Biomedical subjects

Babak J Mehrara

Publications and source records attributed to Babak J Mehrara.

At least 19 recordsLinked to original sources

PubMed2006

Reconstruction of the hypopharynx with the free jejunum transfer.

Microsurgical techniques have revolutionized pharyngolaryngeal reconstruction. Free flap reconstruction with the free jejunal flap enables one stage reconstruction with minimal morbidity and mortality. This review will examine indications, operative technique, postoperative management, and expected outcomes for the hypopharyngeal reconstruction with the free jejunum flap. This procedure allows for maintenance of oral sections and rapid return of per-oral feeds and swallowing. The vast majority of patients resume swallowing and can maintain adequate nutrition without the need for supplemental enteral feeding via a tube. The free jejunal transfer can be rapidly harvested in most instances and transplanted to the hypopharyngeal region with a greater than 95% success rate. The jejunum fee flap is most useful for circumferential defects of the hypopharynx, but can also be used for partial defects. The most common local complications are stricture and fistula formation. A history of preoperative radiation therapy increases the risk of local complications.

Contraindications↗

PubMed2006

Scalp reconstruction.

Scalp reconstruction after oncologic resection can be challenging. Wide surgical resections, in combination with co-morbid conditions such as infected alloplastic material, cerebrospinal fluid (CSF) leak, or devascularized bone after craniotomy necessitate healthy, vascularized tissues for reconstruction. Although primary closure is feasible in some cases, the mainstay of treatment involves local tissue rearrangement with or without split thickness skin grafting. In addition, free tissue transfer is an important adjunct to therapy in patients with poor local tissues. Careful analysis of the defect and local tissues can help tailor the method of reconstruction and result in satisfactory closure in a majority of patients. Current techniques used for scalp reconstruction after surgical ablation are the subject of this review.

Craniotomy↗

PubMed2006

Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction.

Vaginal defects from oncologic resection present a complex array of reconstructive challenges. Increased use of adjuvant radiation and chemotherapy demands uncomplicated wound healing. As patients are being diagnosed at earlier stages of disease and at younger ages, maintenance of sexual function and body image are fundamental goals. This review provides an algorithm approach to defect classification and flap reconstruction. Carefully appreciation of the specific defect facilitates flap choice. There are two basic defect types partial (Type I) and circumferential defects (Type II) 1. These defect types can be further subclassified. Type IA defects are partial and involve the anterior and/or lateral wall. Type IB defects are also partial, but involve the posterior vaginal wall. Type IIA defects are circumferential, involving the upper two-thirds of the vagina. Type IIB defects represent circumferential, total vaginal resection, most commonly following pelvic exenteration. Using this method of defect classification, three pedicled flaps can be used to successfully reconstruct the majority of defects: the Singapore (or pudendal thigh) flap, the rectus flap, and the gracilis flap. With appropriate flap choice and a multidisciplinary approach to patient care, rapid wound healing, restoration of the pelvic floor, and re-establishment of sexual function may be most reliably achieved.

Algorithms↗

PubMed2006

Complications after microvascular breast reconstruction: experience with 1195 flaps.

BACKGROUND: Reconstruction is an important adjunct to breast cancer management. This study evaluated the frequency of major and minor complications in the largest reported series of consecutive mastectomy patients treated with free tissue transfer for breast reconstruction. METHODS: All patients treated with microvascular breast reconstruction at the University of California, Los Angeles, Medical Center over an 11-year period were identified using a retrospective analysis. Frequency of complications was assessed. RESULTS: A total of 1195 breast reconstructions were performed in 952 patients. Transverse rectus abdominis musculocutaneous flaps were used in most cases (81.8 percent), whereas the superior gluteal musculocutaneous flap (10.1 percent) and other free flaps were used in the remaining patients. The overall complication rate was 27.9 percent and consisted primarily of minor complications (21.7 percent). Major complications were noted in 7.7 percent, including six total flap losses (0.5 percent). Obesity was a major predictor of complications. Smoking was not associated with increased rates of overall or microsurgical complications. Neoadjuvant chemotherapy was also an independent predictor of complications and was associated with wound-healing problems and fat necrosis. Prior abdominal surgery in transverse rectus abdominis musculocutaneous flap patients increased the risk of partial flap loss, fat necrosis, and donor-site complications. CONCLUSIONS: Microsurgical breast reconstruction is a safe and highly effective technique. Complications tend to be minor and do not affect postreconstruction adjuvant therapy. Obesity is a major predictor of flap and donor-site complications, and these patients should be appropriately counseled. Similarly, neoadjuvant preoperative chemotherapy and prior abdominal surgery increase the rates of minor complications.

Adult↗

PubMed2006

Reconstruction of extensive partial or total sacrectomy defects with a transabdominal vertical rectus abdominis myocutaneous flap.

Following partial or total sacrectomy, extensive soft tissue defects are frequently created. These ablations typically involve an anterior and a posterior approach, creating a large communication between the abdominal cavity and the central gluteal region. Local flap options are usually not sufficient for definitive closure of these large defects. We have found that the most useful option for reconstruction in these cases is a vertical rectus abdominis myocutaneous (VRAM) flap, passed transabdominally through the peritoneal cavity into the sacral defect during the initial anterior-approach portion of the procedure and then inset following completion of the posterior-approach final resection. Advantages of the VRAM flap are that it can supply ample skin, as well as soft tissue bulk, is easy to perform, and does not require microvascular techniques. Utilizing a prospectively maintained database, all patients over the last 14 years who underwent reconstruction utilizing a transabdominal VRAM flap following extensive partial or total sacrectomy with intraabdominal communication were identified. A retrospective chart review was then performed. Our study population consisted of 12 patients with a mean age of 58.5 years. Following sacrectomy, all patients underwent reconstruction with a VRAM flap. Flap sizes averaged 9.1 x 27 cm. Early flap complications included 3 small areas of flap necrosis at the distal, superior portion of the flap, 2 of which required minimal operative intervention of debridement and reclosure. No late flap complications have occurred, and all 12 patients completely healed, with a mean follow-up time of 29.1 months. Following sacrectomy, extensive soft tissue defects are created in the sacral area and communicate with the abdominal cavity. In these situations, we have found the inferiorly-based pedicled VRAM, passed transabdominally, to be the most reliable and useful choice of flap reconstruction. It has a low incidence of complications, low morbidity, and is easy to perform with a high success rate.

Adult↗

PubMed2006

Use of the anterolateral thigh flap as an alternative to the rectus flap in obese and overweight patients.

INTRODUCTION: Oncologic reconstruction in obese patients can be challenging. Donor tissues, such as the rectus flap, can be excessively bulky and result in significant cosmetic and functional deformities. Although the use of the anterolateral thigh (ALT) flap as an alternative to the radial forearm flap has been extensively described, few studies have evaluated the use of the ALT flap as an alternative to the rectus flap. The purpose of this study was to evaluate our experience with the ALT flap in overweight or obese patients. METHODS: A retrospective review was conducted of all ALT flaps performed over a 2-year period at Memorial Sloan-Kettering Cancer Center. All patients with a body mass index (BMI) >25 kg/m2 were identified and evaluated. RESULTS: Twenty-seven patients underwent ALT flap reconstruction during the study period. Of these, 11 patients were overweight (BMI, 25.1-30 kg/m2) or obese (BMI, >30 kg/m2). Reconstructions were performed for a variety of oncologic defects, including head and neck (n = 7), extremity (n = 2), chest wall (n = 1), and abdominal wall (n = 1). Complications were, in general, mild and infrequent. One patient experienced a minor infection, 1 patient had partial flap loss, and 2 patients had partial skin graft loss at the donor site. There were no flap losses. CONCLUSIONS: The ALT flap is a safe and reliable flap for reconstruction of diverse defects in overweight or obese patients. Large flaps can be designed and tailored to the defect by harvesting variable amounts of skin, subcutaneous tissues, fascia, and muscle. The ALT flap may be a good alternative to the rectus flap in overweight or obese patients.

Adult↗

PubMed2006

Management of salivary fistulas after microvascular head and neck reconstruction.

UNLABELLED: Salivary fistulas after head and neck microvascular reconstruction are difficult problems whose treatment remains controversial. Although aggressive, early operative intervention has been suggested by some groups, we have found that many patients respond to conservative management with bedside debridement and aggressive local wound care. The purpose of this study was, therefore, to review our experience with the management of postoperative salivary fistulas. METHODS: A retrospective review was performed and all patients who developed a salivary fistula after microvascular head and neck reconstruction over a 7-year period at Memorial Sloan-Kettering Cancer Center were identified and evaluated. RESULTS: Six hundred thirty-seven patients underwent reconstruction during the study period. Of these, 35 patients developed a postoperative salivary fistula (5.4%). The majority of patients (81%) who developed fistulas shortly after the index procedure (<30 days) were successfully treated with conservative management. Similarly, 50% of late salivary fistulas (>30 days) responded to bedside debridement and wound care. There were no significant differences in the rate of total flap loss, carotid artery blowout, delay in onset of adjuvant radiation therapy (>6 weeks), or return to oral feeds between the conservative and operatively managed groups. CONCLUSIONS: Aggressive surgical intervention in early postoperative salivary fistulas is usually not necessary, although the treatment plan should be individualized. Bedside debridement and aggressive wound care are adequate in most cases of early salivary fistulas. This approach is not associated with an increased rate of complications.

Adolescent↗

PubMed2006

Bone grafts and substitutes.

Bone is a complex organ system that provides structural support for the human body while also serving an important protective function for the internal organs. It is estimated that over 500,000 bone-grafting procedures are performed annually in the United States. These procedures have stimulated the pursuit of novel biomaterials with ideal properties. Key goals are to develop a biomaterial to replace bone that is inexpensive, biocompatible, radiolucent, resistant to infection, compressible, and replaced by host bone. The purpose of this review is to present the uses of commercially available bone grafts substitutes including allografts, calcium sulfates, calcium phosphates, and polymer materials. Descriptions of these biomaterials are provided in the context of their applications including craniofacial surgery, neurosurgery, fracture repair, dental and periodontal procedures, as well as pediatric reconstruction.

Bone Substitutes↗

PubMed2005

Nipple-areola reconstruction following chest-wall irradiation for breast cancer: is it safe?

Radiation therapy (RT) is considered by some to be a contraindication to nipple-areola reconstruction (NAR) particularly in patients with breast implant reconstruction. In this retrospective chart review, all patients who underwent breast reconstruction with tissue expanders and implants from 1997-2003 were reviewed. A subset of patients with a history of radiation therapy (pre- or postoperative) was identified. Postoperative complications, surgical technique, and the time course of reconstructive procedures were analyzed. Thirteen percent of patients with a history of RT had NAR compared with 36% of similarly reconstructed patients without a history of RT. Reconstruction was accomplished using a variety of local flaps, with an overall complication rate of 25%. Nipple-areola reconstruction after chest-wall irradiation in patients reconstructed with breast implants should be performed in carefully selected patients. Acceptable surgical candidates demonstrate resolution of acute radiation changes, no evidence of late radiation changes, and appropriate thickness of the mastectomy skin flaps.

Adult↗

PubMed2005

Complications in smokers after postmastectomy tissue expander/implant breast reconstruction.

Smoking is universally considered to be a risk factor for surgical complications. The incidence of complications following tissue expander/implant breast reconstruction in patients who smoke has not been previously evaluated.A review of complications following tissue expander/implant reconstruction in 515 patients was performed. Patients who had 2-stage, tissue expander/implant reconstruction at Memorial Sloan-Kettering Cancer Center between May 2002 and December 2003 were included. Complications in smokers (n=132) and nonsmokers (n=383) were compared. The rate of overall complications, reconstructive failure, mastectomy flap necrosis, and infectious complications was significantly higher in smokers compared with nonsmokers. The rate of complications in ex-smokers was also higher than in nonsmokers. Using multivariate statistical analysis to adjust for confounding variables, smoking was identified as independent predictor of postoperative complications.A significant association between smoking status and postoperative complications exists. Thus, smokers who undergo postmastectomy expander/implant reconstruction should be informed of the increased risk of surgical complications and should be counseled on smoking cessation.

Breast Implants↗

PubMed2005

Gene expression profiling in the rat cranial suture.

Although many theories have attempted to explain the etiopathogenesis of premature cranial suture fusion, which results in craniosynostosis, recent studies have focused on the role of growth factors and receptors. Using a well-established model of cranial suture biology, the authors developed a novel approach to quantitatively analyze the gene expression profiles of candidate cranial suture growth factors and their receptors. We collected suture mesenchyme and adjacent osteogenic fronts from Sprague-Dawley rats at postnatal days 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 35. RNA was extracted from posterior frontal (PF) and sagittal (SAG) sutures, and reverse transcription-polymerase chain reaction (RT-PCR) was performed for cranial suture candidate cytokines BMP2, BMP3, BMP4, FGF-2, FGFR1, FGFR2, FGFR4, TGF-betaRI, TGF-betaRII, and TGF-betaRIII. The authors confirmed quantitative RT-PCR results with Southern and dot blot analyses. Suture growth factor and receptor expression levels changed significantly with time. Expression levels decreased toward baseline in the SAG suture by day 35. There was a marked difference in FGFR1, FGF-2, TGF-betaRI, and TGF-betaRII expression levels when comparing the fusing PF and nonfusing SAG sutures. Although FGF-2 ligand expression was low, FGF receptor 1 (FGFR1) levels were markedly elevated with a bimodal expression pattern in both PF and SAG similar to that of BMP2, BMP3, and BMP4. Although there were statistically significant differences in TGF-betaRI and TGF-betaRII expression in the PF and SAG sutures, TGF-betaRIII levels were unchanged. The authors report a novel approach to cranial suture growth factor/receptor profiling and confirm their results with standard analytic tools. The data confirm, quantify, and extend the results of previously published studies. By quantifying the gene expression profiles of normal cranial suture biology, we may begin to understand the aberrant growth factor cascades of craniosynostosis and devise targeted therapeutic interventions that can alter the course of this malady.

Animals↗

PubMed2004

Soft tissue reconstruction following tumor resection in the hand.

With advances in diagnosis, staging, imaging, and adjuvant chemo- and radiotherapy,upper limb salvage surgery has become a realistic option for upper limb malignancies. Following an adequate and complete resection, reconstruction of ensuing defects consequently has become an area of increasing importance. Many options are available,including primary closure, skin grafting, local soft tissue flaps, regional pedicle and island flaps, free tissue transfer, composite free tissue transfer, allografts, endoprostheses,and tendon, nerve, or arterial grafting. Form, function, and cosmetic outcome influence surgical decision making, as do characteristics of the patient, tumor, and involved site.

Elbow↗

PubMed2004

Reconstruction after soft tissue sarcoma resection in the setting of brachytherapy: a 10-year experience.

Management of recurrent soft tissue sarcomas often involves surgical resection and adjuvant brachytherapy. This study reviews our experience in the management of these patients and proposes a logical approach toward reconstruction. All patients who underwent soft tissue sarcoma resection, adjuvant brachytherapy, and soft tissue flap reconstruction (pedicled or free) during the 10-year period from 1991 to 2000 were included in this study. There were 17 patients (14 male, 3 female) with a mean age of 51 years (range, 16-80 years). Soft tissue sarcomas were distributed in the lower extremity (n = 9), upper extremity (n = 5), and trunk (n = 3). Reconstruction was accomplished by regional transposition flaps (n = 10) and free tissue transfer (n = 7). The average defect size was 143 cm. Patients received 5 to 12 (mean, 8) brachytherapy catheters. The brachytherapy dose delivered ranged from 1600 to 4500 cGy (mean, 3773 cGy). Brachytherapy catheters were loaded with radioactive sources between 5 and 7 days postoperatively. All flaps in this series survived. One patient required return to the operating room for revision of a venous thrombosis with flap salvage. Closed suction drainage tubes were left in place until after the brachytherapy catheters were removed to avoid dislodging the catheters. Two patients developed postradiation partial-thickness skin necrosis with delayed secondary wound healing. This study demonstrates that soft tissue reconstruction in the setting of sarcoma resection and brachytherapy catheter placement is safe and efficacious. Postoperative wound healing complications can be minimized through coordination among the ablative surgeon, reconstructive surgeon, and radiation oncologist. Specifically, placement of microvascular anastomoses well away from the radiation target area is indicated whenever possible. Finally, removal of closed suction drainage tubes should be deferred until after the brachytherapy catheters are removed to minimize complications resulting from catheter dislodgement.

Adolescent↗

PubMed2004

Reconstruction of complex oncologic chest wall defects: a 10-year experience.

The repair of complex chest wall defects presents a challenging problem for the reconstructive surgeon. Although the majority of such defects could be repaired with the use of local and regional musculocutaneous flaps, more complicated cases require increasingly sophisticated reconstructive techniques. This study reviews the experience at a single cancer center with chest wall reconstruction over a decade. A retrospective review was undertaken for each patient who underwent chest wall reconstruction from 1992 to 2002. Patient demographics and variables, including pathologic diagnosis, extent of resection, size of defect, method of reconstruction, and outcome were evaluated. There was a total of 113 patients, 88 females and 25 males. The average age was 58 years (range, 19-88 years). The most common diagnoses were breast cancer and sarcoma. The average area of the chest wall defect after resection was 266 cm. One hundred fifty-seven musculocutaneous or muscle flaps were performed for reconstruction of the chest wall. Eleven percent of patients underwent reconstruction with autologous free tissue transfer. One hundred six patients underwent a single operation. Seven patients required a second operation for salvage of a complication. In 19 cases (15%), more than 1 flap was used simultaneously to complete the reconstruction. Eighty-four percent of the patients achieved stable chest wall reconstruction with no complications. Seven patients (4%) had partial (>10%) flap loss. The most common remaining postoperative complications were delayed wound healing (3% of patients), infection (2.5%), and hematoma (2.5%). Immediate chest wall reconstruction is safe, reliable, and can most often be accomplished with 1 operation. A variety of flaps, both single and in combination, could be used to achieve definitive coverage of the chest wall after extirpative surgery. The reconstructive choice is dependent on factors such as size of the defect, location on the chest wall, arc of rotation of the flap, and availability of recipient vessels. Based on this single institutional experience over a decade, an algorithm to chest wall reconstruction is provided.

Algorithms↗

PubMed2004

Scalp reconstruction: a 15-year experience.

Scalp reconstruction after ablative surgery can be challenging. A useful reconstructive algorithm is lacking. The purpose of this study was to evaluate the authors' experience and to identify an appropriate reconstructive strategy. This was a retrospective review of all patients treated by the authors' service for scalp defects during a 15-year period. Reconstructive methods, independent factors, and outcomes were analyzed. A total of 73 procedures were performed in 64 patients. Techniques for reconstruction included primary closure, grafts, and local and distal flaps. A correlation between reconstructive technique and complications could not be demonstrated. However, an increased incidence of complications was correlated with a history of radiation, chemotherapy, cerebrospinal fluid leaks, and an anterior location of the ablative defect (P < 0.05). Important tenets for successful management of scalp defects are durable coverage, adequate debridement, preservation of blood supply, and proper wound drainage. Local scalp flaps with skin grafts, and free tissue transfer remain the mainstay of reconstruction in most instances.

Adolescent↗

PubMed2004

Timing of percutaneous endoscopic gastrostomy tube placement after cervical esophageal reconstruction with free jejunal transfer.

The timing of percutaneous endoscopic gastrostomy (PEG) tube placement in patients who undergo cervical esophageal reconstruction using free jejunal transfer is controversial. The purpose of this study was to review the authors' experience with pharyngeal reconstruction using free jejunal transfer to establish useful guidelines for enteral tube placement. A retrospective analysis of all patients treated with free jejunal autografts for reconstruction of cervical esophageal defects during a 12-year period was performed. A total of 105 patients underwent 108 esophageal reconstructions using these techniques. Sixty-three patients (60%) did not have enteral tube placement at any time, whereas 42 patients had gastrostomy or PEG tubes placed preoperatively (n = 12), intraoperatively (n = 8), or postoperatively. The majority of patients were able to resume per-oral feeds and avoid long-term tube feeds (86.7%). Most patients who underwent preoperative or intraoperative enteral tube feed placement had them removed postoperatively (82%). Only patients who required postoperative placement of feeding tubes required prolonged feeding tube support. In conclusion, most patients who undergo esophageal reconstruction using free jejunal transfer recover the ability to swallow and maintain adequate nutrition without supplemental enteral tube feeds. Preoperative gastrostomy tube placement is not necessary in most patients unless severe preoperative nutritional compromise is present.

Endoscopy, Gastrointestinal↗

PubMed2004

Use of liposuction for secondary revision of irradiated and nonirradiated free flaps.

A number of patients with free tissue transfer require secondary revision to improve contour and regional definition to maximize function or appearance. However, there is controversy with regard to whether irradiated free flaps can be revised safely using liposuction. The purpose of this study was to compare the outcomes of revisionary procedures requiring liposuction in irradiated versus nonirradiated flaps. From December 1992 to July 2001, office and hospital records were reviewed retrospectively to identify patients who had undergone free tissue transfer and subsequent flap revision at a single institution. The number of revisions, amount of fat aspirated, timing of revision and the postoperative complications including infection, hematoma, wound dehiscence, and flap loss were reviewed. A total of 41 flap revisions using liposuction alone or with direct excision were performed on 33 free flaps (31 head and neck, 1 chest wall, and 1 extremity). The rectus musculocutaneous flap was the most commonly revised (88%). The average length of time to secondary revision of patients who had received postoperative radiotherapy to their flaps was significantly higher that those whose flaps had not been irradiated (P < 0.05). There were no postoperative complications except for 1 partial (20%) flap loss in a patient whose flap was irradiated. The difference in complication rates between the irradiated and nonirradiated group was not statistically significant. Secondary free flap revision using liposuction and direct excision is a safe technique for recontouring free flaps. There was no significant difference in complication rates for irradiated and nonirradiated flaps. Postoperative radiation therapy is therefore not a contraindication to secondary revision. However, these procedures should be delayed for several months after the acute effects of radiation have resolved.

Adolescent↗

PubMed2004

Outcome of split-thickness skin grafts after external beam radiotherapy.

There are many technical considerations in patients who require radiotherapy after oncologic reconstruction. A traditional tenet is to avoid skin grafts in this setting. However, this is not always avoidable. Therefore, the objective of this study was to evaluate the wound healing and functional outcome of patients in the authors' institution whose skin grafts were subsequently irradiated. A retrospective analysis of all patients treated with split-thickness skin grafts and postoperative radiotherapy at Memorial Sloan-Kettering Cancer Center from 1995 to 2002 was performed. Parameters evaluated included indications for skin graft, defect size, time to postoperative radiotherapy, total radiotherapy dose, delays and interruptions in radiotherapy, wound complications, and the need for further skin grafting. There were 30 patients (23 men, 7 women) with a mean defect size of 152 +/- 132 cm2. All split-thickness skin grafts were placed on healthy vascular tissue beds. In most instances (67%) skin grafts were used to cover muscle flaps. Median time to initial radiotherapy after grafting was 8 weeks (range, 4-60 weeks). There was 1 delay and 4 interruptions in radiotherapy treatment. There were 2 partial skin graft losses (<20%) after radiation that healed with conservative treatment. There was 1 complete skin graft loss after radiotherapy that required regrafting. Split-thickness skin grafts can tolerate postoperative radiotherapy without significant complications. Postoperative external beam radiation can begin as early as 6 to 8 weeks after skin grafting. If the requirement for postoperative radiotherapy is known, split-thickness grafts should ideally be placed on well-vascularized muscle beds. Minor skin graft loss resulting from postoperative radiotherapy can usually be treated conservatively without the need for additional surgery.

Adolescent↗