1
|
Contrera KJ, Hassan AM, Shuck JW, Bobian M, Ha AY, Chang EI, Garvey PB, Roubaud MS, Lee ZH, Hanasono MM, Gross ND, Myers JN, Yu P, Largo RD. Outcomes for 160 Consecutive Lateral Arm Free Flaps for Head and Neck Reconstruction. Otolaryngol Head Neck Surg 2024; 170:747-757. [PMID: 38037485 DOI: 10.1002/ohn.596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/10/2023] [Accepted: 10/21/2023] [Indexed: 12/02/2023]
Abstract
OBJECTIVE Examine outcomes for lateral arm autologous tissue transfer in head and neck reconstruction. STUDY DESIGN Retrospective cohort study. SETTING Tertiary cancer center. METHODS All patients who underwent traditional lateral arm, extended lateral arm, and lateral forearm flaps for head and neck reconstruction from 2012 to 2022 were assessed. Disabilities of the arm, shoulder, and hand (DASH) was measured. Factors associated with complications and enteral or mixed diet were evaluated by multivariable regression. RESULTS Among 160 patients followed for a median of 2.3 ± 2.1 years, defects were 54% oral tongue, 18% external, 9% maxilla, 8% buccal mucosa, 9% floor of mouth, and 3% pharynx. Flap types (and median pedicle lengths) were 41% traditional lateral arm (8 cm), 25% extended lateral arm (11.5 cm), and 34% lateral forearm (14 cm). All donor sites were closed primarily; 19.6% and 0% of patients had increased DASH scores 2 and 12 weeks after reconstruction. Major complications occurred in 18.1% of patients, including 6.3% reoperation, 6.9% readmission, 3.7% fistula, and 1.8% flap loss. Complications were independently associated with peripheral vascular disease (odds ratio [OR]: 5.71, 95% confidence interval [CI]: 1.5-21.6, P = .01), pharyngeal defects (OR: 11.3, 95% CI: 1.4-94.5, P = .025), and interposition vein grafts (OR: 3.78, 95% CI: 1.1-13.3, P = .037). CONCLUSION The lateral arm free flap was safe, versatile, and reliable for head and neck reconstruction with low donor-site morbidity. Complications occurred in a fifth of patients and were associated with peripheral vascular disease, pharyngeal defects, and vein grafts.
Collapse
Affiliation(s)
- Kevin J Contrera
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Abbas M Hassan
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - John W Shuck
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Bobian
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Austin Y Ha
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Edward I Chang
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patrick B Garvey
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Margaret S Roubaud
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Z-Hye Lee
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mathew M Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey N Myers
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rene D Largo
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
2
|
Chi D, Ha AY, Alotaibi F, Pripotnev S, Patterson BCM, Fongsri W, Gouda M, Kahn LC, Mackinnon SE. A Surgical Framework for the Management of Incomplete Axillary Nerve Injuries. J Reconstr Microsurg 2023; 39:616-626. [PMID: 36746195 DOI: 10.1055/s-0042-1757752] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Axillary nerve injury is the most common nerve injury affecting shoulder function. Nerve repair, grafting, and/or end-to-end nerve transfers are used to reconstruct complete neurotmetic axillary nerve injuries. While many incomplete axillary nerve injuries self-resolve, axonotmetic injuries are unpredictable, and incomplete recovery occurs. Similarly, recovery may be further inhibited by superimposed compression neuropathy at the quadrangular space. The current framework for managing incomplete axillary injuries typically does not include surgery. METHODS This study is a retrospective analysis of 23 consecutive patients with incomplete axillary nerve palsy who underwent quadrangular space decompression with additional selective medial triceps to axillary end-to-side nerve transfers in 7 patients between 2015 and 2019. Primary outcome variables included the proportion of patients with shoulder abduction M3 or greater as measured on the Medical Research Council (MRC) scale, and shoulder pain measured on a Visual Analogue Scale (VAS). Secondary outcome variables included pre- and postoperative Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) scores. RESULTS A total of 23 patients met the inclusion criteria and underwent nerve surgery a mean 10.7 months after injury. Nineteen (83%) patients achieved MRC grade 3 shoulder abduction or greater after intervention, compared with only 4 (17%) patients preoperatively (p = 0.001). There was a significant decrease in VAS shoulder pain scores of 4.2 ± 2.5 preoperatively to 1.9 ± 2.4 postoperatively (p < 0.001). The DASH scores also decreased significantly from 48.8 ± 19.0 preoperatively to 30.7 ± 20.4 postoperatively (p < 0.001). Total follow-up was 17.3 ± 4.3 months. CONCLUSION A surgical framework is presented for the appropriate diagnosis and surgical management of incomplete axillary nerve injury. Quadrangular space decompression with or without selective medial triceps to axillary end-to-side nerve transfers is associated with improvement in shoulder abduction strength, pain, and DASH scores in patients with incomplete axillary nerve palsy.
Collapse
Affiliation(s)
- David Chi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Austin Y Ha
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Fawaz Alotaibi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Stahs Pripotnev
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Brendan C M Patterson
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Warangkana Fongsri
- Hand and Microsurgery Unit, Department of Orthopedic, Prince of Songkla University, Hatyai, Songkhla, Thailand
| | - Mahmoud Gouda
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Zagazig University, Zagazig City, Sharkia Governorate, Egypt
| | - Lorna C Kahn
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| |
Collapse
|
3
|
Wood CB, Ha AY, Puram SV, Jackson RS, Pipkorn P. The two-handed template for planning fibular free flap reconstruction of the head and neck. Head Neck 2021; 44:296-299. [PMID: 34726803 DOI: 10.1002/hed.26901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/10/2021] [Accepted: 10/13/2021] [Indexed: 11/06/2022] Open
Abstract
Fibular free flap reconstruction of head and neck defects is complex, and the anatomic relationships among components of the fibular flap pose challenges to reconstructive surgeons. Various techniques have been employed in planning for fibular free flap procedures, but these are often cumbersome and difficult to implement in clinically. We devised a simplistic tool for pre-operative leg selection, wherein the surgeon uses two hands to represent the various components of the fibular flap. The senior author has used this method to aid in leg selection for fibular free flaps. In all cases, utilization of this technique allowed for appropriate leg selection relative to the location of the vascular pedicle and posterior crural septum. The two-handed template for fibular free flap reconstruction is a simple, reproducible, and affordable tool that can aid reconstructive surgeons when they are planning to use a fibular flap.
Collapse
Affiliation(s)
- C Burton Wood
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Austin Y Ha
- Department of Plastic Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| |
Collapse
|
4
|
Peters BR, Ha AY, Moore AM, Tung TH. Nerve transfers for femoral nerve palsy: an updated approach and surgical technique. J Neurosurg 2021; 136:856-866. [PMID: 34416726 DOI: 10.3171/2021.2.jns203463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 09/12/2020] [Accepted: 02/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Femoral nerve palsy results in significant impairment of lower extremity function due to the loss of quadriceps muscle function. The authors have previously described their techniques utilizing the anterior obturator and sartorius nerves for transfer in cases of femoral nerve palsy presenting within 1 year of injury. In the current study, the authors discuss their updated techniques, results, and approach to partial and complete femoral nerve palsies using femoral nerve decompression and nerve transfers. METHODS They conducted a retrospective review of patients with femoral nerve palsies treated with their technique at the Washington University School of Medicine in 2008-2019. Primary outcomes were active knee extension Medical Research Council (MRC) grades and visual analog scale (VAS) pain scores. RESULTS Fourteen patients with femoral nerve palsy were treated with femoral nerve decompression and nerve transfer: 4 with end-to-end (ETE) nerve transfers, 6 with supercharged end-to-side (SETS) transfers, and 4 with ETE and SETS transfers, using the anterior branch of the obturator nerve, the sartorius branches, or a combination of both. The median preoperative knee extension MRC grade was 2 (range 0-3). The average preoperative VAS pain score was 5.2 (range 1-9). Postoperatively, all patients attained an MRC grade 4 or greater and subjectively noted improved strength and muscle bulk and more natural gait. The average postoperative pain score was 2.3 (range 0-6), a statistically significant improvement (p = 0.001). CONCLUSIONS Until recently, few treatments were available for high femoral nerve palsy. A treatment strategy involving femoral nerve decompression and nerve transfers allows for meaningful functional recovery and pain relief in cases of partial and total femoral nerve palsy. An algorithm for the management of partial and complete femoral nerve palsies and a detailed description of surgical techniques are presented.
Collapse
Affiliation(s)
- Blair R Peters
- 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; and
| | - Austin Y Ha
- 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; and
| | - Amy M Moore
- 2Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Thomas H Tung
- 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; and
| |
Collapse
|
5
|
Abstract
BACKGROUND En bloc capsulectomy has recently increased in prominence as a potential surgical therapy for patients with breast implant illness (BII). However, this procedure has chiefly been recommended for treating breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). OBJECTIVES This study aimed to review the current literature and evaluate the public understanding of treatment options for BII via social media to characterize any potential communication disconnect between clinicians and patients. METHODS An electronic literature review was performed to identify all available publications mentioning evidence-based support for en bloc capsulectomy as treatment for BII and BIA-ALCL. Twitter social media posts referencing BII or BIA-ALCL were analyzed from 2010 to 2019. Author identity and any mention of surgical treatment were assessed. RESULTS A total of 115 publications on the subject of BII and 315 articles on BIA-ALCL were identified. En bloc resection was recommended only for patients with a diagnosis of BIA-ALCL. A total of 6419 tweets referencing BII and 6431 tweets referencing BIA-ALCL were identified. Tweets referencing BIA-ALCL were significantly more likely to be authored by physicians (25.9% vs 5.3%, P < 0.001), and tweets referencing BII were significantly more likely to mention any surgical treatment (7.8% vs 1.9%, P < 0.001) and en bloc capsulectomy (1.4% vs 0.3%, P < 0.001). CONCLUSIONS This study demonstrates that a communication disconnect exists between the scientific literature and social media regarding treatment options for BII and BIA-ALCL. Physicians should be aware of these potential misconceptions to empathetically address patient concerns in a patient-centered manner.
Collapse
Affiliation(s)
- Grace Keane
- From the Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO
| | - David Chi
- From the Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Austin Y Ha
- From the Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Terence M Myckatyn
- From the Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO
| |
Collapse
|
6
|
McInnes CW, Ha AY, Power HA, Tung TH, Moore AM. Femoral nerve decompression and sartorius-to-quadriceps nerve transfers for partial femoral nerve injury: a cadaveric study and early case series. J Neurosurg 2020; 135:904-911. [PMID: 33157531 DOI: 10.3171/2020.6.jns20251] [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] [Received: 01/24/2020] [Accepted: 06/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Partial femoral nerve injuries cause significant disability with ambulation. Due to their more proximal and superficial location, sartorius branches are often spared in femoral nerve injuries. In this article, the authors report the benefits of femoral nerve decompression, demonstrate the feasibility of sartorius-to-quadriceps nerve transfers in a cadaveric study, describe the surgical technique, and report clinical results. METHODS Four fresh-frozen cadaveric lower limbs were dissected for anatomical analysis of the sartorius nerve. In addition, a retrospective review of patients with partial femoral nerve injuries treated with femoral nerve decompression and sartorius-to-quadriceps nerve transfers was conducted. Pre- and postoperative knee extension Medical Research Council (MRC) grades and pain scores (visual analog scale) were collected. RESULTS Up to 6 superficial femoral branches innervate the sartorius muscle just distal to the inguinal ligament. Each branch yielded an average of 672 nerve fibers (range 99-1850). Six patients underwent femoral nerve decompression and sartorius-to-quadriceps nerve transfers. Four patients also had concomitant obturator-to-quadriceps nerve transfers. At final follow-up (average 13.4 months), all patients achieved MRC grade 4-/5 or greater knee extension. The average preoperative pain score was 5.2, which decreased to 2.2 postoperatively (p = 0.03). CONCLUSIONS Femoral nerve decompression and nerve transfer using sartorius branches are a viable tool for restoring function in partial femoral nerve injuries. Sartorius branches serve as ideal donors in quadriceps nerve transfers because they are expendable, are close to their recipients, and have an adequate supply of nerve fibers.
Collapse
Affiliation(s)
- Colin W McInnes
- 1Department of Surgery, Division of Plastic Surgery, Fraser Health Authority/University of British Columbia, New Westminster, British Columbia, Canada
| | - Austin Y Ha
- 2Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Hollie A Power
- 3Department of Surgery, Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada; and
| | - Thomas H Tung
- 2Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Amy M Moore
- 4Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| |
Collapse
|
7
|
Guffey R, Keane G, Ha AY, Parikh R, Odom E, Zhang L, Myckatyn TM. Enhanced Recovery With Paravertebral and Transversus Abdominis Plane Blocks in Microvascular Breast Reconstruction. Breast Cancer (Auckl) 2020; 14:1178223420967365. [PMID: 33597807 PMCID: PMC7863148 DOI: 10.1177/1178223420967365] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/24/2020] [Indexed: 11/17/2022]
Abstract
Purpose: We have shown previously that a preoperative paravertebral nerve block is associated with improved postoperative recovery in microvascular breast reconstruction. The purpose of this study was to compare the outcomes of a complete enhanced recovery after surgery (ERAS) protocol with complete regional anesthesia coverage to our traditional care with paravertebral block. Patients and methods: This was a retrospective cohort study of 83 patients who underwent autologous breast reconstruction by T.M.M. between May 2014 and February 2018 at a tertiary academic center. Patients in the ERAS group were additionally administered acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, a transversus abdominis plane block (liposomal or plain bupivacaine), and primarily oral opioids postoperatively. The patients were mobilized earlier with more rapid diet progression. All patients received a preoperative paravertebral block. Results: Forty-four patients in the ERAS cohort were compared with 39 retrospective controls. The 2 groups were similar with respect to demographics and comorbidities. The ERAS cohort required significantly less opioids (291 vs 707 mg oral morphine equivalent, P < .0001) with unchanged postoperative pain scores and a shorter time to oral only opioid use (16.0 vs 78.2 hours, P < .0001). Median length of stay (3.20 vs 4.62, P < .0001) and time to independent ambulation (1.86 vs 2.88, P < .0001) were also significantly decreased in the ERAS cohort. Liposomal bupivacaine use did not significantly affect the results (P ⩾ .2). Conclusions: Implementation of a robust enhanced recovery protocol with complete regional anesthesia coverage was associated with significantly decreased opioid use despite unchanged pain scores, with improved markers of recovery including length of stay, time to oral only narcotics, and time to independent ambulation.
Collapse
Affiliation(s)
- Ryan Guffey
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Grace Keane
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Austin Y Ha
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Rajiv Parikh
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Elizabeth Odom
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Li Zhang
- Department of Anesthesiology, Wuhan No. 1 Hospital, Wuhan, China
| | - Terence M Myckatyn
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
8
|
Chi D, Chen AD, Ha AY, Yaeger LH, Lee BT. Comparative Effectiveness of Transversus Abdominis Plane Blocks in Abdominally Based Autologous Breast Reconstruction: A Systematic Review and Meta-analysis. Ann Plast Surg 2020; 85:e76-e83. [PMID: 32960515 DOI: 10.1097/sap.0000000000002376] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The abdomen is the most common donor site in autologous microvascular free flap breast reconstruction and contributes significantly to postoperative pain, resulting in increased opioid use, length of stay, and hospital costs. Enhanced Recovery After Surgery (ERAS) protocols have demonstrated multiple clinical benefits, but these protocols are widely heterogeneous. Transversus abdominis plane (TAP) blocks have been reported to improve pain control and may be a key driver of the benefits seen with ERAS pathways. METHODS A systematic review and meta-analysis of studies reporting TAP blocks for abdominally based breast reconstruction were performed. Studies were extracted from 6 public databases before February 2019 and pooled in accordance with the PROSPERO registry. Total opioid use, postoperative pain, length of stay, hospital cost, and complications were analyzed using a random effects model. RESULTS The initial search yielded 420 studies, ultimately narrowed to 12 studies representing 1107 total patients. Total hospital length of stay (mean difference, -1.00 days; P < 0.00001; I = 81%) and opioid requirement (mean difference, -133.80 mg of oral morphine equivalent; P < 0.00001; I = 97%) were decreased for patients receiving TAP blocks. Transversus abdominis plane blocks were not associated with any significant differences in postoperative complications (P = 0.66), hospital cost (P = 0.22), and postoperative pain (P = 0.86). CONCLUSIONS Optimizing postoperative pain management after abdominally based microsurgical breast reconstruction is invaluable for patient recovery. Transversus abdominis plane blocks are associated with a reduction in length of stay and opioid use, representing a safe and reasonable strategy for decreasing postoperative pain.
Collapse
Affiliation(s)
| | - Austin D Chen
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Austin Y Ha
- From the Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, MO
| | - Lauren H Yaeger
- From the Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, MO
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| |
Collapse
|
9
|
Ha AY, Skolnick GB, Chi D, Nguyen DC, Naidoo SD, Smyth MD, Patel KB. School-Aged Anthropometric Outcomes After Endoscopic or Open Repair of Metopic Synostosis. Pediatrics 2020; 146:peds.2020-0238. [PMID: 32784224 DOI: 10.1542/peds.2020-0238] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Metopic craniosynostosis can be treated by fronto-orbital advancement or endoscopic strip craniectomy with postoperative helmeting. Infants younger than 6 months of age are eligible for the endoscopic repair. One-year postoperative anthropometric outcomes have been shown to be equivalent, with significantly less morbidity after endoscopic treatment. The authors hypothesized that both repairs would yield equivalent anthropometric outcomes at 5-years postoperative. METHODS This study was a retrospective chart review of 31 consecutive nonsyndromic patients with isolated metopic craniosynostosis treated with either endoscopic or open correction. The primary anthropometric outcomes were frontal width, interfrontal divergence angle, the Whitaker classification, and the presence of lateral frontal retrusion. Peri-operative variables included estimated blood loss, rates of blood transfusion, length of stay, and operating time. RESULTS There was a significantly lower rate of lateral frontal retrusion in the endoscopic group. No statistically significant differences were found in the other 3 anthropometric outcomes at 5-years postoperative. The endoscopic group was younger at the time of surgery and had improved peri-operative outcomes related to operating time, hospital stay and blood loss. Both groups had low complication and reoperation rates. CONCLUSIONS In our cohort of school-aged children with isolated metopic craniosynostosis, patients who underwent endoscopic repair had superior or equivalent outcomes on all 4 primary anthropometric measures compared with those who underwent open repair. Endoscopic repair was associated with significantly faster recovery and decreased morbidity. Endoscopic repair should be considered in patients diagnosed with metopic craniosynostosis before 6 months of age.
Collapse
Affiliation(s)
- Austin Y Ha
- Division of Plastic and Reconstructive Surgery, Department of Surgery and
| | - Gary B Skolnick
- Division of Plastic and Reconstructive Surgery, Department of Surgery and
| | - David Chi
- Division of Plastic and Reconstructive Surgery, Department of Surgery and
| | - Dennis C Nguyen
- Division of Plastic and Reconstructive Surgery, Department of Surgery and
| | - Sybill D Naidoo
- Division of Plastic and Reconstructive Surgery, Department of Surgery and
| | - Matthew D Smyth
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Kamlesh B Patel
- Division of Plastic and Reconstructive Surgery, Department of Surgery and
| |
Collapse
|
10
|
Phillips BT, Brown S, Ha AY, Janes LE, Malik M, Massand S, Ramly EP, Saha S, Serebrakian AT, Tumkur D, Gosain AK. Spotlight in Plastic Surgery: July 2020. Plast Reconstr Surg 2020; 146:209-212. [DOI: 10.1097/prs.0000000000006972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
11
|
Ha AY, Guffey R, Myckatyn TM. Reply: The Analgesic Effects of Liposomal Bupivacaine versus Bupivacaine Hydrochloride Administered as a Transversus Abdominis Plane Block after Abdominally Based Autologous Microvascular Breast Reconstruction: A Prospective, Single-Blind, Randomized, Controlled Trial. Plast Reconstr Surg 2020; 145:998e-999e. [PMID: 32332565 DOI: 10.1097/prs.0000000000006783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Austin Y Ha
- Division of Plastic and Reconstructive Surgery
| | | | - Terence M Myckatyn
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Mo
| |
Collapse
|
12
|
Lee HK, Kwon B, Lemere CA, de la Monte S, Itamura K, Ha AY, Querfurth HW. mTORC2 (Rictor) in Alzheimer's Disease and Reversal of Amyloid-β Expression-Induced Insulin Resistance and Toxicity in Rat Primary Cortical Neurons. J Alzheimers Dis 2018; 56:1015-1036. [PMID: 28035937 DOI: 10.3233/jad-161029] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [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: 01/11/2023]
Abstract
Mammalian target of rapamycin complex 1 (mTORC1), a nutrient sensor and central controller of cell growth and proliferation, is altered in various models of Alzheimer's disease (AD). Even less studied or understood in AD is mammalian target of rapamycin complex 2 (mTORC2) that influences cellular metabolism, in part through the regulations of Akt/PKB and SGK. Dysregulation of insulin/PI3K/Akt signaling is another important feature of AD pathogenesis. We found that both total mTORC1 and C2 protein levels and individual C1 and C2 enzymatic activities were decreased in human AD brain samples. In two rodent AD models, mTORC1 and C2 activities were also decreased. In a neuronal culture model of AD characterized by accumulation of cellular amyloid-β (Aβ)42, mTORC1 activity was reduced. Autophagic vesicles and markers were correspondingly increased and new protein synthesis was inhibited, consistent with mTORC1 hypofunction. Interestingly, mTORC2 activity in neural culture seemed resistant to the effects of intracellular amyloid. In various cell lines, Aβ expression provoked insulin resistance, characterized by inhibition of stimulated Akt phosphorylation, and an increase in negative mTORC1 regular, p-AMPK, itself a nutrient sensor. Rapamycin decreased phospho-mTOR and to lesser degree p-Rictor. This further suppression of mTORC1 activity protected cells from Aβ-induced toxicity and insulin resistance. More striking, Rictor over-expression fully reversed the Aβ-effects on primary neuronal cultures. Finally, using in vitro assay, Rictor protein addition completely overcame oligomeric Aβ-induced inhibition of the PDK-Akt activation step. We conclude that striking a new balance by restoring mTORC2 abundance and/or inhibition of mTORC1 has therapeutic potential in AD.
Collapse
Affiliation(s)
- Han-Kyu Lee
- Department of Neurology, Rhode Island Hospital and Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Bumsup Kwon
- Department of Neurology, Rhode Island Hospital and Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Cynthia A Lemere
- Ann Romney Center for Neurologic Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Suzanne de la Monte
- Department of Pathology, Rhode Island Hospital and Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Kyohei Itamura
- Department of Neurology, Rhode Island Hospital and Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Austin Y Ha
- Department of Neurology, Rhode Island Hospital and Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Henry W Querfurth
- Department of Neurology, Rhode Island Hospital and Brown University Warren Alpert Medical School, Providence, RI, USA
| |
Collapse
|
13
|
Ha AY, Mangham W, Frommer SA, Choi D, Klinge P, Taylor HO, Oyelese AA, Sullivan SR. Interdisciplinary Management of Minimally Displaced Orbital Roof Fractures: Delayed Pulsatile Exophthalmos and Orbital Encephalocele. Craniomaxillofac Trauma Reconstr 2016; 10:11-15. [PMID: 28210402 DOI: 10.1055/s-0036-1584395] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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: 10/30/2015] [Accepted: 02/20/2016] [Indexed: 10/21/2022] Open
Abstract
Traumatic orbital roof fractures are rare and are managed nonoperatively in most cases. They are typically associated with severe mechanisms of injury and may be associated with significant neurologic or ophthalmologic compromise including traumatic brain injury and vision loss. Rarely, traumatic encephalocele or pulsatile exophthalmos may be present at the time of injury or develop in delayed fashion, necessitating close observation of these patients. In this article, we describe two patients with minimally displaced blow-in type orbital roof fractures that were later complicated by orbital encephalocele and pulsatile exophthalmos, prompting urgent surgical intervention. We also suggest a management algorithm for adult patients with orbital roof fractures, emphasizing careful observation and interdisciplinary management involving plastic surgery, neurosurgery, and ophthalmology.
Collapse
Affiliation(s)
- Austin Y Ha
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - William Mangham
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Sarah A Frommer
- Department of Plastic and Reconstructive Surgery, Rhode Island Hospital, Providence, Rhode Island
| | - David Choi
- Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island
| | - Petra Klinge
- Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island
| | - Helena O Taylor
- Division of Plastic and Reconstructive Surgery, Mount Auburn Hospital, Cambridge, Massachusetts
| | | | - Stephen R Sullivan
- Division of Plastic and Reconstructive Surgery, Mount Auburn Hospital, Cambridge, Massachusetts
| |
Collapse
|
14
|
Ha AY, Shalvoy RM, Voisinet A, Racine J, Aaron RK. Controversial role of arthroscopic meniscectomy of the knee: A review. World J Orthop 2016; 7:287-292. [PMID: 27190756 PMCID: PMC4865718 DOI: 10.5312/wjo.v7.i5.287] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/22/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
The role of arthroscopic partial meniscectomy (APM) in reducing pain and improving function in patients with meniscal tears remains controversial. Five recent high-quality randomized controlled trials (RCTs) compared non-operative management of meniscal tears to APM, with four showing no difference and one demonstrating superiority of APM. In this review, we examined the strengths and weaknesses of each of these RCTs, with particular attention to the occurrence of inadvertent biases. We also completed a quantitative analysis that compares treatment successes in each treatment arm, considering crossovers as treatment failures. Our analysis revealed that each study was an excellent attempt to compare APM with non-surgical treatment but suffered from selection, performance, detection, and/or transfer biases that reduce confidence in its conclusions. While the RCT remains the methodological gold standard for establishing treatment efficacy, the use of an RCT design does not in itself ensure internal or external validity. Furthermore, under our alternative analysis of treatment successes, two studies had significantly more treatment successes in the APM arm than the non-operative arm although original intention-to-treat analyses showed no difference between these two groups. Crossovers remain an important problem in surgical trials with no perfect analytical solution. With the studies available at present, no conclusion can be drawn concerning the optimal treatment modality for meniscal tears. Further work that minimizes significant biases and crossovers and incorporates sub-group and cost-benefit analyses may clarify therapeutic indications.
Collapse
|
15
|
Ha AY, DePasse JM, Piskorski A, Treaba DO, Kojic EM, Daniels AH. Compressive spinal epidural mass caused by Propionibacterium acnes. Spine J 2016; 16:e347-51. [PMID: 26721733 DOI: 10.1016/j.spinee.2015.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/25/2015] [Accepted: 12/11/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Propionibacterium acnes is a gram-positive and facultative anaerobe bacillus that is found within sebaceous follicles of the human skin and recognized as a cause of infections after spinal surgery. To our knowledge, there has been no previously reported case of symptomatic compressive chronic inflammatory epidural mass caused by P. acnes in a patient with no prior spinal procedures. PURPOSE This study aimed to describe a case of primary spinal infection by P. acnes. STUDY DESIGN This study is a case report of a condition not previously described in the literature. METHODS We present the history, physical examination, laboratory, radiographic, and histopathologic findings of a chronic inflammatory epidural mass caused by P. acnes in an immunocompetent adult male with no history of spinal surgery. RESULTS A 51-year-old man presented to our clinic with sudden onset bilateral lower extremity weakness, inability to ambulate, and urinary retention. His past clinical history was remarkable only for hernia and left knee surgery but no spinal surgery. A year earlier, he had an infected draining abscess of the right axilla that was successfully managed medically. At presentation, his serum erythrocyte sedimentation rate and C-reactive protein were moderately elevated. Pan-spine magnetic resonance imaging was notable for a circumferential epidural mass from C5 to T6. He underwent emergent decompression; the mass was removed and sent for culture and pathologic evaluation. Cultures from all three specimens collected during surgery grew P. acnes, and the patient was successfully managed on intravenous ceftriaxone, while pathology revealed a chronic inflammatory reactive process. CONCLUSIONS This is the first reported case of a primary spinal mass with chronic inflammatory features caused by P. acnes. In cases of epidural mass of unknown origin, both pathologic specimens and cultures should be obtained as slow-growing organisms may mimic oncologic processes.
Collapse
Affiliation(s)
- Austin Y Ha
- Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA.
| | - J Mason DePasse
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, 593 Eddy St, Providence, RI 02903, USA
| | - Anna Piskorski
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School of Brown University, 593 Eddy St, Providence, RI 02903, USA
| | - Diana O Treaba
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School of Brown University, 593 Eddy St, Providence, RI 02903, USA
| | - Erna M Kojic
- Department of Immunology, Warren Alpert Medical School of Brown University, 593 Eddy St, Providence, RI 02903, USA
| | - Alan H Daniels
- Department of Orthopaedics, Division of Spine Surgery-Adult Spinal Deformity Service, Warren Alpert Medical School of Brown University, 593 Eddy St, Providence, RI 02903, USA
| |
Collapse
|
16
|
Johnston BR, Ha AY, Brea B, Liu PY. The Mechanism of Hyperbaric Oxygen Therapy in the Treatment of Chronic Wounds and Diabetic Foot Ulcers. R I Med J (2013) 2016; 99:26-29. [PMID: 26827082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Non-healing wounds are a growing public health concern, and more than $25 billion per year in the US are spent caring for patients with chronic wounds. Many of these patients are referred to specialized wound centers, where hyperbaric oxygen therapy (HBO2T) has become a mainstay in healing wounds, especially diabetic foot ulcers (DFU). However, it is costly, with a typical course of therapy running into the tens of thousands of dollars. Presently, as many as 30-40% of DFU patients with Wagner's Grade 3 and 4 ulcers treated with HBO2T fail to heal by 24 weeks. Unfortunately, the patient will have already received lengthy therapy (30-60 daily treatments over 6-10 week time period) before having the wound deemed non-responsive. Currently, practitioners employ a combination of clinical markers, diagnostic testing and a four-week preliminary healing response, but this approach is inaccurate and delays definitive identification of HBO2T responder and non-responder phenotypes.
Collapse
Affiliation(s)
| | - Austin Y Ha
- Warren Alpert Medical School, Brown University
| | | | - Paul Y Liu
- Warren Alpert Medical School, Brown University; Department of Plastic and Reconstructive Surgery, Rhode Island Hospital
| |
Collapse
|
17
|
Johnston BR, Ha AY, Kwan D. Surgical Management of Chronic Wounds. R I Med J (2013) 2016; 99:30-33. [PMID: 26827083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
In this article, we outline the important role the surgeon plays in the management of chronic wounds. Debridement and washout are required for grossly infected wounds and necrotizing soft tissue infections. Cutaneous cancers such as squamous cell carcinomas may contribute to chronic wounds and vice versa; if diagnosed, these should be treated with wide local excision. Arterial, venous, and even lymphatic flows can be restored in select cases to enhance delivery of nutrients and removal of metabolic waste and promote wound healing. In cases where vital structures, such as bones, joints, tendons, and nerves, are exposed, vascularized tissue transfers are often required. These tissue transfers can be local or remote, the latter of which necessitates anastomoses of arteries and veins. Pressure sores are managed by relieving pressure, treating acute trauma or infection, and using rotation fasciocutaneous flaps. Lastly, the surgeon must always consider the possibility of osteomyelitis and retained foreign body as etiology for chronic wounds.
Collapse
Affiliation(s)
| | - Austin Y Ha
- Warren Alpert Medical School, Brown University
| | - Daniel Kwan
- Department of Plastic and Reconstructive Surgery, Rhode Island Hospital
| |
Collapse
|
18
|
Fallon EA, Ha AY, Merck DL, Ciullo SS, Luks FI. Interactive Instrument-Driven Image Display in Laparoscopic Surgery. J Laparoendosc Adv Surg Tech A 2015; 25:531-5. [PMID: 25942694 DOI: 10.1089/lap.2014.0261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A significant limitation of minimally invasive surgery is dependence of the entire surgical team on a single endoscopic viewpoint. An individualized, instrument-driven image display system that allows all operators to simultaneously define their viewing frame of the surgical field may be the solution. We tested the efficacy of such a system using a modified Fundamentals of Laparoscopic Surgery™ (Society of American Gastrointestinal and Endoscopic Surgeons, Los Angeles, CA) bead transfer task. MATERIALS AND METHODS A program was custom-written to allow zooming and centering of the image window on specific color signals, each attached near the tip of a different laparoscopic instrument. Two controls were used for the bead transfer task: (1) a static, wide-angle view and (2) a single moving camera allowing close-up and tracking of the bead as it was transferred. Time to task completion and number of bead drops were recorded. RESULTS Thirty-six sessions were performed by surgical residents. Average time for bead transfer was 127.3±21.3 seconds in the Experimental group, 139.1±27.8 seconds in the Control 1 group, and 186.2±18.5 seconds in the Control 2 group (P=.034, by analysis of variance). Paired analysis (the Wilcoxon Signed-Rank Test) showed that the Experimental group was significantly faster than the Control 1 group (P=.035) and the Control 2 group (P=.028). CONCLUSIONS We have developed an image navigation system that allows intuitive and efficient laparoscopic performance compared with two controls. It offers high-resolution images and ability for multitasking. The tracking system centers close-up images on the laparoscopic target. Further development of robust prototypes will help transition this in vitro system into clinical application.
Collapse
Affiliation(s)
- Eleanor A Fallon
- Departments of Surgery and Medical Imaging, Alpert Medical School of Brown University and Rhode Island Hospital , Providence, Rhode Island
| | - Austin Y Ha
- Departments of Surgery and Medical Imaging, Alpert Medical School of Brown University and Rhode Island Hospital , Providence, Rhode Island
| | - Derek L Merck
- Departments of Surgery and Medical Imaging, Alpert Medical School of Brown University and Rhode Island Hospital , Providence, Rhode Island
| | - Sean S Ciullo
- Departments of Surgery and Medical Imaging, Alpert Medical School of Brown University and Rhode Island Hospital , Providence, Rhode Island
| | - Francois I Luks
- Departments of Surgery and Medical Imaging, Alpert Medical School of Brown University and Rhode Island Hospital , Providence, Rhode Island
| |
Collapse
|
19
|
Ha AY, Nguyen JE, Doyle RJ, Feller E. Actual and perceived HBV status among Asian Pacific Islander Americans in Rhode Island: a cross-sectional study. R I Med J (2013) 2015; 98:15-18. [PMID: 25938399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Chronic hepatitis B (HBV) in the Asian and Pacific Islander (API) American population is an under-recognized health issue in the United States. Among foreign-born API, the prevalence of HBV is approximately 10%. The prevalence in the general population is below 0.5%; among non-Hispanic whites it is below 0.2%. We examined beliefs held by the API populations in Rhode Island (RI) about personal HBV status and compared them with their actual HBV status. Of 59 total study participants, only 19 (32%) participants correctly knew their HBV status. Six (10%) participants were carriers of HBV; 18 (31%) lacked immunity to the virus. This pilot study suggests the RI API population is not knowledgeable about their own HBV status and are inadequately screened, vaccinated against, and treated for HBV. Increased statewide screening and education efforts, tailored to address this population, are needed to identify and inform those in need of medical attention or vaccination.
Collapse
Affiliation(s)
- Austin Y Ha
- medical student at The Warren Alpert Medical School, Brown University
| | - Joyce E Nguyen
- medical student at The Warren Alpert Medical School of Brown University
| | - Richard J Doyle
- research associate in the Department of Family Medicine at The Warren Alpert Medical School, Brown University
| | - Edward Feller
- clinical professor of medicine and adjunct professor of health services, policy and practices at The Warren Alpert Medical School, Brown University
| |
Collapse
|