutaneous flap group. In the third category, flap loss requiring additional soft tissue reconstruction was 18.52% (n = 10) in the muscle group versus 2.08% (n = 1; p = 0.008) in the fasciocutaneous flap group. Our data support the existing literature indicating that fasciocutaneous flaps can tolerate secondary procedures better than muscle flaps and should initially be considered in patients with higher probability of needing additional orthopedic procedures after reconstruction.

Management of Postsurgical Pyoderma Gangrenosum Following Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Role for a Dermal Regeneration Template.

INTRODUCTION: Pyoderma gangrenosum (PG) is a relatively uncommon necrotizing and ulcerative cutaneous disorder. It is often associated with a systemic inflammatory disease but may also present following trauma to the skin due to pathergy. Given its rare occurrence and nonspecific histology, PG is primarily a diagnosis of exclusion, which often results in delayed treatment. Very few cases of PG following autologous breast reconstruction have been reported in the literature, particularly in the absence of systemic disease. CASE REPORT: Presented is the case of a 62-year-old female with a history of ductal carcinoma in situ who underwent a left breast mastectomy with immediate deep inferior epigastric perforator flap breast reconstruction complicated by fever and leukocytosis as well as erythema, edema, and bullae involving the mastectomy flaps. Initially, necrotizing soft-tissue infection was suspected, and 2 debridements were performed. A diagnosis of PG was made on postoperative day 7, and the patient responded favorably to high-dose prednisone. Reconstruction was performed with a bilayer wound matrix and delayed skin grafting. Despite significant loss of mastectomy skin flap, the free flap was preserved. CONCLUSIONS: Although PG is a rare complication, it should be considered in the differential diagnosis for patients with atypical presentation of infection following breast reconstruction, even in the absence of systemic inflammatory disease. Early diagnosis and multidisciplinary management may prevent unnecessary surgical intervention and enable flap preservation. Furthermore, bilayer wound matrix placement may be useful as an intermediate reconstruction to determine if it is safe to proceed with skin grafting to avoid further pathergy. The findings in this case suggest that final reconstruction may be safely performed sooner than noted in the literature.

Comparative Analysis of Prepectoral versus Subpectoral Implant-based Breast Reconstruction.

Recent advances in mastectomy and reconstruction have allowed for an evolution in implant-based breast reconstruction to a muscle-sparing, prepectoral approach. Advantages of this technique may include reductions in postoperative pain, shorter hospitalization, less narcotic usage, and improved aesthetic outcomes. Postoperative complication rates are described as comparable to subpectoral techniques; however, little comparative data exist to adequately assess prepectoral versus subpectoral implant placement. METHODS: To address this knowledge gap, we performed a single institution retrospective review of 186 (83 prepectoral, 103 subpectoral) consecutive immediate breast reconstructions. All cases were tracked for a minimum of 2 years between 2016 and 2021. RESULTS: Prepectoral patients demonstrated an overall higher seroma rate (P = 0.001), with all other postoperative complications being comparable. Prepectoral patients tolerated higher intraoperative tissue expander fill volumes (P < 0.001), shorter hospital stays (P = 0.007), fewer clinic visits for tissue expansion (P < 0.001), and experienced less animation deformity (P = 0.005). Both groups demonstrated similar pain scores (P = 0.65) and needs for narcotics (P = 0.8) as well as comparable scores of capsular contracture (P = 0.791). CONCLUSIONS: Our comparative analysis of consecutive immediate implant-based breast reconstructions finds prepectoral reconstruction to be safe and effective. Compared with subpectoral reconstruction, the prepectoral approach may offer quicker tissue expansion, less postoperative office visits, less need for muscle relaxants, and a shorter hospital stay with a comparable complication profile.

Clinical course of venous thromboembolism following abdominally based microsurgical breast reconstruction: A case series.

BACKGROUND: Venous thromboembolism (VTE) is a potentially devastating complication following abdominally based microsurgical breast reconstruction, with a reported incidence of 0.08-4%. The authors aim to describe disease presentation and clinical course following VTE diagnosis in patients within their practice. METHODS: A retrospective chart review identified patients who underwent microsurgical breast reconstruction from January 2007 through December 2018. Patients with VTE diagnosed within 90 days of surgery were included. Demographics, co-morbidities, signs and symptoms, and characteristics of oncologic, surgical, and post-operative care were analyzed. RESULTS: Seven hundred one patients underwent microsurgical breast reconstruction. Eleven patients with pulmonary embolism (PE) and four with deep vein thrombosis (DVT) were identified, resulting in VTE incidence of 2.1% (0.57% DVT, 1.6% PE). Patients were on average 51 years old and had an average body mass index (BMI) of 31.7 kg/m2. Two had a history of VTE, and none had a known hypercoagulable disorder. Using the 2005 Caprini model, all were high risk and seven were highest risk. Among those with PE, the most common symptom was shortness of breath, and the most common signs were desaturation or supplemental oxygen requirements. VTE was diagnosed on average 14.2 days post-operatively (range 2-52 days). CONCLUSION: VTE is an infrequent complication following abdominally based microsurgical breast reconstruction. We recommend a high index of suspicion in women reporting shortness of breath or having desaturation, especially in those with high BMI, high Caprini scores, post-operative complications, or early return to the operating room.

Exploring the Role of Partner Satisfaction in Predicting Patient Satisfaction Regarding Post-mastectomy Breast Reconstruction.

Qualitative studies have suggested that perceived partner satisfaction is an important predictor of patient satisfaction in post-mastectomy breast reconstruction. To better characterize these relationships, a couple-based study employing a quantitative analysis was conducted. METHODS: BREAST-Q and a novel partner survey were used to assess relationships among patient satisfaction, perceived partner satisfaction, and reported partner satisfaction in 11 couples. Breast reconstruction patients completed the postoperative BREAST-Q, and their partners completed a survey designed to assess satisfaction with their emotional relationship, partner's breasts, partner's medical care, and sexual relationship. RESULTS: The majority of patients were married. Seventy-three percent of women had an implant-based reconstruction, while 27% had an abdominal-based reconstruction. The majority (82%) of patients reported no complications with reconstructive procedures. The mean patient BREAST-Q score was 86 (range, 48-97), and the mean partner score was 87 (64-98). There was a correlation of 0.85 between reported partner satisfaction and patient satisfaction. Fifty-eight percent of partners reported being afraid to touch their partner's reconstructed breasts out of fear of causing pain; 7% of patients reported experiencing pain in the area of their reconstructed breasts. CONCLUSIONS: This study reveals that partner satisfaction with breast reconstruction correlates with patient satisfaction. With this knowledge, we will be able to formulate suggestions on how preoperative consultations could be conducted as to optimize patient and partner satisfaction and bridge the gap between patient and partner knowledge of postoperative pain.

Successful Salvage of Delayed Venous Congestion After DIEP Flap Breast Reconstruction.

Objective: Failure rates of microvascular autologous breast reconstruction are reportedly low. When failure of the microvascular anastomoses does occur, it is most likely to be salvaged if detected early. Flap compromise or venous congestion occurring several weeks later is uncommon and with significantly lower salvage rates. Methods: We present a unique case of delayed venous congestion of a single-perforator deep inferior epigastric perforator flap breast reconstruction in which the usual pedicle thrombosis was not identified. Presentation of the flap compromise occurred 72 hours postoperatively and again in the delayed setting 5 weeks after surgery, from suspected compression at the perforator level. Results: The deep inferior epigastric perforator flap was successfully salvaged with conservative measures, and the flap healed without fat necrosis or further complication. Conclusion: This case highlights the higher risk of flap compromise with reconstructions in a radiated field and potentially with single-perforator flaps.

Microsurgical Breast Reconstruction in the Obese: A Better Option Than Tissue Expander/Implant Reconstruction?

BACKGROUND: Obesity has reached epidemic proportions, with 72 million people in the United States classified as obese in 2010. This significant increase in obese patients is reflected in the breast cancer population seeking breast reconstruction. Previous studies demonstrated increased complication rates and decreased satisfaction in obese patients undergoing breast reconstruction. This study aims to directly compare prosthetic and autologous reconstruction in the obese population by evaluating surgical outcomes and patient satisfaction. METHODS: In an institutional review board-approved study, a retrospective chart review was conducted on patients with a body mass index of 30.0 kg/m or greater who underwent breast cancer reconstruction after mastectomy with either free tissue transfer from the abdomen or prosthetic reconstruction over a 3-year period. The authors identified 96 patients with 141 reconstructions. Demographic, intraoperative, and postoperative variables were collected. All patients were sent the BREAST-Q questionnaire by means of mail to study the impact and effectiveness of breast surgery from the patient's perspective. Statistical analysis was completed with Fisher's exact test, Mantel-Haenszel chi-square test, Pearson chi square test, or Mann-Whitney-Wilcoxon test. RESULTS: Prosthetic-based breast reconstruction was associated with increased major breast complications (p < 0.001), mastectomy skin flap necrosis (p = 0.009), infection (0.006), and overall reconstructive failure (p < 0.0001) compared with autologous reconstruction. When evaluating the results of the BREAST-Q studies, the autologous reconstruction group had improved satisfaction with breasts (p < 0.0001), satisfaction with outcome (p = 0.01), psychosocial well-being (p = 0.007), and sexual well-being (p = 0.006). CONCLUSION: In the obese population, reconstruction with free tissue transfer from the abdomen resulted in decreased complications of the breast reconstruction site and improved patient satisfaction with outcomes compared with prosthetic reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Salvaging the Unavoidable: A Review of Complications in Pediatric Tissue Expansion.

BACKGROUND: Tissue expansion, while a mainstay of reconstruction for pediatric cutaneous lesions, has significant complication rates. The authors review the complications in a single-surgeon series of tissue expansion to identify risk factors for complications and guide subsequent therapy so that reconstructive goals in patients can be met irrespective of intervening complications. METHODS: A retrospective chart review was conducted of all pediatric patients who underwent tissue expansion performed by the senior author (A.K.G.) over a 12-year period. In total, 282 expanders were placed in 94 patients. RESULTS: A total of 65 complications occurred in 39 of 94 patients (41.5 percent), involving 65 of the 282 expanders (23.0 percent) placed. Major complications that required expander removal included exposure (n = 11), rupture (n = 15), and migration (n = 11). The most frequent minor complications, which did not require immediate expander removal, included migration (n = 13) and port malfunction (n = 9). The majority of expanders were placed in the scalp (n = 114), followed by the torso (n = 100), face and neck (n = 52), and the extremities (n = 16). Serial expansion beyond the second round resulted in a marked increase in complications. Despite complications, tissue expansion in the majority of patients could be salvaged, and a satisfactory outcome was achieved. CONCLUSIONS: Families must be made aware that approximately one-third of patients may have a complication requiring additional surgery or modification of the initial reconstructive plan. However, these complications need not preclude attainment of reconstructive goals. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Microsurgical repair of neonatal iliac artery injuries with saphenous vein grafts.

Two neonates with congenital heart disease, one and thirty-one days old respectively, suffered inadvertent arterial injury from cardiac catheterization. Both insults resulted in unrecognized avulsion of the external iliac artery from its origin. The patients quickly decompensated, with their right lower extremities becoming critically ischemic. In both cases, segments of reversed greater saphenous vein were used as interposition grafts from the common iliac artery to the common femoral artery. Reperfusion of the right foot was immediate for the one-day-old. She is now three years old and able to run, but is followed for a mild limb length discrepancy. The 31-day-old had restoration of flow to the right limb; however, the foot remained ischemic and eventually required transmetatarsal amputation. She is now 16 months old and able to crawl; she also is followed for limb length discrepancy. Without vein grafting, both infants would likely have lost their affected limbs, and possibly lost their lives. These cases advocate for microsurgical repair of arterial injuries in even the youngest patients, and promote the use of vein grafts when direct anastomosis is not feasible.

Current Practices in the Management of Postoperative Arterial Vasospasm in Microsurgery.

BACKGROUND: Postoperative microvascular arterial vasospasm is a rare clinical entity. There are no published management algorithms and also the pathophysiology of this phenomenon has not been elucidated. METHODS: An email survey of American Society for Reconstructive Microsurgery (ASRM) and World Society for Reconstructive Microsurgery (WSRM) members regarding their experiences with postoperative arterial vasospasm was conducted, returning 116 responses. A comprehensive literature search was conducted regarding the current body of knowledge on this entity. RESULTS: Sixty-five percent of respondents encountered cases where postoperative arterial vasospasm was clearly the cause of flap ischemia. The majority (62%) of surgeons believed a damaged segment of the artery was responsible for the spasm, with technical issues cited as the most likely cause. Sixty-two percent and 50% of surgeons used segmental resection of the recipient and donor vessels, respectively.Rated for proclivity to vasospasm, superficial inferior epigastric artery (SIEA) was the flap, superior thyroid artery (STA) the recipient vessel, and the lower limb the anatomic region most frequently mentioned.Most widely used management strategies were: topical vasodilators (91%), adventitial stripping (82%), and dilation of recipient and donor vessels (76%). Over 50% of surgeons used some type of vessel resection technique. CONCLUSIONS: When flap ischemia is encountered without mechanical issues or thrombus, vasospasm can be the root cause. Certain vessels (SIEA, STA) and anatomic regions (lower limb) pose a higher risk for this phenomenon. When a vessel is affected, it is common practice to excise the questionable segment and use a graft as needed. Vessel resection as part of a multimodal approach can result in a reasonable salvage rate.

Increasing Calcium Level Limits Schwann Cell Numbers In Vitro following Peripheral Nerve Injury.

Background After peripheral nerve injury, there is an increase in calcium concentration in the injured nerves. Our previous publications have shown that increase in calcium concentration correlated well with degree of nerve injury and that local infusion of calcitonin has a beneficial effect on nerve recovery. Schwann cells play a pivotal role in regeneration and recovery. We aim to examine cultured Schwann cell survivals in various concentrations of calcium-containing growth media and the effect of calcitonin in such media. Methods To establish baseline in postinjury state, crush injury was induced in male Sprague-Dawley rats' sciatic nerves. Extra- and intraneural calcium concentrations were measured. To study Schwann cell survival, uninjured sciatic nerve segment was harvested and cultured in media containing various amounts of calcium. To study the effect of calcitonin, nerve harvest and culture were done in four additional media: (1) normal control, (2) normal control with calcitonin, (3) high calcium medium, and (4) high calcium medium with calcitonin. Schwann cells were studied and analyzed under fluorescent conditions. Results With increasing calcium concentration, there was a significant decrease in the number of Schwann cells. For the experimental groups, in which calcitonin had been added to the growth medium, there were similar amounts of Schwann cells present in both high and low calcium-containing medium. Conclusion Schwann cells are sensitive to increasing calcium concentration. Calcitonin counteracts the detrimental effects of high calcium on Schwann cell survival. This can have significant future clinical implications for patients with peripheral nerve injuries.

Microvascular surgery in the congenital cardiac patient: A case series exploring feasibility and practical applications.

BACKGROUND: Pediatric congenital heart disease patients are at risk for vascular injuries during surgical procedures or when the arterial system is accessed for monitoring or diagnostic studies. Our treatment of emergent situations in this patient population using microvascular techniques shows the feasibility of such techniques. METHODS: A retrospective chart review of patients aged 0-18 years with congenital heart disease identified six patients who underwent microvascular surgery by the senior surgeon from June 2007 to May 2015. We studied this series, highlighting technical aspects of surgery and perioperative care to determine their effect on outcome. RESULTS: Six patients with congenital cardiac defects requiring cardiothoracic surgery were studied, body weight ranging from 3.2 to 19.1 kg at the time of surgery. Five suffered iatrogenic arterial injury to the heart or vessels used for access or diagnostic studies, including coronary artery laceration, brachial artery thrombosis, and external iliac artery avulsion. Interventions included direct end-to-end repair and vein grafting. Vessel diameter averaged 1 mm. Patients received vasopressors intraoperatively and were on vasopressors and antihypertensives postoperatively. One patient died because of disseminated intravascular coagulation on postoperative day 17, but bypass graft was patent prior to death. The rest survived with clinical evidence of patency of the repaired vessel for a long-term. CONCLUSIONS: Microsurgical intervention may be life-saving as a revascularization procedure to the heart by direct coronary repair or bypass grafting. Iatrogenic injuries to the limb may cause critical ischemia; limbs can be salvaged by microsurgical repair. Despite technical and physiological challenges, microsurgery is feasible and sometimes crucial in this patient population.

Best time window for the use of calcium-modulating agents to improve functional recovery in injured peripheral nerves-An experiment in rats.

Peripheral nerve injury can have a devastating effect on daily life. Calcium concentrations in nerve fibers drastically increase after nerve injury, and this activates downstream processes leading to neuron death. Our previous studies showed that calcium-modulating agents decrease calcium accumulation, which aids in regeneration of injured peripheral nerves; however, the optimal therapeutic window for this application has not yet been identified. In this study, we show that calcium clearance after nerve injury is positively correlated with functional recovery in rats suffering from a crushed sciatic nerve injury. After the nerve injury, calcium accumulation increased. Peak volume is from 2 to 8 weeks post injury; calcium accumulation then gradually decreased over the following 24-week period. The compound muscle action potential (CMAP) measurement from the extensor digitorum longus muscle recovered to nearly normal levels in 24 weeks. Simultaneously, real-time polymerase chain reaction results showed that upregulation of calcium-ATPase (a membrane protein that transports calcium out of nerve fibers) mRNA peaked at 12 weeks. These results suggest that without intervention, the peak in calcium-ATPase mRNA expression in the injured nerve occurs after the peak in calcium accumulation, and CMAP recovery continues beyond 24 weeks. Immediately using calcium-modulating agents after crushed nerve injury improved functional recovery. These studies suggest that a crucial time frame in which to initiate effective clinical approaches to accelerate calcium clearance and nerve regeneration would be prior to 2 weeks post injury. © 2017 Wiley Periodicals, Inc.

Effect of calcitonin on cultured schwann cells.

INTRODUCTION: After nerve injury, calcium concentrations in intranerve fibers quickly increase. We have shown that functional recovery of injured nerves correlates with calcium absorption. A slight increase in calcium reduces the number of Schwann cells present. Calcitonin therapy greatly improves regeneration by accelerating calcium absorption. We examined the effect of adding calcitonin to higher concentration calcium media on cultured Schwann cells. METHODS: The cells, isolated from intact sciatic nerves, were cultured with normal or higher concentration calcium media with or without calcitonin. Schwann cells were incubated with anti-S-100, goat-anti-mouse, and propidium iodide and then viewed through fluorescent light and phase-contrast microscopy for observation and analysis. RESULTS: The cells in each calcitonin-containing medium showed many Schwann cells, however, the cells in the higher concentration calcium media showed fewer and more defective Schwann cells. CONCLUSION: These results show that calcitonin protects against the harmful effects of excessive calcium encountered in peripheral nerve injury. Muscle Nerve 56: 768-772, 2017.

When the Gastrointestinal Conduit for Total Esophageal Reconstruction Is Not an Option: Review of the Role of Skin Flaps and Report of Salvage With a Single-Stage Tubed Anterolateral Thigh Flap.

This review adds to the limited body of literature describing the use of skin flaps for reconstruction of the esophagus and includes a report of a successful 1-stage, intrathoracic reconstruction of the cervical and thoracic esophagus after failed gastrointestinal conduit. Already widely used for reconstruction of the pharynx and cervical esophagus, the versatile anterolateral thigh flap can be considered an option for more extensive defects of the cervical and thoracic esophagus in this challenging patient population when gastric, jejunal, or colon conduits are not available. The authors believe the anterolateral thigh flap should be considered in 1-stage anatomic reconstruction of the cervical and thoracic esophagus in the absence of feasible gastrointestinal conduits.