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Maus JC, Hemal K, Khan M, Calder BW, Marks MW, Defranzo AJ, Pestana IA. Dermal Regeneration Template and Staged Skin Grafting for Extirpative Scalp Wound Reconstruction: A 14-Year Experience. Otolaryngol Head Neck Surg 2021; 165:275-281. [PMID: 33588623 DOI: 10.1177/0194599820986582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Dermal regeneration template and staged split-thickness skin grafting may mitigate the need for flap coverage of postoncologic scalp defects. This technique has been studied previously in small case series. We examine the effect of risk factors, surgical technique, irradiation, and dressing modalities on reconstructive outcomes in a highly comorbid patient cohort. STUDY DESIGN Retrospective review. SETTING Academic medical center. METHODS Full- and partial-thickness extirpative scalp wounds reconstructed with dermal regeneration template and staged skin grafting were reviewed over a 14-year period. Stage 1 consisted of template application following burr craniectomy in cases lacking periosteum. Stage 2 consisted of skin grafting. Negative pressure wound therapy (NPWT) was variably used to support adherence. RESULTS In total, 102 patients were analyzed (average age 74, mean follow-up 18 months). Eighty-one percent were American Society of Anesthesiologists class 3 or 4. Defect size averaged 56 cm2. Average skin graft take was 94.5% in full-thickness wounds. Seven patients failed this method. Preoperative scalp irradiation was associated with major complication and delayed graft healing. Comorbidities, wound size, and burring were not associated with complication. Patients were more likely to heal with NPWT compared to bolster (hazard ratio, 1.67; 95% CI 1.01-2.77; P = .046). Time between stages was 6.6 days shorter when NPWT was applied (P < .001). CONCLUSION Dermal template and staged skin grafting is a reliable option for postcancer scalp reconstruction in poor flap candidates. Radiotherapy is associated with adverse outcomes. Negative pressure wound therapy simplifies postoperative wound care regimens and may accelerate healing.
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Affiliation(s)
- Jacob C Maus
- Department of Plastic and Reconstructive Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Kshipra Hemal
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mija Khan
- Department of Plastic and Reconstructive Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Bennett W Calder
- Department of Plastic and Reconstructive Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Malcolm W Marks
- Department of Plastic and Reconstructive Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Anthony J Defranzo
- Department of Plastic and Reconstructive Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Ivo Alexander Pestana
- Department of Plastic and Reconstructive Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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Abstract
BACKGROUND Despite extensive use of Integra in burn reconstruction, little has been published regarding its utility in complex hand wounds from nonburn trauma or cancer resection. This study aimed to review outcomes following Integra use for hand reconstruction following cancer resection or nonburn trauma with exposed bone, joints, and/or tendons. METHODS Retrospective review was performed of patients undergoing hand reconstruction with Integra for exposed bones, joints, or tendons over a 6-year period at a single institution. RESULTS Fourteen patients underwent hand reconstruction using Integra, 8 following cancer resection and 6 following acute nonburn trauma. The mean defect size was 19 cm2, 79% had exposed tendon without peritenon, 43% had exposed bone without periosteum, and 28% had exposed joint capsule. Mean time from Integra to skin graft was 11.3 days, and negative-pressure wound therapy did not significantly decrease the mean time from Integra to skin graft placement ( P = .76). Overall, 13 patients achieved successful reconstruction with mean skin graft take of 97%, and 1 required revision amputation at the proximal interphalangeal (PIP) joint. Six months postoperative, 92% patients had return of preoperative hand function. Without any surgical revision, 85% of patients were extremely satisfied with the aesthetic result and 15% were fairly satisfied. CONCLUSIONS Integra is an effective method to treat complex hand wounds with exposed bone, joints, and/or tendons. This technique can be used in the office, lessens the need for local or free flap coverage, and provides an excellent aesthetic outcome. Integra should be considered a viable option in hand reconstruction algorithm.
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Affiliation(s)
| | | | - Nicholas J. Walker
- Wake Forest Baptist Health, Winston-Salem, NC, USA,Nicholas J. Walker, Department of Plastic and Reconstructive Surgery, Wake Forest Baptist Health, 1 Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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Cartwright MS, Griffin LP, Dowlen H, Bargoil JM, Caress JB, Li ZJ, Defranzo AJ, Wiesler ER, Tuohy CJ, Balakrishnan N, Molnar JA, Baute V, Koman LA, Poehling GG, Walker FO. A randomized trial of diagnostic ultrasound to improve outcomes in focal neuropathies. Muscle Nerve 2015; 52:746-53. [PMID: 26296394 DOI: 10.1002/mus.24884] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/10/2015] [Accepted: 08/20/2015] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Neuromuscular ultrasound is valid, reliable, and accurate, but it is not known whether combining it with electrodiagnostic studies leads to better outcomes in individuals with focal neuropathies. METHODS One hundred twenty individuals with focal neuropathy, based on history, examination, and electrodiagnosis, were enrolled in this study. All patients underwent neuromuscular ultrasound and were randomized to either have their ultrasound results sent to the referring physician or not have them sent. Outcomes were assessed at 6 months by evaluators blinded to group assignment. RESULTS The Overall Disability Sum Score and 7 of 8 domains of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) showed more improvement in the "report sent" group, although only the general health perception domain was significant (P = 0.005). CONCLUSIONS Most 6-month outcomes did not reach statistical significance between the 2 groups. However, the "report sent" group had trends toward better outcomes, with significance being reached in the general health perception domain of the SF-36.
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Affiliation(s)
- Michael S Cartwright
- Department of Neurology, Wake Forest School of Medicine, Main Floor Reynolds Tower, Winston-Salem, North Carolina, 27157, USA
| | - Leah P Griffin
- Division of Public Health Sciences, Department of Biostatistics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Hugh Dowlen
- Department of Neurology, Wake Forest School of Medicine, Main Floor Reynolds Tower, Winston-Salem, North Carolina, 27157, USA
| | - Jessica M Bargoil
- Department of Neurology, Wake Forest School of Medicine, Main Floor Reynolds Tower, Winston-Salem, North Carolina, 27157, USA
| | - James B Caress
- Department of Neurology, Wake Forest School of Medicine, Main Floor Reynolds Tower, Winston-Salem, North Carolina, 27157, USA
| | - Zhongyu J Li
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anthony J Defranzo
- Department of Plastic & Reconstructive Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ethan R Wiesler
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Christopher J Tuohy
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nikhil Balakrishnan
- Department of Neurology, Wake Forest School of Medicine, Main Floor Reynolds Tower, Winston-Salem, North Carolina, 27157, USA
| | - Joseph A Molnar
- Department of Plastic & Reconstructive Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Vanessa Baute
- Department of Neurology, Wake Forest School of Medicine, Main Floor Reynolds Tower, Winston-Salem, North Carolina, 27157, USA
| | - L Andrew Koman
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Gary G Poehling
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Francis O Walker
- Department of Neurology, Wake Forest School of Medicine, Main Floor Reynolds Tower, Winston-Salem, North Carolina, 27157, USA
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Cartwright MS, White DL, Demar S, Wiesler ER, Sarlikiotis T, Chloros GD, Yoon JS, Won SJ, Molnar JA, Defranzo AJ, Walker FO. Median nerve changes following steroid injection for carpal tunnel syndrome. Muscle Nerve 2011; 44:25-9. [PMID: 21674517 DOI: 10.1002/mus.22067] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Neuromuscular ultrasound is a painless, radiation-free, high-resolution imaging modality for assessment of the peripheral nervous system. The purpose of this study was to use neuromuscular ultrasound to assess the changes that occur in the median nerve after steroid injection for carpal tunnel syndrome (CTS). METHODS Ultrasound and nerve conduction studies were performed at baseline and 1 week, 1 month, and 6 months after steroid injection in 19 individuals (29 wrists) with CTS. RESULTS Significant changes were noted in median nerve cross-sectional area (P < 0.001), mobility (P = 0.001), and vascularity (P = 0.042) at the distal wrist crease after steroid injection, and the nerve cross-sectional area correlated with symptom score and electrodiagnostic parameters. Changes in the ultrasonographic parameters were seen within 1 week of injection. CONCLUSIONS These findings suggest neuromuscular ultrasound is potentially helpful for the assessment of individuals undergoing treatment for CTS, as typical changes can be expected after successful treatment injection.
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Affiliation(s)
- Michael S Cartwright
- Department of Neurology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157, USA.
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Wood BC, David LR, Defranzo AJ, Stewart JH, Shen P, Geisinger KR, Marks MW, Levine EA. Impact of Sentinel Lymph Node Biopsy on Immediate Breast Reconstruction after Mastectomy. Am Surg 2009. [DOI: 10.1177/000313480907500704] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Traditionally, sentinel lymph node biopsy (SLNB) is performed at the time of mastectomy and reconstruction. However, several groups have advocated SLNB as a separate outpatient procedure before mastectomy, when immediate reconstruction is planned, to allow for complete pathologic evaluation. The purpose of this study was to determine the impact of intraoperative analysis of SLNB on the reconstructive plan when performed at the same time as definitive surgery. A retrospective review was conducted of all mastectomy cases performed at a single institution between September 1998 and November 2007. Of the 747 mastectomy cases reviewed, SLNB was conducted in 344 cases, and there was immediate breast reconstruction in 193 of those cases. There were 27 (7.8%) false negative and three (0.9%) false positive intraoperative analysis of SLNB. Touch preparation analysis from the SLNB changed the reconstructive plan in four (2.1%) cases. In our experience, SLNB can be performed at the time of mastectomy with minimal impact on the reconstructive plan. A staged approach incurs significant additional expense, increases the delay in initiation of systemic therapy and the propensity of procedure-related morbidity; therefore, SLNB should not be performed as a separate procedure before definitive surgery with immediate breast reconstruction.
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Affiliation(s)
- Benjamin C. Wood
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Lisa R. David
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - John H. Stewart
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Perry Shen
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Kim R. Geisinger
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Malcolm W. Marks
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Edward A. Levine
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Wood BC, David LR, Defranzo AJ, Stewart JH, Shen P, Geisinger KR, Marks MW, Levine EA. Impact of sentinel lymph node biopsy on immediate breast reconstruction after mastectomy. Am Surg 2009; 75:551-557. [PMID: 19655597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Traditionally, sentinel lymph node biopsy (SLNB) is performed at the time of mastectomy and reconstruction. However, several groups have advocated SLNB as a separate outpatient procedure before mastectomy, when immediate reconstruction is planned, to allow for complete pathologic evaluation. The purpose of this study was to determine the impact of intraoperative analysis of SLNB on the reconstructive plan when performed at the same time as definitive surgery. A retrospective review was conducted of all mastectomy cases performed at a single institution between September 1998 and November 2007. Of the 747 mastectomy cases reviewed, SLNB was conducted in 344 cases, and there was immediate breast reconstruction in 193 of those cases. There were 27 (7.8%) false negative and three (0.9%) false positive intraoperative analysis of SLNB. Touch preparation analysis from the SLNB changed the reconstructive plan in four (2.1%) cases. In our experience, SLNB can be performed at the time of mastectomy with minimal impact on the reconstructive plan. A staged approach incurs significant additional expense, increases the delay in initiation of systemic therapy and the propensity of procedure-related morbidity; therefore, SLNB should not be performed as a separate procedure before definitive surgery with immediate breast reconstruction.
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Affiliation(s)
- Benjamin C Wood
- Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA
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