INTRODUCTION:Morel-Lavallee lesions (MLL) are closed degloving injuries, often requiring complex management when infected. We evaluated if early debridement reduces infection risk compared to observation. METHODS:We conducted a single-center retrospective study of MLL in adults from 2012 to 2022, analyzing diagnoses, infection, demographics, and hospital outcomes. Patients undergoing debridement within 48 ​h were compared to those initially observed. RESULTS:Of 219 patients, 79 (36 ​%) underwent initial surgical debridement, and 140 (64 ​%) were initially observed. The overall infection rate was 9 ​%. The surgery group had longer hospital stays (14vs7 days, p ​< ​0.001) and more debridements (2vs0, p ​< ​0.001). While infection rate was higher in the surgery group (13.9%vs6.4 ​%, p ​= ​0.064), this difference was not statistically significant. Multivariate analysis identified higher BMI, hip location, and RBC transfusions as significant infection predictors. CONCLUSION:No significant differences in infection rates were found, but several risk factors were identified. Greater awareness and better study designs are needed for improved MLL management guidelines.

BACKGROUND:Myelomeningoceles threaten newborns with central nervous system infectious risk. While some myelomeningoceles can be repaired fetally, limited donor tissue in newborns makes covering a substantial defect challenging. This study evaluated the effectiveness of acellular dermal regeneration templates (ADRT) in safely healing refractory myelomeningoceles. METHODS:Seven myelomeningocele repair cases using ADRT (Integra LifeSciences, Plainsboro, NJ) at an academic children's hospital from April 2020 to June 2023 were reviewed. Patients had unsuccessful closure attempts through fetoscopic, postnatal, or revision surgeries by neurosurgery and plastic surgery, leading to complications that required ADRT to protect the dural repair and promote quicker granulation. RESULTS:The case series included 3 male and 4 female patients, with a median delivery age of 37 weeks (IQR: 33-37). Three underwent fetoscopic repairs, and 4 had postnatal repairs within 48 hours of birth. Six patients required ADRT placement due to failed primary repair. One patient failed fetoscopic closure and required immediate ADRT placement following an emergent cesarean delivery. The median wound size covered was 12 cm 2 (range, 4-20 cm 2 ), and the median hospital stay was 84 days (IQR: 43-105). Three weeks post-ADRT placement, 4 patients showed healthy granulation tissue, and the external silicone layer was removed. Three patients needed additional ADRT for complete wound coverage and successful granulation. After granulation, all wounds eventually epithelialized by secondary intention, with no postoperative infection or wound dehiscence observed. CONCLUSIONS:ADRT can aid in wound healing and protect dural repair in myelomeningoceles, offering a viable option for complex or failed primary closures with limited donor tissue.

BACKGROUND:The rising clinical importance of assessing frailty is driven by its predictive capability for postoperative outcomes. This study assesses the effectiveness of RAI-rev (Revised Risk Analysis Index) in predicting adverse outcomes in lower extremity (LE) flap reconstruction. METHODS:Analyzing NSQIP (National Surgical Quality Improvement Program) data from 2015 to 2020, we compared demographics, perioperative factors, and 30-day outcomes in all locoregional and free-flap cases. Frailty scores, calculated using RAI-rev, were categorized with <15 as nonfrail and >35 as the most frail. Adjusted odds ratios (aORs) for specific complications were calculated using nonfrail as the reference group. Frailty scores in locoregional flaps were compared with those in free flaps. RESULTS:We identified 270 locoregional and 107 free-flap cases. Higher RAI-rev scores in locoregional flaps correlated with increased complications, such as deep surgical site infection (1% nonfrail vs. 20% RAI 31-35), stroke (0% nonfrail vs. 17% most frail), and mortality (0% nonfrail vs. 17% most frail). Locoregional flap cases with RAI-rev scores in the most frail group had a significantly elevated aOR for stroke (51.0, 95% confidence interval [CI]: 1.8-1402.5, p = 0.02), mortality (43.1, 95% CI: 1.6-1167.6, p = 0.03), and any complication (6.8, 95% CI: 1.2-37.4, p = 0.03). In free-flap cases, higher RAI-rev scores were associated with increased complications, with only sepsis showing a statistically significant difference (6% nonfrail vs. 100% most frail; aOR: 42.3, CI: 1.45-1245.3, p = 0.03). Free-flap cases had a significantly lower RAI-rev score compared with locoregional flap cases (14.91 vs. 17.64, p = 0.01). CONCLUSION:Elevated RAI-rev scores (>35) correlated with more complications in locoregional flaps, while free-flap reconstruction patients had generally low RAI-rev scores. This suggests that free flaps are less commonly recommended for presumed higher risk patients. The study demonstrates that RAI-rev may be able to serve as a risk calculator in LE reconstruction, aiding in the assessment of candidates for limb salvage versus amputation.

BACKGROUND:Infection is a common complication following tissue expander (TE)-based breast reconstruction. Few studies have examined risk factors specifically in the unique populations encountered at safety-net hospitals. The purpose of this study was to identify predictors of TE infection at Harris Health safety-net hospitals, which serve the third most populous county in the United States. METHODS:A retrospective review was performed to evaluate women over the age of 18 years who underwent TE placement at two safety-net hospitals from October 2015 to November 2022. Demographic information, medical history, operative details, and postoperative course were recorded for each individual TE. The primary outcome was TE infection, for which univariate and multivariate analysis was conducted. The secondary outcome was the time to onset of TE infection, for which a Kaplan-Meier analysis was undertaken. RESULTS:There were 279 patients, totaling 372 breasts, meeting the inclusion criteria. The TE infection rate was 23%. Increased body mass index (BMI), diabetes, use of acellular dermal matrix (ADM), and prolonged surgical drain use were all significantly associated with TE infection in univariate and multivariate analysis. Similarly, BMI ≥30 kg/m2, diabetes, and ADM use were also associated with earlier onset of TE infection. CONCLUSIONS:This study demonstrated similar TE infection rates at our safety-net hospitals compared with previously reported literature. To optimize the quality of care for patients in safety-net institutions, these risk factors must be addressed in the context of the unique challenges encountered in these settings.

Introduction: Comprehensive management of cleft lip with or without cleft palate (CL/P) often begins prenatally, continues into adulthood, and involves multidisciplinary collaboration. This study aims to review the current literature and summarize sociodemographic disparities that impact access to care, management, and postoperative outcomes in patients with CL/P. Methods: A systematic review was conducted using Pubmed, Embase, and Medline databases. Studies discussing sociodemographic disparities regarding access to care, management, and treatment outcomes for patients with CL/P were included. Studies performed outside the US and published before the year 2000 were excluded. Results: Of 3782 studies initially identified, 26 met the inclusion criteria. Disparities discussed included access to care (n = 11), missed appointments (n = 2), use of nasoalveolar molding [NAM] (n = 3), surgical timing (n = 8), and surgical outcomes (n = 8). Minority race or ethnicity, particularly black, Hispanic, Asian, and Native-American, as well as public insurance were associated with impaired access to care. Other factors causing impaired access to care were non-English primary language and high cost. Predictors for missed appointments were black race and Medicaid insurance. Decreased use of or success with NAM was associated with Asian race, public insurance, and long travel distance to a cleft care center. Factors associated with delayed CL surgery were Asian or black race, Hispanic ethnicity, public insurance, and non-English primary language. Surgical outcomes were assessed using various esthetic, speech, and quality of life measures; factors linked to worse outcomes included black or latin race and public insurance. Conclusion: Patients with CL/P from minority racial or ethnic groups, particularly black, Asian, and Hispanic, as well as those with public insurance are disproportionately impacted by health disparities. Disparities related to age, geographic location, and primary language have also been reported, among others. Statewide or institutional social programs may help address these disparities.

INTRODUCTION:Radiographs (XRs), computed tomography (CT) scans, and cone-beam CT (CBCT) scans are utilized for assessment of secondary alveolar bone graft (SABG) in patients with cleft lip and palate (CLP). However, the optimal choice for imaging modality remains unclear. This study compares the image fidelity and safety profile for XR, CT, and CBCT in the assessment of patients with CLP who have undergone SABG.METHODS:Articles from MEDLINE and Elsevier Embase were screened. The primary outcome was graft success rate. Secondary outcomes were percent-by-volume of graft maintained and patient safety, defined by radiation exposure. A random effects model was used to calculate the pooled outcomes for each imaging modality. Chi-squared analysis was used to compare pooled outcomes between different imaging modalities.RESULTS:Of the 149 articles identified initially, 14 were included. Computed tomography exhibited a significantly higher image fidelity demonstrated by a lower graft success rate (62.0%) compared with both XR (72.6%, P<0.01) and CBCT (69.8%, P<0.01). Cone-beam CT had the lowest reported percent-by-volume of graft maintained (32.1%). Computed tomography had a higher mean radiation dosage (39.7 milligray) than what has been reported for both XR and CBCT.CONCLUSION:Computed tomography demonstrated lower graft success rates than both XR and CBCT, possibly indicating a higher image fidelity. However, compared with CBCT, CT may have a higher radiation exposure. Randomized trials and longitudinal studies are necessary to perform a direct comparison between CT and CBCT and to correlate the image fidelity of these modalities with clinical outcomes.

Background Free flap (FF) reconstruction is frequently required for soft-tissue coverage after significant orthopaedic trauma of the lower extremity (LE). While usually the final step in limb salvage, re-elevation of the previously inset FF may be necessary to restore a functional limb. In this study, we present our algorithm for LE FF re-elevation and review our experience to identify factors associated with successful limb salvage and return to ambulation. Methods A retrospective, single-institution review was conducted of adult patients with LE wounds who required FF reconstruction from 2016 to 2021. From this cohort, patients who required re-elevation of their LE FF were identified. Successful FF re-elevation was defined by limb salvage and return to ambulation. Results During the study period, 412 patients with LE wounds required flap reconstruction. Of these patients, 205 (49.8%) underwent free tissue transfer, and 39 (9.5%) met our inclusion criteria. From this cohort, 34 had successful FF re-elevation, while 1 was non-weight bearing and 4 were elected for amputation due to chronic complications unrelated to their FF. Univariate analysis revealed the total number of FF re-elevations (p < 0.001), the frequency of re-elevation indicated for orthopaedic access (p < 0.001), and infections necessitating return to the operating room (p = 0.001) were each negatively associated with limb salvage and return to ambulation. Conclusion The described algorithm highlights the preoperative planning and meticulous flap preservation necessary for the successful coverage of critical structures following FF re-elevation. Our data demonstrate that LE FFs can be safely re-elevated for hardware access or flap revision. In these complex cases of LE trauma, management by a multidisciplinary team is essential for successful limb salvage.

The Journal of Craniofacial Surgery 34(5):p 1610, July/August 2023. | DOI: 10.1097/SCS.0000000000009381