Fibrin Sealants and STSG

[Winged Scapula]

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Has anyone used these (ie, Tisseel) to secure STSGs to the bed? If so, how long do I have to adjust the meshed graft before the stuff fixes?

Do you guys have any preference for full thickness tissue loss coverage? Biologics, synthetics, etc?

I've got a patient with radiated tissue and a cancer recurrence and am thinking about wound coverage after resection; not sure a flap is the right choice for her.

 

[maxheadroom]

My place was involved in a clinical study using fibrin glue to fix STSGs. I'm not wild about it. It takes a whole lot longer and doesn't seem to have any real extra benefit. I can't remember how long you had to get the graft in place, but it wasn't long. If you're really worried about the viability of a graft on a spot like that then use a STSG to improve your take and use a VAC as your bolster. There's some data that suggests that the VAC helps improve take in less than ideal wound beds. I agree -- I wouldn't be wild about putting a flap on the site of a local recurrence.

 

[jdm51]

Our burn Center at Regions Hospital, St. Paul presented the use of fibrin glue at the midwest burn conference last year. It was primarily advocated as a replacement for staples, meaning you can avoid the painful staple removal in the clinic.

You have a couple of minutes before the graft sets.

It may be useful to get the graft to adhere to an irregular wound bed but I would worry about thick buildup of fibrin being a barrier to the graft imbibition.

 

[Winged Scapula]

My place was involved in a clinical study using fibrin glue to fix STSGs. I'm not wild about it. It takes a whole lot longer and doesn't seem to have any real extra benefit.

Takes longer than all those sutures/staples holding it down? I actually thought it would be quicker (and as you know, in PP, time is $$), hence my question. I didn't want to use staples and was thinking about the time to place sutures (although I guess with my PA-C it wouldn't be too long).

I can't remember how long you had to get the graft in place, but it wasn't long.

That's what I was worried about...I'm sort of a fusser and straightener when it comes to placing these. 😀

If you're really worried about the viability of a graft on a spot like that then use a STSG to improve your take and use a VAC as your bolster. There's some data that suggests that the VAC helps improve take in less than ideal wound beds.

That's actually how I've booked the case. Pre-op imaging doesn't suggest any muscle invasion but the bed will be irregular nonetheless. I'm concerned a bit about whether or not her insurance company will approve the VAC; we've had some problems in the past for outpatients and for patients with a 20% co-pay and no co-insurance (which ends up being several hundred dollars for VNA, VAC, etc.).

I agree -- I wouldn't be wild about putting a flap on the site of a local recurrence.

That and her vascular disease, general decrepitness makes me not so interested in doing it as well.

Thanks to both of you for your thoughts on the topic; I appreciate it.

 

[droliver]

Kimberly,

We used tisseal awhile back (~2000-2001) for this for grafts in hard areas (think the axillae in large burns) but it kind of faded. Tisseal and others analogs are expensive biologic products.

As the VAC became more commonly used, tisseal kind of faded in popularity for securing grafts. To use it, there's a special pain in the ass dilution of the product you used to have to use (or the viscosity acts as a barrier to graft take) plus you need the custom aerosolizing unit Baxter makes.

I'd go with a VAC over Adaptec gauze (the best nonadherant), Mepitel (a silicone mesh which is harder to handle), or Xeroform gauze (a little more likely to stick to the graft). The nonstick "white" VAC foam is excellent as well if your hospital has it. KCI recomends turning the suction down to 75 or 100 mmHg when using the VAC as a bolster to minimize shear BTW.

You might consider staging this procedure with an excision and VAC and assess the wound bed and your permanent margins before going back for definative closure days later. Depending on what extent you're excising, skin grafts can be real poor performers in heavily radiated beds. The off the shelf products (Integra, Alloderm, Biobrane, Transcyte, etc...) will do even worse in radiated tissue and be substancially more expensive.

I have no problem putting flaps (rectus, latissimus, chest wall advancement) into chest wall recurrence sites if that's what it takes to fix it, you really need prior confirmatons of your margins preferably. In little old ladies, you can get a lot of abdominal skin up onto the chest with a "reverse abdominoplasty" or more elegant epigastric perforator based flaps on the abdominal wall

Is this a lumpectomy/XRT recurrence?

 

[Winged Scapula]

Thanks Rob.

Yes, she is a recurrence after lumpectomy/whole breast irradiation. Interestingly, she had a 0.19mm micromet in her axilla at the time. I "inherited" her from another surgeon.

By pre-op imaging, all recurrence appears to be in the skin, which is pretty fibrotic from the RT.

I wanted to send her to PRS to consider a flap, although I had concerns as I mentioned above. She is not particularly interested in it, but I may ask her to come back in for further discussion and explain it in more detail to her. The staged procedure is a good idea.

I hadn't seen many of these in training and appreciate the input from those of you that have.

 

[DrDre311]

Kimberly,

We used tisseal awhile back (~2000-2001) for this for grafts in hard areas (think the axillae in large burns) but it kind of faded. Tisseal and others analogs are expensive biologic products.

As the VAC became more commonly used, tisseal kind of faded in popularity for securing grafts. To use it, there's a special pain in the ass dilution of the product you used to have to use (or the viscosity acts as a barrier to graft take) plus you need the custom aerosolizing unit Baxter makes.

I'd go with a VAC over Adaptec gauze (the best nonadherant), Mepitel (a silicone mesh which is harder to handle), or Xeroform gauze (a little more likely to stick to the graft). The nonstick "white" VAC foam is excellent as well if your hospital has it. KCI recomends turning the suction down to 75 or 100 mmHg when using the VAC as a bolster to minimize shear BTW.

You might consider staging this procedure with an excision and VAC and assess the wound bed and your permanent margins before going back for definitive closure days later. Depending on what extent you're excising, skin grafts can be real poor performers in heavily radiated beds. The off the shelf products (Integra, Alloderm, Biobrane, Transcyte, etc...) will do even worse in radiated tissue and be substantially more expensive.

I have no problem putting flaps (rectus, latissimus, chest wall advancement) into chest wall recurrence sites if that's what it takes to fix it, you really need prior confirmatons of your margins preferably. In little old ladies, you can get a lot of abdominal skin up onto the chest with a "reverse abdominoplasty" or more elegant epigastric perforator based flaps on the abdominal wall

Is this a lumpectomy/XRT recurrence?

My input is significantly less valuable than Dr. Oliver's because I'm just a junior PRS resident and not an attending, but I will echo his sentiments and say that in my experience (at my institution) the general tactic for this kind of situation is to do the excision (for purposes of margins) followed by VAC placement, and definitive closure at some later date. I will admit that my program is pretty VAC-happy and it can be a pain trying to set up a patient with a VAC at home, but they can make your life a little easier.

 

[Winged Scapula]

I used VACs a lot in residency, so am quite comfortable with them, although as you and I both note, it can be hard to get them set up for VNA and home use.

My major problem locally is that most of the plastic surgeons do not take insurance and are not interested in doing flaps. For the reimbursement, they feel the amount of work and possible complications is just not worth it and tend to stick to aesthetics. I often suggest Mayo to the patients who want these flaps, but they also don't take a lot of insurances and many, if not most, of my patients will not drive that far (I drive it every day, but for some reason they think its on the other side of the planet).

But I do have a couple that I work with that will do them and will take insurance. Essentially she's got lesions from clavicle to inframammary fold, with a couple near the sternum. She needs a MRM with all that skin gone, so it would be a fairly good size defect. Good point about margins before definitive coverage; I'll tell her we should two stage it and ask her to see one of my PRS colleagues for further info.

Thanks again.

 

[Fah-Q]

I used VACs a lot in residency, so am quite comfortable with them, although as you and I both note, it can be hard to get them set up for VNA and home use.

My major problem locally is that most of the plastic surgeons do not take insurance and are not interested in doing flaps. For the reimbursement, they feel the amount of work and possible complications is just not worth it and tend to stick to aesthetics. I often suggest Mayo to the patients who want these flaps, but they also don't take a lot of insurances and many, if not most, of my patients will not drive that far (I drive it every day, but for some reason they think its on the other side of the planet).

But I do have a couple that I work with that will do them and will take insurance. Essentially she's got lesions from clavicle to inframammary fold, with a couple near the sternum. She needs a MRM with all that skin gone, so it would be a fairly good size defect. Good point about margins before definitive coverage; I'll tell her we should two stage it and ask her to see one of my PRS colleagues for further info.

Thanks again.

If I remember correctly you did a breast fellowship? Do they teach any reconstruction in those fellowships? If not, do you think they should?

 

[Winged Scapula]

If I remember correctly you did a breast fellowship?

That is correct.

Do they teach any reconstruction in those fellowships?

Not to the point of being able to do them, at least not the flaps. I assisted in a number of lat dorsi flaps as well as tissue expander and implant placements. None of the current breast fellowships teach reconstruction in any more detail than that. There *are* breast reconstruction fellowships that some of the breast surgery fellows have gone one to do (often these are people who did not match into PRS and are trying the back door route in).

If not, do you think they should?

Not in the current model or practice milieu. A year or two is not enough time to learn about breast surgery, get enough independent sentinel and axillary node biopsies (to get privileges), to learn about adjuvant therapies, etc. AND learn to do reconstruction. Like many other procedures, the tissue expander/implant is not hard to do, but its understanding what to do when you have complications. The PRS guys get so much more training and its not just about learning how to put them in but what to do when you have problems.

The practice milieu also makes it difficult. My partner and I have a local PRS guy that wants to train us to do them; I'm interested but realize:

1) most patients, rightfully so, want a plastic surgeon to do their reconstruction;

2) legally, as droliver mentions above, it can be a nightmare, especially if our 'training" consisted of a friend showing us

I think if you spent an extra year just doing breast reconstruction after your breast fellowship, it would be reasonable to do them, but not as the training currently stands.

 

[Fah-Q]

A year or two is not enough time to learn about breast surgery, get enough independent sentinel and axillary node biopsies (to get privileges), to learn about adjuvant therapies, etc. AND learn to do reconstruction.

This is exactly how most of the head and neck cancer fellowships are structured. It is an intense year but the model has been working well for the last ~15 years. Breast cancer seems like a field where a similar model could work. I was just wondering if there were any leaders within the breast world who felt this way.

 

[Winged Scapula]

This is exactly how most of the head and neck cancer fellowships are structured. It is an intense year but the model has been working well for the last ~15 years. Breast cancer seems like a field where a similar model could work. I was just wondering if there were any leaders within the breast world who felt this way.

I don't know much about H&N fellowships. Are you saying that they learn about the oncologic management but not much in the way of reconstruction? And that if flaps are needed for coverage that it is done by PRS (assuming the H&N surgeon was not PRS trained already)?

 

[DrDre311]

I don't know much about H&N fellowships. Are you saying that they learn about the oncologic management but not much in the way of reconstruction? And that if flaps are needed for coverage that it is done by PRS (assuming the H&N surgeon was not PRS trained already)?

This varies from institution to institution, depending on the relative strengths of the PRS and ENT departments/divisions. There are places where ENT is strong, and they do most of the H&N recon, and there are others where plastics does it. Similarly, there are places where PRS does everything in the upper extremity when they're on hand call, and other places where ortho is dominant and PRS just stays distal to the carpal tunnel.

It just depends on the individual institution, money factors, politics, etc. At my current institution PRS does a great deal of H&N and UE stuff, but at my med school plastics definitely took a back seat to both ortho and ENT. You'd have to talk to an oto but I think most ENT programs train their residents in H&N recon, not just oncologic management.

 

[Fah-Q]

I don't know much about H&N fellowships. Are you saying that they learn about the oncologic management but not much in the way of reconstruction? And that if flaps are needed for coverage that it is done by PRS (assuming the H&N surgeon was not PRS trained already)?

Yes, the H&N fellowships are geared towards free flap reconstruction. It is generally expected that you learned resection and management in residency and your fellowship is really a microvascular fellowship, but this varies. An ENT resident would know local and regional flaps well but not many programs graduate residents comfortable with free flaps, which is why there are so many fellowships. There are still places that have PRS do the flap but this is becoming more rare.

 

[DrDre311]

Yes, the H&N fellowships are geared towards free flap reconstruction. It is generally expected that you learned resection and management in residency and your fellowship is really a microvascular fellowship, but this varies. An ENT resident would know local and regional flaps well but not many programs graduate residents comfortable with free flaps, which is why there are so many fellowships. There are still places that have PRS do the flap but this is becoming more rare.

I don't think this is exactly rare. A number of places I interviewed (including my current institution) were still heavily involved in H&N recon.

 

[droliver]

Essentially she's got lesions from clavicle to inframammary fold, with a couple near the sternum. She needs a MRM with all that skin gone, so it would be a fairly good size defect. Good point about margins before definitive coverage.

I did a case like this not too long ago with a lady peppered with lymphangiosarcoma on her breast after XRT had been applied a few years prior to a TRAM (with marginal indication I might add). Editorial comment: The morbidity from radiation is underdescribed signifigantly and dealing with it makes most plastic surgeons wonder why anyone with any sense would go for lumpectomy/XRT over mastectomy & reconstruction.

With a defect the size you're going to make, you're going to need a latissimus or omental flap (or both) with skin graft to cover the chest.

You can harvest the omentum laparoscopically and pass it up onto the chest easily thru a small hernia you create. It takes skin grafts better then any other tissue I've ever seen. (I did one for a sternal wound last week and have been doing 3-4 annually with total sternectomy patients). As you still have general surgery privledges, it's something you could attempt within your scope of practice that can give you coverage if your reconstruction colelagues are scarce. They actually pay fairly well.

I'm surprised you're having so much trouble finding plastic surgeons for this. Breast reconstruction and reductions are usually the only type of reconstruction a number of people still do.

 

[Winged Scapula]

I did a case like this not too long ago with a lady peppered with lymphangiosarcoma on her breast after XRT had been applied a few years prior to a TRAM (with marginal indication I might add). Editorial comment: The morbidity from radiation is underdescribed signifigantly and dealing with it makes most plastic surgeons wonder why anyone with any sense would go for lumpectomy/XRT over mastectomy & reconstruction.

You're not kidding. I saw a patient today with *severe* radiation fibrosis frm her XRT 5 years ago. She is convinced that she was mishandled and that the area, biopsied twice and shown to be XRT fibrosis, is a recurrence. I have to admit, I was pretty impressed myself, especially seeing the PET/CT and adherence of the tissue to the sternum, but it does look like fibrosis rather than cancer.

A couple of weeks ago at ASBS they presented data that showed that there was a trend back toward mastectomy from BCT; not known why - fear of recurrence, avoidance of XRT, or surgeon preference.

With a defect the size you're going to make, you're going to need a latissimus or omental flap (or both) with skin graft to cover the chest.

You can harvest the omentum laparoscopically and pass it up onto the chest easily thru a small hernia you create. It takes skin grafts better then any other tissue I've ever seen. (I did one for a sternal wound last week and have been doing 3-4 annually with total sternectomy patients). As you still have general surgery privledges, it's something you could attempt within your scope of practice that can give you coverage if your reconstruction colelagues are scarce. They actually pay fairly well.

Funny you mention omental flap as I was considering that. I've seen it done for lower pole defects, having read several articles by the Japanese and French, and was thinking I could just tunnel down and grab it through my incision.

I'm surprised you're having so much trouble finding plastic surgeons for this. Breast reconstruction and reductions are usually the only type of reconstruction a number of people still do.

Well, you have to know the area. Scottsdale and the environs have tons of PRS guys, but those that go to the hospitals I practice at either don't take insurance, want my office staff to get out of network benefits and do all the paperwork so they can be paid (rather than have their office staff do it), or only do implants. Frankly, I honestly tell my patients that if they are interested in flaps, they need to see someone at Mayo or in LA, because its just not done here. The vast majority are only interested in fast aesthetic cases.

BUT I do have one here I work with a lot - excellent technically, friendly, patients love him, well regarded by his peers, takes insurance AND is willing to drive 30 mins from his office to service the west side. I left the patient a message today to call me so I could get her in to see him; I"ll discuss the options with him.

I'm actually starting to look forward to this, a little out of my daily norm.😀

 

[DrDre311]

BUT I do have one here I work with a lot - excellent technically, friendly, patients love him, well regarded by his peers, takes insurance AND is willing to drive 30 mins from his office to service the west side. I left the patient a message today to call me so I could get her in to see him; I"ll discuss the options with him.

I'm actually starting to look forward to this, a little out of my daily norm.😍

Ah, WS realizes that real plastic surgeons do have it all.

 

[droliver]

A couple of weeks ago at ASBS they presented data that showed that there was a trend back toward mastectomy from BCT; not known why - fear of recurrence, avoidance of XRT, or surgeon preference.

I think patients are making the intuitive decision with their cancer- ie. "GET IT ALL OFF!". If you explain to patients that their recurrence rates after lumpectomy/XRT may be up to 20%, that they'll likely have skin/tissue dimpling, and they'll make future reconstruction efforts difficult they quickly get a lot less enthusiastic about breast conservation. The mortality data suggesting equivalent cancer related outcomes just get overwhelmed by that for most patients when you give informed consent as most plastic surgeons would suggest..

One thing you hear at a lot of the oncoplastic breast meetings is real skepticism over commonly cited data involving recurrence after lumpectomy. Reconstructive Surgeons at a lot of tertiary centers say they see disturbing numbers of systemic recurrence (rather then local) in these patients. Is this just selection bias of these practices or are there systemic problems? One of the things I'm convinced of is that XRT (and chemotherapy to some degree) delivery is very poorly standardized out in community practices and these anecdotal observations of recurrence rates reflect this.