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Treatment of long-segment tracheal defects remains a challenge in thoracic surgery with no standard surgical option. Aortic allografts have been used for this purpose with varying degrees of success. In a patient that suffered anastomotic dehiscence after tracheal resection with primary anastomosis, we performed complete tracheal resection and replacement using a stented circumferential aortic allograft. Currently, this patient is able to breathe normally without tracheostomy assistance 22 months postoperatively. Our report is the first in the English literature of long-term survival without tracheostomy dependence and close interval follow-up after circumferential tracheal resection and replacement with a cryopreserved aortic allograft.

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INTRODUCTION: Socioeconomic disparities impact outcomes after cardiac surgery. At our institution, cardiac surgery cases from the safety-net, county funded hospital (CH), which primarily provides care for underserved patients, are performed at the affiliated university hospital. We aimed to investigate the association of socioeconomic factors and CH referral status with outcomes after coronary artery bypass grafting (CABG). METHODS: The institutional Adult Cardiac Surgery database was queried for perioperative and demographic data from patients who underwent isolated CABG between January 2014 and June 2020. The primary outcome was major adverse cardiovascular event (MACE), a composite of postoperative myocardial infarction, stroke, or death. Secondary outcomes included individual complications. Chi-square, Wilcoxon rank-sum, and logistic regression analyses were used to compare differences between CH and non-CH cohorts. RESULTS: We included 836 patients with 472 (56.5%) from CH. Compared to the non-CH cohort, CH patients were younger, more likely to be Hispanic, non-English speaking, and be completely uninsured or require state-specific financial assistance. CH patients were more likely to have a history of tobacco and drug use, liver disease, diabetes, prior myocardial infarction, and greater degrees of left main coronary and left anterior descending artery stenosis. CH cases were less likely to be elective. The incidence of MACE was significantly higher in the CH cohort (16.3% versus 8.2%, P = 0.001). There were no significant differences in 30-d mortality, home discharge, prolonged mechanical ventilation, bleeding, sepsis, pneumonia, new dialysis requirement, cardiac arrest, or multiorgan system failure between cohorts. CH patients were more likely to develop renal failure and less likely to develop atrial fibrillation. On multivariable analysis, CH status (odds ratio 2.39, 95% confidence interval 1.25-4.55, P = 0.008) was independently associated with MACE. CONCLUSIONS: CH patients undergoing CABG presented with greater comorbidity burden, more frequently required nonelective surgery, and are at significantly higher risk of postoperative MACE.

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BACKGROUND: Scalp reconstruction has evolved over time. Given the large surface area, location, and high likelihood of sun exposure, the scalp is particularly prone to sun damage and skin cancer. Resection of scalp cancers often leaves a large defect that can be challenging for reconstruction. The authors present objective data and recommendations based on more than 10 years of consecutive scalp reconstructions performed by the senior author (J.F.T.). In addition, the authors describe each method of reconstruction and delineate an algorithm based on the senior author's approach and the cases assessed. METHODS: The authors conducted a retrospective review of patients who underwent scalp reconstruction after Mohs cancer excision over a 10-year period. Each case was evaluated for key patient characteristics, defect location, defect size, defect composition, reconstructive modality, and complications. RESULTS: The senior author (J.F.T.) performed 913 scalp reconstruction procedures. Defects most commonly involved the forehead or vertex of the scalp, with a wide range of sizes. A significant majority of the patients' defects were repaired with the use of adjacent tissue transfer or Integra dermal regeneration templates. There were 94 complications (12.5 percent) noted, ranging from graft loss to cancer recurrence. CONCLUSIONS: Reconstruction of scalp defects after Mohs cancer excision presents the plastic surgeon with numerous patient and defect preoperative variables to consider. Each defect should be evaluated, and a plan based on composition of the defect and the needs of the patient should be developed. Scalp reconstruction is safe to perform in an outpatient setting, even in elderly patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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