Publications by authors named "Damien Grinsell"

70 Publications

Reply to "Anesthesia using microcannula and sharp needle in upper blepharoplasty: A randomized, double-blind clinical trial evaluating pain, bruising, and ecchymosis".

J Plast Reconstr Aesthet Surg 2021 Apr 2. Epub 2021 Apr 2.

Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, VIC 3065, Australia; Horizon Plastic Surgery, Melbourne, Victoria, Australia.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.bjps.2021.03.053DOI Listing
April 2021

Case Report: Revisiting the Internal Mammary Artery Perforator Flap: Salvage Option for Circumferential Pharyngo-Esophageal Defects.

Front Surg 2021 17;8:638345. Epub 2021 Mar 17.

Department of Plastic Surgery, Royal Melbourne Hospital, Parkville, VIC, Australia.

Patients that present with pharyngeal strictures and pharyngocutaneous fistulas in the context of previous reconstruction and post-operative radiotherapy often report significant morbidity and reduction in quality of life. Reconstruction of such defects present a substantial clinical challenge requiring the importation of unirradiated vascularized tissue to facilitate healing in a friable, fibrotic, and vessel depleted tissue bed. The authors present a case report demonstrating an adaptation of the internal mammary artery perforator (IMAP) flap for reliable reconstruction of circumferential pharyngeal defects with primary tension free closure of the donor site. This technique avoids the use of free tissue transfer in a hostile, irradiated neck. The tubed IMAP flap is an excellent option, serving the purposes of reconstruction as well as addressing the patient's presenting issues of a chronic sinus and pharyngeal stricture inhibiting oral intake.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fsurg.2021.638345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011658PMC
March 2021

Refining our knowledge of macrovascular arteriovenous shunts (MAS): Anatomical and pathological studies.

J Plast Reconstr Aesthet Surg 2020 Aug 19;73(8):1490-1498. Epub 2020 Feb 19.

Department of Plastic and Reconstructive Surgery, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK. Electronic address:

Background: The macrovascular arteriovenous shunt (MAS) connecting the deep inferior epigastric artery (DIEA) and superficial inferior epigastric vein (SIEV) in the abdominal wall has already been identified as an important structure, and further study has been deemed necessary to establish its role and function.

Methods: Review of CT angiograms (CTA) of 38 female patients was undertaken, by means of analysis of fine-cut axial images and three-dimensional image reconstructions of the cutaneous vasculature of the deep and superficial vasculature. In vivo dissection of the structure was also performed to establish its communications. Lastly, a histopathological analysis was carried out to investigate its intrinsic structure and function.

Results: The MAS was identified in both sides of the abdomen in all subjects and the diameter ranges from 0.72 to 2.81 mm with a median diameter of 1.28 mm. In vivo dissection revealed it as a distinct structure connecting the DIEA and SIEV. Pathological analysis showed that it has characteristics of both elastic and muscular arteries, which constitutes a new vessel.

Conclusion: These further investigations have yielded a better understanding of the MAS shunt, its position, structure and function. This can be of crucial importance to reconstructive surgeons when raising the DIEP flap.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.bjps.2020.02.027DOI Listing
August 2020

Intramuscular pathway and fascicular characteristics of the segmental intercostal innervation to rectus abdominis.

ANZ J Surg 2020 06 20;90(6):1052-1056. Epub 2020 Jan 20.

Medical School, St Vincent's Hospital, Melbourne, Victoria, Australia.

Background: Rectus abdominis is a muscle that is commonly used clinically as a muscle flap, especially in reconstructive surgery. Its intramuscular innervation, however, has rarely been examined in detail or accurately mapped. The purpose of this study was to use biopsied, histological specimens complemented with a staining technique to investigate intramuscular nerve connections and distribution of the rectus abdominis.

Methods: Four fresh human cadavers were included in the study and rectus abdominis was dissected bilaterally. Nerve sections innervating the rectus abdominis were biopsied and histologically processed. Sections were viewed under the microscope, and axons within each fascicle were counted using imaging software. All specimens were stained with a modified Sihler's staining technique. Intramuscular innervation was observed and the number as well as distribution was recorded.

Results: Macroscopically stained specimens showed that the eighth, ninth, 10th and 12th intercostal nerves innervated the eight muscle bellies of rectus abdominis. The greatest number of minor nerve branching as well as intramuscular nerve communications originated from nerve roots T9 and T10. Minor nerve branches crossed tendinous intersections to communicate with adjacent nerves and innervate adjacent muscle bellies. Nerves originating from T9 had the greatest number of nerve fascicles and the highest axon count in each cadaver.

Conclusion: The rectus abdominis is divided into four compartments with each receiving its own independent nerve supply. Minor nerve branches crossed tendinous intersections to communicate with adjacent muscle bellies and nerves suggesting that rectus abdominis can be used as a whole in innervated free flap transfer procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ans.15682DOI Listing
June 2020

Proximal interphalangeal joint arthroplasty post digital replant: a case report.

ANZ J Surg 2020 09 30;90(9):1798-1799. Epub 2019 Dec 30.

Department of Plastic Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ans.15679DOI Listing
September 2020

Lymphoedema rates in pedicled anterolateral thigh flaps for coverage of irradiated groin defects.

ANZ J Surg 2020 01 15;90(1-2):135-138. Epub 2019 Dec 15.

Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia.

Background: Limb salvage surgery in conjunction with adjuvant radiotherapy is the preferred treatment for soft tissue sarcoma. This study aims to determine if ipsilateral pedicled anterolateral thigh (ALT) flap reconstruction of groin defects post soft tissue sarcoma resection results in acceptable rates of lymphoedema, while also providing good soft tissue cover and minimal donor site morbidity.

Methods: A retrospective chart audit was conducted with ethics approval, obtaining a case series of 16 patients operated on at a single institution by the senior surgeon. Patients who underwent ipsilateral pedicled ALT flap coverage of irradiated groin defects following soft tissue sarcoma resection were included. Comparative six-point limb circumference measurements were utilized to diagnose lymphoedema, with a difference of 10% when compared to the non-operative side being deemed significant.

Results: Lymphoedema was noted in three patients (18.8%) with an average follow-up period of 40.9 (range 8-59) months.

Conclusion: Previously published lymphoedema rates in sarcoma limb salvage surgery of 15.5-30% are comparable to the rates obtained in this cohort. Lymphoedema rates do not appear to be higher in patients undergoing ipsilateral pedicled ALT flap reconstruction, thus making it a useful soft tissue coverage technique in this cohort.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ans.15576DOI Listing
January 2020

Outcomes of dental and craniofacial osseointegrated implantation in head and neck cancer patients.

Head Neck 2019 09 19;41(9):3290-3298. Epub 2019 Jun 19.

ENT/Head and Neck Unit, St Vincent's Hospital Melbourne, Victoria, Australia.

Background: Treatment of head and neck cancer may result in disfiguring and debilitating anatomical changes. Osseointegrated implants may be used in these patients to facilitate attachment of implant-retained dentures or cosmetic prostheses.

Methods: A retrospective audit was performed, reviewing the treatment of patients who received dental or craniofacial osseointegrated implants during treatment of head and neck cancer.

Results: One hundred sixty implants were inserted in 54 patients with oral, nasal, orbital, or auricular defects. Overall, 85% of implants were successful after mean follow-up of 25.7 months. The brand of implant used was shown to impart a statistically significant implant survival difference, and orbital implants had poorer survival compared to nonorbital implants. There was a statistical insignificant implant survival advantage in both nonsmokers and patients who did not undergo radiotherapy.

Conclusions: Dental and craniofacial osseointegrated implants may be reliably used in patients with head and neck cancer. However, further research is required to clarify the role of smoking in osseointegrated implant failure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/hed.25845DOI Listing
September 2019

Comparative osteoradionecrosis rates in bony reconstructions for head and neck malignancy.

J Plast Reconstr Aesthet Surg 2019 Sep 24;72(9):1478-1483. Epub 2019 May 24.

Department of Plastic and Recontstructive Surgery, Royal Melbourne Hospital. 300 Grattan Street, Parkville, Victoria 3050, Australia.

Background: Bony free flaps are used to reconstruct head and neck cancer defects. The most commonly used flaps are the free fibula flap and the deep circumflex iliac artery (DCIA) flap. Radiotherapy may be given post-operatively to prevent cancer recurrence. This radiotherapy can, however, destroy the bone; a complication termed osteoradionecrosis (ORN). Although there have been studies comparing free fibula and DCIA flaps in terms of success rates and complications, few have assessed the incidence of ORN in both groups.

Methods: A retrospective cohort study was conducted involving patients from Royal Melbourne Hospital and St Vincent's Hospital Melbourne who had either a free fibula or DCIA flap for head and neck cancer reconstruction in the past 10 years. Data collected included demographic, operative, and postoperative data. Analysis was performed using Statistical Package for Social Sciences and Microsoft Excel, utilising t-tests, chi-square tests and logistic regression analyses.

Results: A total of 154 patients were identified. Of these patients, 127 had free fibula flaps and 27 had free DCIA flaps. Twelve patients had ORN post-op, 10 had free fibula flaps, and 2 had free DCIA flaps. No statistically significant difference was found between the ORN rates in free fibula flaps and free DCIA flaps.

Conclusion: Rates of ORN incidence should not be a major consideration in preoperative planning of free flaps for mandibular reconstruction as both fibula and DCIA free flaps are comparable.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.bjps.2019.04.017DOI Listing
September 2019

Comparison between traditional saline versus air expanders: a patient's perspective.

ANZ J Surg 2019 04;89(4):282-283

Department of Reconstructive and Plastic Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ans.15002DOI Listing
April 2019

The innervated rectus abdominis flap for quadriceps reconstruction.

J Plast Reconstr Aesthet Surg 2019 Jun 21;72(6):941-945. Epub 2019 Mar 21.

Department of Surgery, The University of Melbourne, Grattan Street, Parkville Victoria 3052, Australia; Department of Orthopaedic Surgery, St.Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia.

Background: The vertical rectus abdominis myocutaneous (VRAM) and transverse rectus abdominis myocutaneous (TRAM) flaps have traditionally been excluded from consideration of reconstructions with functional potential, because of their segmental innervation. We present a case series that aimed to demonstrate that segmental innervation does not preclude successful neural anastomoses and can deliver a functional reconstruction of a total compartment in the anterior thigh.

Methods: This review included all patients who required total anterior thigh compartmentectomy and reconstruction between December 2009 and February 2016 were included from the first author's prospective database.

Results: Eleven cases were identified, with innervated rectus abdominis flaps used for anterior thigh reconstruction. During the median follow up period of 12 months, all patients had reinnervation of the rectus with six reaching M5, one M4+, one M4, two M3 and one M2, according to Medical Research Council power grades.

Conclusion: All patients had successful functional reconstruction in the thigh using the rectus abdominis myocutaneous flap.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.bjps.2019.03.002DOI Listing
June 2019

Composite pronator quadratus: radial forearm free flap in functional lip reconstruction.

ANZ J Surg 2019 07 1;89(7-8):940-944. Epub 2019 Feb 1.

Department of Plastic Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia.

Background: Reconstruction of lip defects following neoplasia and trauma is a common procedure in plastic surgery. Reconstruction of large lip defects is a difficult undertaking and some degree of residual functional impairment and disability are likely to occur. Microsurgical reconstruction is the recommended technique for large lip defects; however, limitations exist regarding optimal aesthetic and functional outcomes with current free flap options.

Method: We propose a new composite flap design based on the innervated pronator quadratus with the radial forearm free flap for a more dynamic reconstruction of total or near total lip defects. Results of our series of four patients have been reviewed.

Results: The radial forearm flap - innervated pronator quadratus flap has been used in four patients thus far for lip reconstruction. This flap, in our limited series has shown excellent results in achieving oral competence, good motor function and acceptable cosmetic appearance.

Conclusion: The composite radial forearm-pronator quadratus flap is a promising new lip reconstruction technique that has potential to provide a higher level of oral competence, sphincteric function and symmetrical lip movement, than current microsurgical options in dynamic lip reconstruction. This method warrants further investigation in plastic surgery literature.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ans.14980DOI Listing
July 2019

Y-Peg-in-a-Round-Hole Closure for Immediate Periareolar Mastectomy Expander Reconstruction.

Ann Plast Surg 2019 02;82(2):145-151

Department of Plastic Surgery, St Vincent's Hospital, Melbourne.

Introduction: Mastectomies closed with a linear scar can distort the resulting shape of the breast. We present our novel Y-peg-in-a-round-hole closure method of the mastectomy scar, which improves the shape of the reconstructed breast while maintaining reliable healing, implant coverage, and minimum scar size for covering by tattoo.

Materials And Methods: A retrospective review of all breast reconstruction cases performed by the senior surgeon during the period from January 2010 to January 2017 was undertaken. Data were analyzed for wound healing problems, infection rates and mastectomy skin flap necrosis.

Results: Data were extracted for 126 consecutive patients with 154 breast reconstructions. Twelve breasts (7.7%) experienced wound healing problems, for which 7 (4.5%) required revisionary surgery. Eighteen breasts (11.7%) developed an infection requiring antibiotics, of which 8 (5.2%) needed a further operation. Four breasts (2.6%) needed removal of the implant. No patients were lost to follow-up.

Conclusion: After nipple resecting mastectomy, the Y-peg-in-a-round-hole scar minimizes radial size and contour deformity but allows for reliable wound healing.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SAP.0000000000001690DOI Listing
February 2019

Propeller flap reconstruction of irradiated sarcoma defects: A comparison.

J Plast Reconstr Aesthet Surg 2019 Feb 9;72(2):181-187. Epub 2018 Nov 9.

Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, 41 Victoria Parade, Fitzroy VIC 3065, Australia.

Introduction: The treatment for soft tissue sarcomas has evolved to include radiotherapy, wide local excision and plastic surgical reconstruction. Goals for the reconstruction of these irradiated defects are the introduction of non-irradiated healthy tissue, tension-free closure and obliteration of potential dead space. Although many defects once required free tissue transfer for reconstruction, greater knowledge of anatomical vascular pattern has led to the increasing use of propeller perforator flaps, islanded and transposed into the defect. Propeller flap outcomes for the reconstruction of irradiated skin defects have only been reported in case reports. We evaluated the use of propeller perforator flaps at St Vincent's Hospital Melbourne in a series of patients for the reconstruction of irradiated sarcoma defects.

Methods: All patients who underwent sarcoma resection with plastic surgical reconstruction at St Vincent's Hospital from January 2009 to February 2017 were identified from unit audits and medical record data and compared depending on the type of reconstruction. Propeller perforator flaps were evaluated compared to other methods of reconstruction.

Results: Thirty-nine cases involved single perforator propeller flaps for reconstruction. The frequency of propeller flap reconstruction has greatly increased from 3 in their first year of use in 2013 to 12 in 2015. Most propeller flaps were used to reconstruct thigh defects (43.6%) followed by shoulder defects (17.9%). Generally the defects were smaller (138.7 cm) than free flaps (214.2 cm), and the usual composition of the defect was skin and subcutaneous tissue only. Patients who underwent propeller flap reconstruction had a significantly short length of inpatient stay (p < 0.01), and there were no total failures.

Conclusion: Propeller perforator flaps are useful for the reconstruction of irradiated defects in sarcoma reconstruction surgery, particularly small- to moderate-sized fasciocutaneous defects. They offer less morbidity, faster recovery and better aesthetic results than free or standard pedicle flaps. The success of propeller flaps has changed the algorithm for how we approach towards the reconstruction of irradiated sarcoma defects to consider their use as the first reconstructive option for superficial sarcoma defects.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.bjps.2018.10.011DOI Listing
February 2019

Microsurgical reconstruction using the middle temporal vein: a case report.

ANZ J Surg 2019 09 23;89(9):E420-E421. Epub 2018 Aug 23.

Department of Plastic and Reconstructive Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ans.14698DOI Listing
September 2019

Preoperative Radiotherapy and Wide Resection for Soft Tissue Sarcomas: Achieving a Low Rate of Major Wound Complications with the Use of Flaps. Results of a Single Surgical Team.

Front Surg 2017 22;4:79. Epub 2018 Jan 22.

Department of Orthopaedics, St. Vincent's Hospital, Melbourne, VIC, Australia.

Background: Surgery in combination with radiotherapy (RT) has become the standard of care for most soft tissue sarcomas. The choice between pre- and postoperative RT is controversial. Preoperative RT is associated with a 32-35% rate of major wound complications (MWC) and 16-25% rate of reoperation. The role of vascularized soft tissue "flaps" in reducing complications is unclear. We report the outcomes of patients treated with preoperative RT, resection, and flap reconstruction.

Patients And Methods: 122 treatment episodes involving 117 patients were retrospectively reviewed. All patients were treated with 50.4 Gy of external beam radiation. Surgery was performed at 4-8 weeks after completion of RT by the same combination of orthopedic oncology and plastic reconstructive surgeon. Defects were reconstructed with 64 free and 59 pedicled/local flaps.

Results: 30 (25%) patients experienced a MWC and 17 (14%) required further surgery. 20% of complications were exclusively related to the donor site. There was complete or partial loss of three flaps. There was no difference in the rate of MWC or reoperation for complications with respect to age, sex, tumor site, previous unplanned excision, tumor grade, depth, and type of flap. Tumor size ≥8 cm was associated with a higher rate of reoperation (11/44 vs 6/78;  = 0.008) but the rate of MWC was not significant (16/44 vs 14/78;  = 0.066).

Conclusion: The use of soft tissue flaps is associated with a low rate of MWC and reoperation. Our results suggest that a high rate of flap usage may be required to observe a reduction in complication rates.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fsurg.2017.00079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786513PMC
January 2018

How to do breast reconstruction using free flaps with short pedicles: a stepwise technique for easier, safer anastomoses.

ANZ J Surg 2018 Jan 12;88(1-2):104-105. Epub 2017 Nov 12.

Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ans.14247DOI Listing
January 2018

Reconstructive options for large back free flap donor sites.

ANZ J Surg 2018 10 9;88(10):1066-1070. Epub 2017 Nov 9.

Department of Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia.

Background: Reconstruction of posterior thoracic and trunk defects can prove challenging even to the most seasoned surgeons. Many commonly used techniques for closing back defects include primary closure and split skin grafts. Often times, however, other techniques are needed in order to give the patient the best aesthetic and functional outcome. In this study, we focus on and evaluate donor site closure techniques for defects in the back created by harvesting scapular and parascapular flaps.

Methods: Twenty patients were operated on to remove pathologically diagnosed sarcomas using a wide local excision. The defects, ranging from 5 to 22 cm in width, were closed using donor flaps from the scapular/parascapular region. Nine donor sites were then closed primarily with wide undermining, while 11 donor sites were closed using multiple techniques, such as large transposition flaps, large rotation advancement flaps, keystone neurovascular island flaps, latissimus dorsi advancement flap and large Y-V advancement flaps.

Results: All recipient and donor flaps survived with good aesthetic and functional outcome. Patient satisfaction was high and only two of 20 donor site flaps required further surgery due to wound dehiscence. No other complications were seen during the follow-up period.

Conclusion: The proposed advanced techniques for donor site closure in back defects have shown that primary wound healing can be achieved with the use of a variety of different techniques and the avoidance of the complications of a skin graft.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ans.14240DOI Listing
October 2018

Immediate autologous breast reconstruction after neoadjuvant chemoradiotherapy for breast cancer: initial results of the first 29 patients.

ANZ J Surg 2018 Mar 24;88(3):E137-E141. Epub 2017 Sep 24.

Department of Plastic Surgery, St. Vincent's Hospital, Melbourne, Victoria, Australia.

Background: Breast reconstruction after mastectomy in the treatment of locally advanced breast cancer is often done in stages and before radiotherapy. We have previously published an algorithm for immediate free autologous reconstruction after neoadjuvant chemotherapy and preoperative radiotherapy. This protocol was designed to provide a shorter and simpler reconstructive path whilst improving cosmesis and maintaining oncological efficiency.

Methods: A total of 29 patients were included and underwent surgery for 30 cancers by the first author between 2010 and September 2015. Data were prospectively entered into a database and analysed for tumour size, chemotherapeutic response, lymph node involvement, surgical complications and tumour recurrence.

Results: The mean age was 55 ± 7 years. Eighty percent of patients had either a partial or complete chemotherapeutic response defined as >25% decrease in tumour size. Twenty-eight patients had free abdominal tissue transfer. One patient was excluded due to advanced disease. There were no take-backs due to microsurgical issues. One patient was reoperated on for a haematoma. Four patients had recurrent cancer during follow-up, three of whom are deceased.

Conclusion: Many, but not all, breast reconstructive surgeons consider autologous reconstruction as the 'gold' standard in the presence of radiotherapy. Rearranging the order of radiotherapy and surgery means operating in a recently irradiated field. We believe the surgical challenges are outweighed by a shorter and simpler reconstructive journey that additionally results in a better cosmesis. It is possible to perform immediate free autologous reconstruction after neoadjuvant chemotherapy and preoperative radiotherapy with excellent results and at least equivalent oncological efficacy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ans.14079DOI Listing
March 2018

Creation of a Large Adipose Tissue Construct in Humans Using a Tissue-engineering Chamber: A Step Forward in the Clinical Application of Soft Tissue Engineering.

EBioMedicine 2016 Apr 23;6:238-245. Epub 2016 Mar 23.

Department of Chemical and Biomolecular Engineering, Particulate Fluids Processing Centre, University of Melbourne, Australia.

Tissue engineering is currently exploring new and exciting avenues for the repair of soft tissue and organ defects. Adipose tissue engineering using the tissue engineering chamber (TEC) model has yielded promising results in animals; however, to date, there have been no reports on the use of this device in humans. Five female post mastectomy patients ranging from 35 to 49years old were recruited and a pedicled thoracodorsal artery perforator fat flap ranging from 6 to 50ml was harvested, transposed onto the chest wall and covered by an acrylic perforated dome-shaped chamber ranging from 140 to 350cm(3). Magnetic resonance evaluation was performed at three and six months after chamber implantation. Chambers were removed at six months and samples were obtained for histological analysis. In one patient, newly formed tissue to a volume of 210ml was generated inside the chamber. One patient was unable to complete the trial and the other three failed to develop significant enlargement of the original fat flap, which, at the time of chamber explantation, was encased in a thick fibrous capsule. Our study provides evidence that generation of large well-vascularized tissue engineered constructs using the TEC is feasible in humans.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ebiom.2016.03.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4856786PMC
April 2016

Bone-patellar tendon-bone allograft reconstruction for peri-patellar tendon sarcomas: case series.

Springerplus 2015 26;4:740. Epub 2015 Nov 26.

Department of Orthopaedics, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, 3065 Australia ; Department of Surgery, St. Vincent's Hospital Melbourne, University of Melbourne, Level 2, Clinical Sciences Building, 29 Regent Street, Fitzroy, VIC 3065 Australia.

Introduction: Reconstruction after wide resection for a sarcoma involving the knee extensor mechanism is challenging even if the tumor is small.

Case Description: We report on four consecutive peri-patellar tendon sarcomas treated similarly at a single institution. Histological diagnoses were synovial sarcoma (two cases), clear cell sarcoma and extraskeletal Ewing's sarcoma (one case each). Follow-up periods after surgery were 18-67 months. All cases underwent pre-operative radiotherapy and subsequent surgery. After preoperative radiotherapy and wide resection including the patellar tendon, bone-patellar tendon-bone allograft was fixed to the residual patella and tibial tuberosity with screws and a cable wire. Soft tissue and skin defect over allograft was covered by free antero-lateral thigh flap. Post-operatively, the operated knee was splinted straight for at least 6 weeks, and then range-of-motion exercise was gradually introduced. Except for one case with a proximal tibial stress fracture 5 months post-operatively, no complication was observed. Both bone-bone junctions between allograft and residual bones were united within 1 year after surgery. At the latest clinical follow-up, all the patients had satisfactory functions with Musculoskeletal Tumor Society score of 28-30 out of 30 points and virtually full range of motion.

Discussion And Evaluation: This case series is the first to report bone-patellar tendon-bone allograft for reconstruction after tumor resection with joint preservation and with satisfactory clinical outcomes.

Conclusions: Bone-patellar tendon-bone allograft reconstruction with vascularized flap reconstruction is a viable option for peri-patella tendon sarcomas.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s40064-015-1510-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4661164PMC
December 2015

Modifications of the deep circumflex iliac artery free flap for reconstruction of the maxilla.

J Plast Reconstr Aesthet Surg 2015 Aug 23;68(8):1044-53. Epub 2015 May 23.

Monash University, Melbourne, Australia.

Background: The deep circumflex iliac artery (DCIA) free flap remains underused in maxillectomy reconstruction. A number of surgical techniques have been described however, maxillary defects vary greatly and modifying techniques to account for such variation can be challenging.

Purpose: This article presents the first standardized approach to DCIA free flap modification for maxillary reconstruction where graded modifications are made to a standard procedure based on defect grade. A review of 11 cases that underwent maxillectomy reconstruction with this technique is presented.

Methods: Defect complexity is stratified according to the Brown Classification System and graded modifications of increasing complexity are made to a standard harvest and flap inset technique. Modifications include increasing the depth of the harvested iliac crest bone to correspond to the height of the anterior maxillary wall defect, addition of a titanium mesh plate to reconstruct the orbital floor and harvest of the internal oblique muscle to fill the orbital cavity. Short and long-term outcomes and complications of 11 cases that underwent maxillectomy reconstruction according to this technique were documented.

Results: Defects ranged from Brown Class I-IV, b-c. All but two patients had malignant diagnoses with squamous cell carcinoma (n = 5) being the most prevalent. Short-term flap related complications were neck cellulitis (n = 1) and donor site haematoma (n = 2) whilst long-term flap related complications were mild trismus (n = 1) and donor site pain (n = 1). There were no reported problems with speech, swallowing or vision.

Conclusions: This stepwise approach to DCIA free flap modification for maxillectomy defect reconstruction may be used as a guide for future maxillary reconstruction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.bjps.2015.04.028DOI Listing
August 2015

The Deep Inferior Epigastric Perforator Learning Curve in the Current Era.

Ann Plast Surg 2016 Jan;76(1):72-7

From the *Department of Plastic and Reconstructive Surgery, Western Health Melbourne; and †Department of Plastic and Reconstructive Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.

Background: Over the last 2 decades, the deep inferior epigastric perforator (DIEP) flap has gained significant popularity in breast reconstruction. However, for some, the increased technical difficulties associated with DIEP breast reconstruction can be a discouraging factor in adopting this technique. There has been a trend in the literature to acknowledge an acute learning curve in the adoption of DIEP breast reconstruction but little evidence to support its ongoing relevance to surgeons who gain significant exposure in training.

Methods: We test the learning curve concept on the senior author's series of 214 DIEP and superficial inferior epigastric artery flaps in a single-surgeon, retrospective study analyzing chronological trends in complication rates both major (total and partial flap loss, reexploration) and minor (fat necrosis, donor site hernia and bulge).

Results: The total complication rate was 7.9%, including 1 (0.5%) partial and 1 (0.5%) total flap failure. A comparison of complication rates in the initial 30 flaps in comparison to the remainder of the series revealed no significant difference in major complications (3.3% vs 3.3%, P = 1.00) or minor complications (6.7% vs 4.3%, P = 0.635). Linear-by-linear analysis performed on chronologically ordered groups of 30 flaps revealed no statistically significant trends over the series.

Conclusions: The learning curve associated with the DIEP is complex and likely relates to competency gained in both technical and decision-making aspects of breast reconstruction. This series has demonstrated that with adequate training and an algorithmic approach to DIEP breast reconstruction, eliminating the early learning curve and improving early outcomes are possible.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SAP.0000000000000528DOI Listing
January 2016

Refinements and restoring contour in head and neck reconstruction.

ANZ J Surg 2016 Sep 22;86(9):675-80. Epub 2015 Apr 22.

Department of Plastics and Reconstructive Surgery, St Vincent's Hospital, The Western Hospital, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.

Background: To date head and neck reconstructions of oncological defects have concentrated on primarily filling the defect to achieve primary wound healing, secondly restore function and lastly cosmesis. This paper describes a refinement of existing free tissue transfer techniques for improvement of contour, function and aesthetics.

Methods: A retrospective review of 38 patients operated on by one surgeon at St Vincent's, Royal Melbourne and Western Hospitals over a 3-year period was conducted. Data were collected on patient demographics, tumour details, nature of the defect, type of reconstructive procedure, nature of additional tissue used, radiotherapy, complications and outcome.

Results: We present refinements in using de-epithelialized skin paddles, flexor hallucis longus, and rectus and vastus lateralis muscle in order to achieve optimal reconstruction. Free tissue transfer refinements are discussed in anterolateral thigh, fibula, rectus and anteromedial thigh free flaps. The average defect size and volume of neck dissection prior to reconstruction is presented. A variation of radical, modified radical and selective neck dissections were required for oncological staging and clearance. Rare and minor associated complications are discussed. Post-operative radiotherapy treatment was used in the majority of patients with preoperative adjuvant therapy required in some salvage cases. All patients achieved primary wound healing post-operatively with no salivary leaks, flap failures or exposure of neck vessels.

Conclusions: Supplementary microsurgical tissue transfer of de-epithelialized skin, vastus lateralis, flexor hallucis longus and rectus muscles is a valuable option for restoring contour, aesthetics and vessel protection post-radiotherapy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ans.13061DOI Listing
September 2016

Severe, Steroid-responsive, Myositis Mimicking Necrotizing Fasciitis following Orthopedic Surgery: A Pyoderma Variant with Myonecrosis.

Plast Reconstr Surg Glob Open 2014 Jun 9;2(6):e175. Epub 2014 Jul 9.

Infectious Diseases Unit, Wollongong Hospital, NSW, Australia; University of Wollongong, NSW, Australia; Infectious Diseases Unit, St Vincent's Hospital Melbourne, VIC, Australia; and Plastic Surgery Department, St Vincent's Hospital Melbourne, VIC, Australia.

Summary: Postoperative pyoderma gangrenosum is a rare neutrophilic dermatosis that may be confused for necrotizing fasciitis. The inflammatory response is triggered by the trauma of surgery and thus must be managed nonsurgically. Clinical and pathological findings in the 2 diseases can be identical, leading to misdiagnosis and massive surgical defects from the ensuing surgery. This report documents a severe case of postsurgical pyoderma following an elective rotator cuff repair presenting with myositis and myonecrosis. The patient was initially treated as having an infection, which resulted in multiple aggressive surgical debridements. Despite this, the patient continued to deteriorate and was in a critical and hemodynamically unstable condition. Following administration of high-dose intravenous corticosteroids, the patient made a dramatic recovery and went on to have internal fixation of the shoulder and closure of the wound with a combination of a free flap and a rotational flap. Extensive myositis, as seen in this case, has not been previously reported in postoperative pyoderma gangrenosum variants. Clinicians should be aware that the presence of myositis and myonecrosis should not preclude this diagnosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/GOX.0000000000000124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4174247PMC
June 2014

Stacked abdominal flap for unilateral breast reconstruction.

J Reconstr Microsurg 2015 Mar 26;31(3):179-86. Epub 2014 Sep 26.

Plastic Surgery Department, St Vincent's Hospital, Fitzroy, Victoria, Australia.

Background: The abdominal flap can be used in a stacked, double-pedicle configuration for unilateral breast reconstruction. Aided by preoperative mapping, this is a good option when a single-pedicle flap is deemed unsuitable. We present reliable outcomes using the stacked flap and a logical classification system for its use.

Methods: From 2008 to 2013, 18 patients underwent a stacked abdominal flap for unilateral breast reconstruction. Flaps utilized deep inferior epigastric (D) and superficial inferior epigastric (S) pedicle combinations. Preoperative computed tomography angiogram was performed on all patients. Medical records were reviewed for complications and clinical data, and a thorough clinical evaluation was performed on all patients at follow-up. Flaps were all double-pedicled, with the secondary pedicle anastomosed onto the primary pedicle (type 1 to 3) or onto a second recipient vessel (type 4). Flaps were then classified into groups, based on pedicle dominance and intraflap anastomosis.

Results: Twelve reconstructions were immediate and six delayed. Mean operative time was 7 hours, the most frequently used configuration being a type 1 DD, that is, secondary pedicle (D) anastomosed end-to-end onto the superior continuation of the primary pedicle (D). Average hospital stay was 6 days. There were no flap losses and minimal complications, and mean follow-up was 20 months.

Conclusion: Use of this flap poses a greater challenge to the microsurgical breast reconstruction. We demonstrate its reliable use in women deemed unsuitable for a single-pedicle flap. Our structured system clarifies vascular options, and preoperative perforator mapping tools are essential to the success of this technique.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0034-1390165DOI Listing
March 2015

The functional free innervated medial gastrocnemius flap.

J Reconstr Microsurg 2014 Sep 16;30(7):451-6. Epub 2014 May 16.

Plastic and Reconstructive Surgery Unit, Royal Melbourne Hospital, Parkville, Melbourne, Australia.

Background: The functional free innervated medial gastrocnemius flap has been described in four previous articles for the management of foot drop, Volkmann contracture, and upper limb muscle defects. We expand the indications by describing the use of free innervated medial gastrocnemius musculocutaneous flap in functional reconstruction of the tongue and upper limb musculature.

Methods: The right medial gastrocnemius muscles were raised as myocutaneous flaps in six patients. These flaps were elevated in the supine position and the flaps included a motor nerve from the sciatic nerve and a sensory nerve from the sural nerve. The average size of flap was 15 × 8 cm.

Results: The flaps were transferred successfully with no flap loss and showed consistent reinnervation during follow-up. In particular, all patients who underwent tongue reconstruction exhibited intelligible speech and returned to full oral diet with no aspiration. In patients who underwent upper limb muscle reconstructions, there was moderate to full restoration of power. All donor sites exhibited excellent symmetry in both power and appearance to the contralateral calf.

Conclusions: To our knowledge, this study is the first to describe the use of the innervated medial gastrocnemius free flap in the reconstruction of the tongue and deltoid. The advantages of this flap include its thin reliable skin paddle, strong bulky bipennate muscle, and low donor site morbidity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0034-1372367DOI Listing
September 2014

The inferior gluteal artery myocutaneous flap with vascularized fascia lata to reconstruct extended abdominoperineal defects.

Plast Reconstr Surg 2013 Nov;132(5):836e-840e

Melbourne, Victoria, Australia From Western Health and St. Vincent's Hospitals.

Unlabelled: Abdominoperineal resections have evolved to the point where increasing amounts of skin and pelvic floor are removed, resulting in extensive defects. Many patients receive neoadjuvant chemoradiotherapy and may require adjuvant treatment; thus, primary wound healing is essential. Existing reconstructive techniques may be inadequate and predispose to postoperative complications including wound breakdown and perineal herniation. The authors have developed a novel innervated gluteal flap reconstruction with significant advantages, including preservation of abdominal wall integrity, prone harvest, reliable vascularity, bulky volume, and tailored inset. This robust technique addresses all components required for successful perineal reconstruction comprising dead space obliteration, reconstruction and maintenance of perineal floor integrity, and importation of nonirradiated skin to facilitate primary wound healing. Indications can be extended to include reconstruction of the posterior vaginal wall and large sarcoma/sacrectomy defects.

Clinical Question/level Of Evidence: Therapeutic, IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PRS.0b013e3182a3c0cdDOI Listing
November 2013

New treatment sequence protocol to reconstruct locally advanced breast cancer.

ANZ J Surg 2013 Sep 15;83(9):630-5. Epub 2013 Mar 15.

Western Health, Melbourne, Victoria, Australia.

Background: Current treatment for locally advanced breast cancer (LABC) includes neoadjuvant chemotherapy and post-mastectomy radiotherapy, which may be deleterious for immediate reconstruction. A few trials have instead combined neoadjuvant chemotherapy followed by preoperative radiotherapy. If safe and oncologically efficacious, mastectomy with immediate free autologous reconstruction (transverse rectus abdominis myocutaneous (TRAM)/deep inferior epigastric perforator (DIEP) flap) could then achieve a shorter, simpler reconstructive journey with better cosmesis. No trials have been performed combining this neoadjuvant regime with free autologous reconstruction as an assessment end point.

Methods: We performed a Pubmed/Medline search for oncological efficacy of neoadjuvant chemotherapy followed by preoperative radiotherapy and flap reconstruction of the breast. A new treatment sequencing protocol is proposed in which patients suitable for neoadjuvant chemotherapy followed by preoperative radiotherapy and likely mastectomy are selected. Positive chemotherapeutic response is followed by radiotherapy then surgery within 6 weeks comprising mastectomy/axillary clearance and immediate reconstruction (TRAM/DIEP). Non-responders are offered mastectomy, tissue expander reconstruction, adjuvant radiotherapy then delayed autologous reconstruction. Local/systemic recurrence rates, disease-free survival, complications, patient satisfaction and aesthetics are examined.

Results: Between 1995 and 2012, 10 trials treated LABC patients using combined neoadjuvant chemotherapy followed by preoperative radiotherapy. Compared with chemotherapy alone, increased complete pathological response, complete clinical remission, median survival and tumour-free survival were observed.

Discussion: Our new treatment sequence protocol offers a simpler, more advantageous approach to LABC. We hypothesize equivalent oncological efficacy, optimized oncological management and surgical planning. The aim was to shorten and simplify the reconstructive journey through a single operation including gold-standard reconstruction, offering better cosmesis, fewer complications and reduced costs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ans.12110DOI Listing
September 2013

Reply: "Image-guided" perforator flaps versus "free-style" perforator flaps: where is the evidence?

Plast Reconstr Surg 2013 Mar;131(3):445e-446e

Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne, Parkville, Victoria, Australia.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PRS.0b013e31827c72a3DOI Listing
March 2013
-->