Background:Achieving a vascularized granulation bed is essential prior to split-thickness skin grafting (STSG) but is often protracted with existing dermal substitutes. Porcine-derived extracellular matrix (pECM) powder (XCelliStem Wound Powder; StemSys) supplies structural proteins and growth factors that may shorten this interval. Methods:Three adults with complex wounds-a traumatic dorsal-foot defect, a cervical burn contracture reconstructed with a latissimus flap, and a free omental flap to an upper-extremity degloving injury-received intraoperative application of hydrated pECM powder following meticulous debridement. Wounds were covered with Xeroform and either hypochlorous-soaked gauze or negative pressure wound therapy. Granulation, exudate, and infection were assessed daily; STSG was performed once a uniform, vascular bed formed. Patients were followed for ≥3months. Results:Complete, healthy granulation tissue developed on post-application days 9, 11, and 13, respectively, enabling timely STSG. All grafts achieved 100% take without necrosis, seroma, or infection. At 3 months, each site displayed durable coverage, preserved function, pliable scars with preserved elasticity, and high patient satisfaction. Conclusions:In this preliminary series, pECM powder accelerated wound bed readiness and supported reliable STSG within 2 weeks-substantially faster than the 3- to 7-week intervals reported for Integra Bilayer Matrix (Integra LifeSciences Corp) and NovoSorb Biodegradable Temporizing Matrix (PolyNovo Ltd). The pECM powder appears safe, easy to apply, and may reduce morbidity and resource use; controlled trials are warranted.
Background:Global abdominal wall distention (GAWD) is a phenomenon in which patients present with significant abdominal wall laxity and abdominal bulging unexplained by a rectus diastasis, large panniculus, or abdominal wall hernia. Traditional abdominoplasty techniques do not adequately address GAWD, and treatment of this condition requires modification of the abdominal fasciomuscular complex. This paper aims to describe a novel technique, known as wide-rectus abdominis fascia advancement (WRAFA), developed to address this vexing cosmetic issue. Methods:Over a 30-year period, patients with GAWD were identified in a single surgeon's practice, and, once deemed to be appropriate candidates, they underwent the WRAFA procedure. All patients underwent the procedure in an outpatient setting and were kept for no longer than 23 hours or transferred to a certified recovery setting with skilled nursing. Aesthetic outcomes and complications were tracked over time. Results:Six hundred eighty-five patients underwent abdominoplasty with the WRAFA technique. Two hundred eighty-four patients were available for follow-up for a minimum of 12 months. The average body mass index was 32. The median age was 38 years. Sex distribution was predominantly female (92.5% vs 7.75%). Aesthetic results were deemed to be good to excellent in 80% of patients, moderate in 15%, and minimal in 5%. None of the patients developed abdominal compartment syndrome. There were no fatalities or recurrences. One patient developed a unilateral lower quadrant hernia 15 years after the operation. Conclusions:The WRAFA technique helps redefine the patient's waistline while addressing functional muscular dystonia, ultimately providing excellent aesthetic and functional improvements.
Background:Osteoarthritis of the trapeziometacarpal joint is common. There are limited surgical options for patients who have undergone a failed primary trapeziometacarpal arthroplasty. Methods:The authors conducted a retrospective review of patients who received a porcine dermal graft for failed trapeziometacarpal arthroplasty. Three hundred fifty-five trapeziometacarpal procedures were performed from 2005 to 2015; 9 were revisions. Seven were performed with xenograft interposition. Data included primary procedure, grip and key pinch strength, Visual Analog Score (VAS), motion, time to return to work, Kapandji Score, and radiographs. Results:The mean follow-up was 84 weeks. The mean VAS score was 2.3, and all patients reported notable improvement. The mean Kapandji Score was 8. The mean grip was 20 kg, and the mean key pinch was 5 kg in the operated hand. The mean time to return to work was 12 weeks. The final radiographs showed improvement in spaces. No complications or immunological reactions were encountered. Conclusions:The authors describe a technique for revision trapeziometacarpal arthroplasty with a porcine xenograft acellular dermal matrix. This technique shows a safe and valid treatment option with acceptable clinical outcomes.
Soft tissue coverage of the lower extremity and foot is challenging due to limited tissue reach and high functional demand. The hand, in contrast, is rich with reconstructive options that may be translated to the foot because of its analogous structure. A workhorse flap in the hand is the first dorsal metacarpal artery "kite" flap; however, the analogous first dorsal metatarsal artery flap is rarely described. We present a case of successful use of the first dorsal metatarsal artery flap for reconstruction of a soft tissue defect overlying the dorsal left metatarsophalangeal joint. This flap has proved useful as a local tissue option for the distal, dorsal foot, and its indications may be expanded similarly to those of the first dorsal metacarpal artery flap in the hand.
Background:Trickle charging is a process by which an external power supply is used to maintain charge in a battery. When applied to flaps, trickle charging allows temporary perfusion of the flap (battery) by using a perforator that is discontinuous from the main pedicle (external power supply), allowing main pedicle ligation. Two procedures that benefit from this technique are the conventional open bilateral deep inferior epigastric perforator (DIEP) flap and the robotic bilateral DIEP flap. Methods:In the conventional open bilateral DIEP flap, trickle charging is used to improve perioperative efficiency. In the event that the recipient site is not ready for flap transfer (ie, mastectomy and/or chest vessel preparation are not completed), trickle charging enables the main pedicle to be harvested from the intraabdominal cavity. This facilitates early rectus fascia and partial abdominal closure. In a bilateral robotic DIEP flap, trickle charging allows the second hemi-abdominal flap to maintain perfusion after the main pedicles in the intra-abdominal cavity are robotically harvested. Both scenarios demonstrate the possibility of temporary perfusion of the flap, despite the main pedicle being ligated. Results:Sixteen total patients had hemi-abdominal flaps that were trickle charged (5 conventional, 11 robotic). All the flaps were tested for proper perfusion intraoperatively using multiple different modalities. None of the patients experienced total flap loss, partial flap loss, or fat necrosis. Conclusions:The authors review the safety of trickle charging in consecutive robotic and open bilateral DIEP flap breast reconstructions. This technique can be easily replicated for various other flaps with the help of preoperative computed tomography or magnetic resonance angiography to identify main pedicle vessels and an alternative temporary perforator.
Background:Oronasal fistula (ONF) repair remains a significant challenge in patients with cleft lip and palate, particularly when local palatal tissue is insufficient. Regional flaps, including the buccal myomucosal flap (BMMF) and the facial artery musculomucosal (FAMM) flap, offer reliable reconstructive options. This study reviews the surgical anatomy, design, and clinical outcomes of these buccinator-based flaps in ONF repair. Methods:This retrospective case series included 13 patients who underwent ONF repair using a BMMF or a FAMM flap between 2017 and 2024. Patient demographics, fistula characteristics, surgical details, postoperative care, and outcomes were collected and analyzed. Results:Six patients underwent BMMF reconstruction, while 7 received FAMM flaps. Successful fistula closure was achieved in 66.7% of patients in the BMMF group, with flap dehiscence occurring in 2 cases, both associated with digital manipulation. The FAMM flap cohort had a 100% fistula closure rate but exhibited a high incidence (86%) of postoperative scar contracture, with 4 patients requiring contracture release. Conclusions:Based on this experience, the authors propose an algorithm for flap selection in ONF repair. Posteriorly based BMMFs are well suited for fistulas at the junction of the hard and soft palate (Type III) and the posterior third of the hard palate (Type IV). Superiorly based FAMM flaps are preferred for anterior ONFs, particularly those extending into the alveolus. The central hard palate remains a reconstructive challenge, with FAMM flaps offering better reach, though they require staged inset and debulking. Both BMMF and FAMM flaps provide vascularized tissue for ONF closure with minimal donor site morbidity. Strategic flap selection based on fistula location optimizes outcomes while mitigating complications.
Background:Burns are a global public health problem that enormously impact Nepal's health system. The treatment of burns is a challenging job for developing and underdeveloped countries. Major burn injuries are associated with high mortality in Nepal. However, extensive service is being provided, along with the gradual establishment of dedicated burn care units. This study aimed to determine the demographics of burn patients presented to the authors' center and the outcomes of acute burn care. Methods:This was a retrospective, descriptive, cross-sectional study of burn patients admitted from September 2022 to November 2023. Results:The study included 101 patients ranging in age from 6 months to 77 years, with a median age of 27.8 years. The highest incidence of burns was among the male patients (56.4%), followed by the female patients (43.6%). Children under 15 years old comprised 45.5% of the admitted patients, and scald burns were the most common cause of burns in this group. The incidence of flame burns was highest among the working-class population and older adults. The total body surface area of the admitted patients ranged from 5% to 90%, with a mean of 15.22%. A total of 46.5% of the patients underwent operative management, of whom 36.2% required multiple surgeries. Hospital-stay duration ranged from 1 to 83 days, with a mean stay of 13.9 days. The study showed a 7.9% mortality rate. Conclusions:The number of patients hospitalized due to burns is increasing, especially in the winter season. It mostly affects younger age groups, with the most common cause being scald burn. The mortality rate is found to increase as the extent of burn increases.
Hand-held conducted energy devices, such as the TASER 7 (Axon Enterprise, Inc), are commonly used by law enforcement as a method of "non-lethal" force. However, their use may result in serious injuries. The authors report a case where a TASER 7 barb became embedded in the left supraorbital frontal bone during a field incident. Initial removal attempts were unsuccessful when the cylindrical cartridge broke off. Ultimately, the barb was successfully removed at bedside with a Kocher clamp and firm, constant in-line traction under local anesthesia at a tertiary hospital. This case highlights the potential complications associated with conducted energy devices and provides a bedside removal technique that avoids the need for operative intervention.
Background:Surgical reconstruction of complex wounds requires considerable planning to ensure optimal patient outcomes. A conservative approach utilizing the lower tiers of the reconstructive ladder is preferred, especially in patients with comorbidities lending to a higher risk of poor wound healing. A simplified, low-risk solution with a double-opposing purse-string suture (PSS) and horizontal continuous closure technique may be particularly helpful in reducing the need for more complex techniques of wound reconstruction in select patient populations. Methods:A retrospective chart review was performed on all patients who underwent reconstruction with the double-opposing PSS technique (N = 57) by the senior author (B.J.W.) at the University of Louisville between 2019 and 2022. Results:A total of 46 patients and 57 wounds underwent the double-opposing PSS and horizontal continuous closure technique as directed by the algorithm. The average defect size before and after was 61 and 12 cm2, respectively. A 2-tailed paired t test analysis was performed to explore the relationship between the pre- and post-closure defect size (P = .0003, t (44) = 3.9, 95% CI). A total of 21 wounds required a skin graft, meaning 63% of the wounds were successfully closed without the use of skin graft as a result of the double-opposing PSS technique. In addition, of those 21 wounds, the skin grafts, as well as the donor site sizes, were smaller. Conclusions:This approach to wound closure demonstrates usefulness in reducing the size of or need for skin grafts in complex wound patients, particularly in those with comorbidities. The majority of patients underwent successful closure of their complex defects in various areas (eg, face, extremities) with this technique. Residual defects requiring skin graft allowed for a smaller graft and, thereby, donor site. Ultimately, this technique reduces the risk of complex complications by simplifying and reducing wound size.
