Dr. Black was raised in Bucks County, Pennsylvania and completed her undergraduate studies at Bard College where she majored in biology. After college, she joined Teach For America and taught for two years as a 12th grade physics teacher in the South Side of Chicago. Dr. Black then attended medical school at Georgetown University in Washington, DC, where she continued to advocate for kids’ education and health on a national level as a White House intern in 2016. During the clinical years of medical school, Dr. Black realized her passion for surgery and was especially fascinated by free flap reconstruction. She therefore spent a dedicated year studying autologous breast reconstruction outcomes and lower extremity microsurgical techniques within the plastic surgery department at Georgetown. During her last year of medical school, Dr. Black did an away rotation at Stanford and was attracted to the welcoming community and dedication to research and international volunteering. In her free time, she enjoys cooking, Barre workouts, hiking, kayaking, traveling, art museums, improv comedy, tea, and relaxing with family and friends. Dr. Black is the oldest of four sisters, one of whom works in the wine industry in the nearby Napa Valley.
Honors & Awards
Langer Scholarship, Georgetown University School of Medicine (2019-2020)
Top Abstract Award, Abdominal Wall Reconstruction Conference 2019 (2019)
Top 200 Tier 1 Abstract Award, American Society of Plastic Surgeons – The Meeting 2019 (2019)
Women’s Microsurgery Group ViOptix Travel Scholarship, American Society for Reconstructive Microsurgery (2019)
Top 200 Tier 1 Abstract Award, American Society of Plastic Surgeons – The Meeting 2019 (2020)
Boards, Advisory Committees, Professional Organizations
Resident Member, American Society of Plastic Surgeons (2020 - Present)
Member, Gold Humanism Honor Society (2018 - Present)
MD, Georgetown University School of Medicine (2020)
Reinforced Biologic Mesh Reduces Postoperative Complications Compared to Biologic Mesh after Ventral Hernia Repair.
Plastic and reconstructive surgery. Global open
2022; 10 (2): e4083
The use of biologic mesh to reinforce the abdominal wall in ventral hernia repair has been proposed as a viable alternative to synthetic mesh, particularly for high-risk patients and in contaminated settings. However, a comparison of clinical outcomes between the currently available biologic mesh types has yet to be performed.We performed a retrospective analysis of 141 patients who had undergone ventral hernia repair with biologic mesh, including noncross-linked porcine ADM (NC-PADM) (n = 51), cross-linked porcine ADM (C-PADM) (n = 17), reinforced biologic ovine rumen (RBOR) (n = 36), and bovine ADM (BADM) (n = 37) at the Stanford University Medical Center between 2002 and 2020. Postoperative donor site complications and rates of hernia recurrence were compared between patients with different biologic mesh types.Abdominal complications occurred in 47.1% of patients with NC-PADM, 52.9% of patients with C-PADM, 16.7% of patients with RBOR, and 43.2% of patients with BADM (P = 0.015). Relative risk for overall complications was higher in patients who had received NC-PADM (RR = 2.64, P = 0.0182), C-PADM (RR = 3.19, P = 0.0127), and BADM (RR = 2.11, P = 0.0773) compared with those who had received RBOR. Furthermore, relative risk for hernia recurrence was also higher in all other mesh types compared with RBOR.Our data indicate that RBOR decreases abdominal complications and recurrence rates after ventral hernia repair compared with NC-PADM, C-PADM, and BADM.
View details for DOI 10.1097/GOX.0000000000004083
View details for PubMedID 35141102
View details for PubMedCentralID PMC8820910
Utilizing Breast MRI Blood Flow Data to Improve Clinical Outcomes Following Skin Sparing Mastectomy and Nipple Sparing Mastectomy
ELSEVIER SCIENCE INC. 2021: E13
View details for Web of Science ID 000718306700033
Sclerotherapy as an alternative treatment for complex, refractory seromas.
Journal of surgical case reports
2021; 2021 (8): rjab224
Traditional therapy for seromas often entails compression, aspiration, drainage, or surgical excision and re-closure; however, more complex, treatment-refractory seromas may require additional treatment. Sclerotherapy has been well documented in the treatment of simple pleural effusions, vascular malformations, lymphoceles and seromas. However, little evidence is available on the efficacy of sclerotherapy in complex, treatment-refractory seromas that develop post-operatively in patients with complex medical histories. We present a case series highlighting the use of sclerotherapy by interventional radiology as an alternative or adjunctive treatment method for chronic, high-volume post-operative seromas recalcitrant to multiple attempts of traditional treatment. At long-term follow-up, the seromas resolved after a maximum of four rounds of sclerotherapy with various combinations of known sclerosants. Highly complex cases of large, chronic seromas may be refractory to conservative modalities and re-closure. Sclerotherapy can be considered an alternative method or adjunctive treatment for chronic, recalcitrant post-operative seromas.
View details for DOI 10.1093/jscr/rjab224
View details for PubMedID 34447570
Popliteal artery patency is an indicator of ambulation and healing after below-knee amputation in vasculopaths.
BACKGROUND: The posterior flap is a conventional technique for closing a below-knee amputation (BKA) that uses the gastrocnemius and soleus muscle and relies on the popliteal and posterior compartment arteries. If the prior mentioned arterial blood supply is compromised, this flap likely relies on collateral flow. The purpose of this study is to identify and differentiate any significant associations between preoperative popliteal and tibial arterial flow and BKA outcomes and patient-reported function.METHODS: A retrospective review identified patients from a single tertiary wound care center who received BKAs and angiogram between 2010 and 2017 by a single surgeon. BKA complications, wound healing, and amputee ambulatory status at latest follow-up were all stratified for differences according to baseline tibial vessel run-off (VRO) status, popliteal artery patency, and popliteal angioplasty outcome. Chi-square, Fisher's exact, and Wilcoxon rank sum tests were used with significance defined as p ≤ 0.05.RESULTS: BKAs were performed on 313 patients, of which, 167 underwent preoperative angiography. Thirty-two were excluded due to lack of adequate follow-up leaving a total of 135 patients in the studied population. Diabetes was present in 87%, and 36% had end-stage renal disease. By the study's conclusion, 92% of BKAs had fully healed, with median time-to-healing of 79days (range 19-1314days). 60% of patients were ambulatory at 9.5 months. Higher VRO was associated with higher healing rates and lower complications and time-to-healing. The conversion rate of BKA to above-knee amputation (AKA) was 4%. Preoperative popliteal patency was associated with higher postoperative ambulation rates when compared to patients without popliteal flow preoperatively (patent: 71/109, 65%; occluded: 10/26, 40%; p = 0.02) and independently increased the likelihood of postoperative ambulation.CONCLUSIONS: The posterior flap design for BKA works even in the setting of popliteal occlusion. Complication rates are higher in patients with more compromised blood flow, which may ultimately lead to AKA. Given poor ambulation rates in patients who undergo AKA, the results of this study should encourage surgeons to consider a more functional BKA, even in instances when the popliteal artery is occluded.
View details for DOI 10.1177/17085381211026498
View details for PubMedID 34134560
- Reply: Comparison of the Pedicled Latissimus Dorsi Flap with Immediate Fat Transfer versus Abdominally Based Free Tissue Transfer for Breast Reconstruction. Plastic and reconstructive surgery 2021
"Amputation vs. Free Flap: Long-term Outcomes of Microsurgical Limb Salvage and Risk Factors for Amputation in the Diabetic Population".
Plastic and reconstructive surgery
BACKGROUND: Reconstructive microsurgery is an effective limb saving option for non-healing lower extremity wounds in diabetic patients. However, the ability to predict the future need for amputation is unclear. This paper seeks to identify risk factors for amputation following microsurgical free tissue transfer in the diabetic lower extremity.METHODS: Diabetic patients receiving lower extremity free flaps between August 2011 and January 2018 performed by a single surgeon were retrospectively identified. Patient comorbidities, reconstructive conditions and flap traits, microsurgical outcomes, and long-term outcomes were examined. Variables conferring risk for future amputation were examined via regression analysis.RESULTS: Sixty-four patients met the criteria. Overall immediate flap success was 94% (60/64). Long term, fifty patients (78.1%) were successfully salvaged, and 14 patients (21.9%) required major amputation. Acute flap loss resulted in 4 amputations while delayed complications (hematoma; infection; recurrent nonhealing) resulted in 10 amputations. The average time to amputation was 5.6 months. Risk factors for amputation were ESRD (OR30.7; p=0.0087), hindfoot wounds (OR4.6; p=0.020), elevated HbA1C >8.4% (OR1.4; p=0.05), and positive wound cultures (OR6.1; p=0.003).CONCLUSIONS: Multiple comorbidities and poor sugar control were identified as risk factors for amputation after free flap limb salvage. However, successful limb preservation is possible.
View details for DOI 10.1097/PRS.0000000000007644
View details for PubMedID 33587553
The "Double hit": Free tissue transfer is optimal in comorbid population with irradiated wounds for successful limb salvage.
Journal of plastic, reconstructive & aesthetic surgery : JPRAS
BACKGROUND: Radiation therapy causes histopathologic changes in tissues, including fibrosis, loss of tissue planes, and vascular damage, which can lead to chronic wound formation. Patients with nonhealing, irradiated wounds and comorbidities that affect microvasculature suffer a "double hit", which leads to delayed wound healing. Local wound care and grafts are commonly insufficient. In this study, we evaluated limb salvage outcomes and long-term complications after free tissue transfer (FTT) in patients with chronic, irradiated leg wounds.METHODS: We retrospectively reviewed patients with irradiated lower extremity wounds who underwent FTT from 2012 to 2017. Primary outcomes included limb salvage, ambulation, and overall flap success. Reconstruction involved complete excision of irradiated tissue and coverage with well-vascularized tissue.RESULTS: Seven free flaps in six patients were identified. Average age was 68.4 years and average BMI was 27.8 kg/m2. Comorbid conditions included hypertension (57.1%), peripheral vascular disease (57.1%), underlying hypercoagulability (42.9%), diabetes (14.3%), and tobacco use (14.3%). Wounds were present for an average of 25.5 months prior to FTT. Donor sites included anterolateral thigh (71.4%), vastus lateralis (14.3%), and latissimus dorsi (14.3%). Overall flap success rate was 100% with one patient requiring reoperation for dehiscence. Limb salvage rate was 85.7% with one patient undergoing elective amputation due to pain. All patients could ambulate (one used a prosthesis) at a mean follow-up time of 1.4 years.CONCLUSIONS: Radiation therapy in a comorbid population often leads to the formation of chronic nonhealing wounds. We advocate for earlier consideration of FTT to provide healthy vascularized tissues, thereby avoiding prolonged wound care and patient burden. Successful limb salvage outcomes can be achieved.
View details for DOI 10.1016/j.bjps.2020.10.054
View details for PubMedID 33248934
Plantar Foot Ulcer Recurrence in Neuropathic Patients Undergoing Percutaneous Tendo-Achilles Lengthening.
The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons
Equinus contracture carries 3- and 4-fold associations with diabetes and plantar foot ulceration, respectively. Percutaneous tendo-Achilles lengthening is a useful method to alleviate peak plantar pressure resulting from equinus. We aimed to evaluate the effectiveness of percutaneous tendo-Achilles lengthening and estimate the relative longevity of the approach in reducing ulcer recurrence. The medical records of patients with equinus contracture who underwent percutaneous tendo-Achilles lengthening from 2010 to 2017 were reviewed. Included patients presented with plantar ulcers and a gastroc-soleus equinus of any angle <10° of ankle dorsiflexion with the affected knee extended and flexed. Patients who received concomitant tendon lengthening procedures (including anterior tibial tendon or flexor digitorum longus) were excluded. Outcome measures included time to wound healing, time to ulcer recurrence, and development of transfer lesion. Ninety-one patients underwent percutaneous tendo-Achilles lengthening with subsequent pedal ulceration without concomitant procedures. A total of 69 (75.8%) patients had a plantar forefoot ulcer, 7 (7.7%) had midfoot ulcers, 5 (5.5%) had hindfoot ulcers, and 3 (3.3%) had ulcers in multiple locations. Seven patients received prophylactic tendo-Achilles lengthening. At a mean follow-up of 31.6 months (±26), 66 (78.6%) wounds healed at a median 12.9 weeks. A total of 29 patients (43.9%) experienced ulcer recurrence at a mean of 12 months. Twelve patients (13%) experienced a transfer lesion at a mean of 16.6 months. Tendo-Achilles lengthening can be an effective adjunctive approach to achieve wound healing and reduce long-term ulcer recurrence in patients with equinus contracture and neuropathic plantar foot ulcers. A relengthening procedure may be needed within approximately 12 months from index surgery.
View details for DOI 10.1053/j.jfas.2020.04.011
View details for PubMedID 32863115
Critical evaluation of factors contributing to time to mastectomy within a single health care system
Increased time to mastectomy (TTM) has significant implications for mortality, well-being, and satisfaction. However, certain populations are subject to disparities that increase TTM. This study examines vulnerable populations and the patient-, disease-, provider-, and system-level factors related to treatment delays. Patients undergoing mastectomy for breast cancer from 2014 to 2018 across 8 hospitals in a single health care system were retrospectively reviewed. Demographics, disease characteristics, and provider- and system-level information were collected. Time from biopsy-proven diagnosis to mastectomy was calculated. Univariate analysis identified variables for inclusion in the multivariable model. One thousand, three hundred thirty patients met inclusion. Median TTM was 55.0 days. Factors from all levels-patient, disease, provider, and systemic-were significantly related to disparities. African-American patients had 11.6% longer TTM compared to white patients (69.0 vs 56.0 days, P < .0001). TTM was 15.5% longer for low-income patients when compared to high-income patients (65.0 vs 49.0 days, P = .0014). Preoperative plastic surgery visits led to 19.3% longer TTM (P = .0012); oncologic appointments for neo-adjuvant chemotherapy led to a 231.0% increase (P < .0001). Average time from last neo-adjuvant treatment to mastectomy was 44.4 days (SD 26.5); average TTM from diagnosis for patients not receiving neo-adjuvant chemotherapy was 58.5 days (SD 13.3). Patients with Medicaid waited 14.5% longer compared to patients with commercial insurance (94.0 vs 62.0 days, P = .0005). In our review of care across a large health care system, we identified multiple levels contributing to disparities in TTM. Identification of these disparities offers valuable insight into process improvement and intervention.
View details for DOI 10.1111/tbj.13953
View details for Web of Science ID 000547333600001
View details for PubMedID 32656954
Free Tissue Transfer Using End-to-side Arterial Anastomosis for Limb Salvage in Patients With Lower Extremity Arterial Disease
MOSBY-ELSEVIER. 2020: E268
View details for Web of Science ID 000544100700410
Free Anterolateral Thigh Versus Vastus Lateralis Muscle Flaps for Coverage of Lower Extremity Defects in Chronic Wounds.
Annals of plastic surgery
2020; 85 (S1 Suppl 1): S54–S59
INTRODUCTION: The thigh has been called the reconstructive warehouse. The anterolateral thigh (ALT) and vastus lateralis (VL) flaps are popular options for free tissue transfer in lower extremity reconstruction. We sought to review the largest experience of these flaps in the chronic wound population.METHODS: We retrospectively reviewed patients who underwent lower extremity reconstruction using ALT or VL flaps by a single surgeon between 2012 and 2018.RESULTS: Fifty ALT and 34 VL flaps were identified. Comorbidities were similar between groups with the exception of body mass index (ALT, 26.8; VL, 30.1; P = 0.0121). There was also a significant difference rate of independent ambulation preoperatively (ALT, 98.0%; VL, 85.3%; P = 0.0375). An adjunct was needed for recipient site coverage in 31.5% (19/50) of ALT patients and 100% (34/34) of VL patients. Of the patients who received skin grafts, delayed placement was more frequent in the ALT (53.3%) versus VL cohort (18.2%) (P = 0.0192). Median graft take and the rate of skin graft revision were not statistically different. Flap success rates were similar: ALT, 92.0%; and VL, 94.1%. Overall complication rates were not significantly different: ALT, 26.0%; and VL, 38.2%. Infectious complications were also comparable. Subsequent debulking procedures were performed on 8.0% of ALT flaps and 11.8% VL flaps (P = 0.7092). Limb salvage rates were similar between both cohorts (ALT, 82.0%; VL, 88.2%). Ambulation rate was significantly higher for the ALT cohort at 92.0% compared with 73.5% for the VL cohort (P = 0.0216). Median follow-up was similar for both groups.CONCLUSIONS: We present the largest comparison study of ALT and VL flaps in lower extremity salvage. Complication rates, flap success, and limb salvage were similar between the 2 cohorts. Despite a high prevalence of osteomyelitis in both cohorts, there was no difference in infectious complications. Although the need for skin grafting remains an inherent disadvantage of the VL flap, a significant proportion of ALT recipients also needed an adjunct for recipient site coverage. Ambulation rate was significantly greater in the ALT group. However, flap type was no longer significant for ambulation when controlling for preoperative ambulatory status.
View details for DOI 10.1097/SAP.0000000000002335
View details for PubMedID 32539286
Who, What, Where: Demographics, Severity of Presentation, and Location of Treatment Drive Delivery of Diabetic Limb Reconstructive Services within the National Inpatient Sample
PLASTIC AND RECONSTRUCTIVE SURGERY
2020; 145 (6): 1516–27
Technical advances have been made in reconstructive diabetic limb salvage modalities. It is unknown whether these techniques are widely used. This study seeks to determine the role of patient- and hospital-level characteristics that affect use.Admissions for diabetic lower extremity complications were identified in the 2012 to 2014 National Inpatient Sample using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. The study cohort consisted of admitted patients receiving amputations, limb salvage without flap techniques, or advanced limb salvage with flap techniques. Multinomial regression analysis accounting for the complex survey design of the National Inpatient Sample was used to determine the independent contributions of factors expressed as marginal effects.The authors' study cohort represented 155,025 admissions nationally. White non-Hispanic patients had the highest proportion of reconstruction without and with flaps, whereas black patients had the lowest. Multinomial regression models revealed that controlling for nongas gangrene and critical limb ischemia, both of which have a much greater incidence in minorities, the effect of race against receipt of reconstructive modalities was attenuated. Access to urban teaching hospitals was the strongest protective factor against amputation (9 percent reduction; p < 0.01) and predictor of receiving limb salvage without flaps (5 percent increase; p < 0.01) and with flaps (3 percent increase; p < 0.01).This study identified multiple patient- and hospital-level factors associated with decreased access to the gamut of reconstructive limb salvage techniques. Disparity reduction will likely require a multifaceted strategy that addresses the severity of disease presentation seen in minorities and delivery system capabilities affecting access and use of reconstructive limb salvage procedures.Risk, III.
View details for DOI 10.1097/PRS.0000000000006843
View details for Web of Science ID 000537866300051
View details for PubMedID 32205544
Limb Salvage Rates and Functional Outcomes Using a Longitudinal Slit Arteriotomy End-to-Side Anastomosis for Limb-Threatening Defects in a High-Risk Patient Population
LIPPINCOTT WILLIAMS & WILKINS. 2020: 1302–12
Limb salvage techniques using free tissue transfer in patients with chronic wounds caused by longstanding osteomyelitis, diabetes, and peripheral vascular disease are technically challenging. The longitudinal slit arteriotomy end-to-side anastomosis is the authors' preferred technique because it is the least invasive arteriotomy and is especially important for diseased recipient arteries. The authors reviewed highly comorbid patients who underwent free tissue transfer with this technique to understand the success rates, overall outcomes, and long-term limb salvage rates.A retrospective review was performed to analyze outcomes of free tissue transfer using longitudinal slit arteriotomy end-to-side anastomosis between 2012 and 2018 performed by the senior surgeon (K.K.E.).One hundred fifteen free flaps were identified. Patients were, on average, 55.9 years old, with a body mass index of 29.2 kg/m. Comorbidities included osteomyelitis (83.5 percent), hypertension (60.9 percent), tobacco use (46.1 percent), diabetes (44.3 percent), peripheral vascular disease (44.3 percent), hypercoagulability (35.7 percent), and arterial calcifications (17.4 percent). Overall flap success was 93.0 percent; 27.8 percent required reoperation perioperatively because of complications. On univariate analysis, diabetes mellitus, hypertension, and hypercoagulability were significantly associated with eventual amputation (p < 0.05). Multivariate analysis showed that intraoperative thrombosis and take back was independently associated with flap failure. There was an overall limb salvage rate of 83.5 percent, and of those salvaged, 92.7 percent were ambulating without a prosthesis at a mean follow-up of 1.53 years.This is the largest series of longitudinal slit arteriotomy end-to-side anastomosis for patients undergoing free tissue transfer for limb-threatening defects in the compromised host. Overall flap success, limb salvage rates, and functional outcomes are high using this technique.Therapeutic, IV.
View details for DOI 10.1097/PRS.0000000000006791
View details for Web of Science ID 000531422600054
View details for PubMedID 32332556
Comparison of the Pedicled Latissimus Dorsi flap with Immediate Fat (LIFT) Transfer versus Abdominally-Based Free Tissue Transfer for Breast Reconstruction.
Plastic and reconstructive surgery
Abdominally-based free tissue transfer (FTT) and latissimus dorsi and immediate fat transfer (LIFT) procedures are both fully autologous options for breast reconstruction. The former is specialized and requires comfort with microsurgical technique while the LIFT combines a common set of techniques familiar to all plastic surgeons. Comparison of the two methods for clinical effectiveness and complications for equivalency in outcomes may help elucidate and enhance patient decision making.A retrospective review of a prospectively maintained database between March 2017 and July 2018 was performed to compare the LIFTs and FTTs by the senior surgeon. Outcomes of interest included post-operative complications, flap success, and follow up revision and fat grafting procedures.65 breasts were reconstructed by FTT; 31 breasts were reconstructed with the LIFT. Demographics were similar (p>0.05). The LIFT had a shorter length of operation time (343±128 vs. 49±137 min) (p<0.0001) and a shorter length of stay (1.65±0.85 vs 3.83±1.65 days) (p<0.001). FTTs had a shorter time until drain removal (13.3±4.3 vs 24.0±11.2 days) (p<0.0001). The number of major (requiring operation), and minor complications were not statistically different (FTTs: major 20.0%, minor 27.7%; LIFT: major 12.9%, minor 19.35%) (p>0.05). The need for revisions (FTTs 0.80±0.71 vs. LIFT 0.87±0.71) and fat grafting (FTTs 41.54% vs. LIFT 58.8%) were not statistically different (p>0.05).Both the LIFT and abdominally-based FTT have similar outcomes and complication rates. However, the LIFT may be preferred in patients that require shorter operation times. The LIFT may be the fully autologous breast reconstruction of choice for non-microsurgeons.
View details for DOI 10.1097/PRS.0000000000007027
View details for PubMedID 32355088
Simultaneous Ventral Hernia Repair and Panniculectomy: A Systematic Review and Meta-Analysis of Outcomes
PLASTIC AND RECONSTRUCTIVE SURGERY
2020; 145 (4): 1059–67
Simultaneous ventral hernia repair and panniculectomy (SVHRP) is a procedure that is more commonly being offered to patients with excess skin and subcutaneous tissue in need of a ventral hernia repair; however, there are concerns about surgical-site complications and uncertainty regarding the durability of repair. SVHRP outcomes vary within the literature. This study assessed the durability, complication profile, and safety of SVHRP through a large data-driven repository of SVHRP cases.360 METHODS:: The current SVHRP literature was queried using the MEDLINE, PubMed, and Cochrane databases. Predefined selection criteria resulted in 76 relevant titles yielding 16 articles for analysis. Meta-analysis was used to analyze primary outcomes, identified as surgical-site occurrence and hernia recurrence. Secondary outcomes included review of techniques used and systemic complications, which were analyzed with pooled weighted mean analysis from the collected data.There were 917 patients who underwent an SVHRP (mean age, 52.2 ± 7.0 years; mean body mass index, 36.1 ± 5.8 kg/m; mean pannus weight, 3.2 kg). The mean surgical-site occurrence rate was 27.9 percent (95 percent CI, 15.6 to 40.2 percent; I = 70.9 percent) and the mean hernia recurrence rate was 4.9 percent (95 percent CI, 2.4 to 7.3 percent; I = 70.1 percent). Mean follow-up was 17.8 ± 7.7 months. The most common complications were superficial surgical-site infection (15.8 percent) and seroma formation (11.2 percent). Systemic complications were less common (7.8 percent), with a thromboembolic event rate of 1.2 percent. The overall mortality rate was 0.4 percent.SVHRP is associated with a high rate of surgical-site occurrence, but surgical-site infection seems to be less prominent than previously anticipated. The low hernia recurrence rate and the safety of this procedure support its current implementation in abdominal wall reconstruction.
View details for DOI 10.1097/PRS.0000000000006677
View details for Web of Science ID 000530618900072
View details for PubMedID 32221233
Predicting Ischemic Complications in the Inframammary Approach to Nipple-Sparing Mastectomy: The Midclavicular-to-Inframammary Fold Measurement
PLASTIC AND RECONSTRUCTIVE SURGERY
2020; 145 (2): 251E–262E
The authors refine their anatomical patient selection criteria with a novel midclavicular-to-inframammary fold measurement for nipple-sparing mastectomy performed through an inframammary approach.Retrospective review was performed of all nipple-sparing mastectomies performed through an inframammary approach. Exclusion criteria included other mastectomy incisions, staged mastectomy, previous breast operation, and autologous reconstruction. Preoperative anatomical measurements for each breast, clinical course, and specimen weight were obtained.One hundred forty breasts in 79 patients were analyzed. Mastectomy weight, but not sternal notch-to-nipple distance, was strongly correlated with midclavicular-to-inframammary fold measurement on linear regression (R = 0.651; p < 0.001). Mastectomy weight was not correlated with ptosis. Twenty-five breasts (17.8 percent) had ischemic complications: 16 (11.4 percent) were nonoperative and nine (6.4 percent) were operative. Those with mastectomy weights of 500 g or greater were nine times more likely to have operative ischemic complications than those with mastectomy weights less than 500 g (p = 0.0048). Those with a midclavicular-to-inframammary fold measurement of 30 cm or greater had a 3.8 times increased incidence of any ischemic complication (p = 0.00547) and a 9.2 times increased incidence of operative ischemic complications (p = 0.00376) compared with those whose midclavicular-to-inframammary fold measurement was less than 30 cm.Breasts undergoing nipple-sparing mastectomy by means of an inframammary approach with midclavicular-to-inframammary fold measurement greater than or equal to 30 cm are at higher risk for having ischemic complications, warranting consideration for a staged approach or other incision. The midclavicular-to-inframammary fold measurement is useful for assessing the entire breast and predicting the likelihood of ischemic complications in inframammary nipple-sparing mastectomies.Risk, III.
View details for DOI 10.1097/PRS.0000000000006439
View details for Web of Science ID 000528567100002
View details for PubMedID 31985611
Delivery of nipple-sparing mastectomy within a single healthcare system: The impact of provider preferences.
The breast journal
Nipple-sparing mastectomy (NSM) offers superior esthetic outcomes without sacrificing oncologic safety for select patients requiring mastectomy. While disparities in oncologic care are well established, no study to date has investigated equitable delivery of the various mastectomy types. The objective of this study is to examine multilevel factors related to the distribution of NSM. Patients undergoing mastectomy between 2014 and 2018 across eight hospitals in a single healthcare system were retrospectively reviewed. Patients were categorized by mastectomy type-NSM or other mastectomy (OM). Patient information such as age, race, comorbidities, and median income by ZIP code was collected. Disease characteristics, such as mastectomy weight, breast cancer stage, and treatment history, were identified. Provider and system-level variables, such as specific provider, hospital of operation, and insurance status, were determined. Bivariate analysis was used to identify variables for inclusion in a backward multivariable model. A cohort of 1202 mastectomy patients was identified, with 388 receiving NSM. The average age was 55.8 years (NSM: 48.8, OM: 59.1, P < .001). 39.8% of white patients (n = 242) and 20.0% of African American patients (n = 88) received NSM (P < .001). Average mastectomy weight was 384.3 (SD 195.7) in the NSM group, compared to 839.4 (SD 521.1) in the OM group (P < .001). 41.4% (n = 359) of patients treated at academic centers, and 6.9% (n = 21) of patients treated at community centers received NSM (P < .001). In the multivariate model, the factor with the largest impact on NSM was specific provider. Odds of NSM decreased by 76%-88% for certain surgeons, while odds increased by 63 times for one surgeon. This study utilizes a large multi-institutional database to highlight disparities in NSM delivery. Expectedly, younger, relatively healthy patients, with smaller breast size were more likely to undergo NSM, in accordance with surgical guidelines. However, when all other factors were controlled, provider preferences played the most significant role in NSM delivery rates. These findings demonstrate the need for practice reexamination to ensure equitable access to NSM.
View details for DOI 10.1111/tbj.14112
View details for PubMedID 33274577
Factors contributing to persistent rates of contralateral prophylactic mastectomy in breast cancer patients: Examination of 1051 mastectomies across a single health system.
The breast journal
The American Society of Breast Surgeons (ASBrS) outlined definitive guidelines for contralateral prophylactic mastectomy (CPM) in 2016. Despite this, rates of CPM have remained steady. The objective of this study was to identify factors contributing to persistent over-delivery of CPM. Breast cancer patients across 8 hospitals in a single healthcare system from 2014 to 2018 were retrospectively reviewed. The patients were divided according to whether they received nonindicated CPMs versus other mastectomy types. Nonindicated CPM were those procedures not meeting ASBrS consensus guidelines for recommended patients. CPM rate was calculated for each year in the study period. Patient, disease, provider, and system level factors were obtained. Bivariate analysis was used to identify variables for inclusion in a backward multivariable model. A total of 1,051 patients were analyzed. Nonindicated CPM rates by year remained steady throughout the time period (P = .391). In multivariable regression, patient, disease, and provider level factors were associated with odds of undergoing CPM. Every unit increase in age was associated with a 4% reduction in odds of undergoing CPM (CI 0.941-0.986). Stage 3 breast cancer compared to stage 1 had 53% lower odds of CPM (CI 0.288-0.757). Implant-based breast reconstruction had 2.9-fold higher odds of CPM compared to no reconstruction (CI 1.476-5.551). No system level factors were statistically significant. CPM rates have not notably decreased since the ASBrS consensus statement with certain patient and provider factors impacting persistent overuse of CPM. These results inform oncologic and reconstructive providers of factors contributing to continued use of a nonindicated procedure.
View details for DOI 10.1111/tbj.14080
View details for PubMedID 33037675
The Utility of Preoperative Venous Testing for Lower Extremity Flap Planning in Patients with Lower Extremity Wounds
PLASTIC AND RECONSTRUCTIVE SURGERY
2020; 145 (1): 164E–171E
Although venous thrombosis is a leading cause of flap failure, the majority of lower extremity free flap planning is centered on arterial system evaluation. Preoperative identification of relevant abnormality in lower extremity venous systems by means of duplex ultrasound may aid in the diagnosis of clinically important abnormality that could affect lower extremity flap outcomes.Between November of 2014 and August of 2017, 57 patients underwent preoperative lower extremity venous duplex imaging and free tissue transfer for lower extremity wounds. A retrospective review was performed to describe lower extremity venous pathologic findings, relevant patient demographic data, comorbid conditions, and outcomes. Discovery of venous abnormality helped guide recipient vein selection.Fifty-seven consecutive patients underwent 59 free flap operations to treat chronic lower extremity wounds. Venous duplex ultrasonography detected venous insufficiency (defined as >0.5 second of reflux) in 23 patients (39.0 percent), including 16 (27.2 percent) with deep thigh reflux, six (10.2 percent) with superficial calf reflux, and four (6.78 percent) with deep calf reflux. Deep venous thrombosis was found in four patients (6.78 percent) and treated with anticoagulation. The flap success rate was 98.3 percent. Five patients (8.47 percent) progressed to amputation. At a mean follow-up time of 15.1 ± 9.51 months (range, 1.67 to 35.2 months), 53 patients (89.8 percent) were able to continue community ambulation.Lower extremity venous duplex testing before free tissue transfer may be useful for optimizing flap recipient vessel selection and for detecting potentially unknown venous abnormality. Development of free flap planning protocols incorporating preoperative vascular imaging is important to achieving good functional outcomes in this comorbid patient population.Diagnostic, IV.
View details for DOI 10.1097/PRS.0000000000006384
View details for Web of Science ID 000507912200042
View details for PubMedID 31881626
Analysis of Chest Masculinization Surgery Results in Female-to-Male Transgender Patients: Demonstrating High Satisfaction beyond Aesthetic Outcomes Using Advanced Linguistic Analyzer Technology and Social Media
PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN
2020; 8 (1): e2356
Satisfaction rates are reported as high after subcutaneous mastectomy for chest masculinization. We examined patient satisfaction based on linguistic analysis of social media posts showing postoperative results and compared them to aesthetic quality ratings from plastic surgeons.Fifty publicly available images of subcutaneous mastectomy postoperative results of female-to-male gender transition patients were selected from Instagram. The photograph's corresponding post and comments were then analyzed for sentiment through the IBM Watson tone analyzer, which rated the presence of joy on a continuous scale from 0 to 1. Three plastic surgeons rated aesthetic quality on an ordinal scale of 1 to 10. Results of both analyses were then compared.Joy was rated as a mean value of 0.74 (±0.13) in posts and 0.81 (±0.13) in comments. The mean ratings of results were found to be chest contour 6.1 of 10 (±1.7), scar position 5.3 of 10 (±1.8), scar quality 4.8 of 10 (±1.9), nipple position 5.2 of 10 (±1.9), and nipple quality 5.1 of 10 (±2.0). A positive relationship was found between post joy and nipple quality (r = 0.33, P = 0.0169). There were no other associations detected between level of joy and the ratings of results by plastic surgeons (P > 0.05).Despite wide variety in surgical appearance, there is a high level of satisfaction and community support. This is in contrast to the low-quality ratings by plastic surgeons. The results demonstrate the strong psychological and functional underpinnings chest masculinization has for patients. However, surgical results can be improved through a variety of techniques such that patients have both excellent surgical results and high satisfaction.
View details for DOI 10.1097/GOX.0000000000002356
View details for Web of Science ID 000528608600001
View details for PubMedID 32095382
View details for PubMedCentralID PMC7015616
Comparison of the Pedicled Latissimus Dorsi Flap with Immediate Fat Transfer versus Abdominally Based Free Tissue Transfer for Breast Reconstruction.
Plastic and reconstructive surgery
2020; 146 (2): 137e–146e
BACKGROUND: Abdominally based free tissue transfer (FTT) and latissimus dorsi and immediate fat transfer (LIFT) procedures are both fully autologous options for breast reconstruction. The former is specialized and requires comfort with microsurgical technique, whereas LIFT combines a common set of techniques familiar to all plastic surgeons. Comparing the two methods for clinical effectiveness and complications for equivalency in outcomes may help elucidate and enhance patient decision-making.METHODS: A retrospective review of a prospectively maintained database between March of 2017 and July of 2018 was performed to compare the LIFTs and FTTs performed by the senior surgeon. Outcomes of interest included postoperative complications, flap success, and follow-up revision and fat-grafting procedures.RESULTS: Sixty-five breasts were reconstructed by FTT; and 31 breasts were reconstructed with LIFT. Demographics were similar (p > 0.05). LIFT had a shorter length of operation time (343 ± 128 minutes versus 49 ± 137 minutes) (p < 0.0001) and a shorter length of stay (1.65 ± 0.85 days versus 3.83 ± 1.65 days) (p < 0.001). FTTs had a shorter time until drain removal (13.3 ± 4.3 days versus 24.0 ± 11.2 days) (p < 0.0001). The number of major (requiring operation) and minor complications were not statistically different (i.e., FTTs, 20.0 percent major and 27.7 percent minor; LIFT, 12.9 percent major and 19.35 percent minor) (p > 0.05). The need for revisions (FTTs, 0.80 ± 0.71; LIFT, 0.87 ± 0.71) and fat grafting (FTTs, 41.54 percent; LIFT, 58.8 percent) was not statistically different (p > 0.05).CONCLUSIONS: Both the LIFT and abdominally based FTT have similar outcomes and complication rates. However, LIFT may be preferred in patients who require shorter operation times. The LIFT may be the fully autologous breast reconstruction of choice for nonmicrosurgeons.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
View details for DOI 10.1097/PRS.0000000000007027
View details for PubMedID 32740570
Bridging the Knowledge Gap: An Examination of the Ideal Postoperative Autologous Breast Reconstruction Educational Material with A/B Testing
PLASTIC AND RECONSTRUCTIVE SURGERY
2020; 145 (1): 258–66
Poor health literacy is an epidemic in the United States, associated with higher mortality rates and poor postoperative care. Autologous breast reconstruction is highly complex, and the identification of complications is difficult even for non-plastic surgeon practitioners. The authors sought to explore the problem of health literacy in this context and identify the ideal postoperative patient education materials.Available online postoperative patient education materials for autologous breast reconstruction and corresponding readability scores were assessed. To derive the ideal formula for materials, the authors crowd-sourced quizzes with A/B testing, a method to examine the outcome of two versions of a single variable. The authors implemented their findings and compared performance on postoperative quizzes with and without oral reinforcement.Of the 12 postoperative flap complication patient education materials found through an Internet search, the average grade level readability level was 9.9. Only one of 12 (8.3 percent) mentioned symptoms and signs of flap compromise. The A/B tests result revealed that text approximately 400 to 800 words written on a sixth-grade level led to the highest quiz scores. Patients scored significantly higher on the postoperative day-2 quiz when patient education materials, modeled after these findings, were reinforced with oral presentation (p = 0.0059). Retention of high quiz scores remained at postoperative day 10.Currently available patient education materials are at a high reading level and lack specific information on the identification of flap compromise. The authors propose the most effective postoperative instructions to be approximately 400 to 800 words written on a grade-six level with images and oral reinforcement.
View details for DOI 10.1097/PRS.0000000000006373
View details for Web of Science ID 000507912200097
View details for PubMedID 31609288
Negative pressure wound therapy with intermittent instillation of rifampin for the treatment of an infected vascular bypass graft
JOURNAL OF VASCULAR SURGERY CASES AND INNOVATIVE TECHNIQUES
2019; 5 (4): 435–37
Negative pressure wound therapy with intermittent instillation, especially with the addition of antibiotics in the case of infection, is a versatile treatment modality for the closure of wounds and can be used both primarily after débridement and secondarily after failure of muscle flap coverage. We present a case in which negative pressure wound therapy with intermittent instillation of rifampin was used to successfully close a groin wound secondary to an infected prosthetic vascular graft that initially failed to close with a muscle flap. Consideration of this approach to wound closure and graft salvage is important because of the seriousness and relatively common incidence of prosthetic vascular graft infection after infrainguinal arterial bypass revascularization.
View details for DOI 10.1016/j.jvscit.2019.04.008
View details for Web of Science ID 000504636600011
View details for PubMedID 31660467
View details for PubMedCentralID PMC6806654
- Extensive Sinonasal and Oropharyngeal Necrosis as a Consequence of Adulterated Cocaine with Mimicry of ANCA-Positive Vasculitis. OTO open 2019; 3 (4): 2473974X19894239
Coordination of the Fetal Medicine Institute and the Cleft and Craniofacial Center: Application to Early Management of Infants With Cleft Lip and Palate
JOURNAL OF CRANIOFACIAL SURGERY
2019; 30 (7): 2061–64
The primary objective of this study is to describe the authors' experience at the Children's National Health System with the coordination of the Fetal Medicine Institute and the Cleft and Craniofacial Center. This collaboration highlights the accuracy and completeness of prenatal diagnosis of cleft abnormalities with expedient postnatal management.With Institutional Review Board approval, the authors retrospectively reviewed 74 patients referred for potential orofacial cleft and 44 met the inclusion criteria. Follow-up fetal ultrasonography is typically performed and three-dimensional imaging was performed when feasible. If questionable anomalies or facial findings are present on these studies, the authors proceed with fetal magnetic resonance imaging. A thorough consultation is held with the cleft team, resulting in a comprehensive plan of care. Postnatal examination confirmed the correct prenatal diagnosis in nearly all patients.Sensitivity and specificity for isolated unilateral cleft lip were 89% and 100%, respectively; for unilateral cleft lip and palate, sensitivity and specificity were 82% and 90%, respectively; for bilateral cleft lip and palate, sensitivity and specificity were 97% and 90%, respectively. Initial postnatal evaluation by the cleft surgeon occurred at an average age of 21 days after birth. All patients who were candidates for presurgical orthodontia were treated at an appropriate young age (mean: 66.5 days).Coordinated prenatal evaluation of patients with cleft lip/palate by multidisciplinary centers plays an important role in the care of these complex patients. The results of the authors' study demonstrated high sensitivity and specificity for the prenatal diagnosis of cleft lip/palate, leading to timely postnatal evaluation and treatment.
View details for DOI 10.1097/SCS.0000000000005950
View details for Web of Science ID 000500374200079
View details for PubMedID 31524754
- Discussion: A Simplified Cost-Utility Analysis of Inpatient Flap Monitoring after Microsurgical Breast Reconstruction and Implications for Hospital Length of Stay PLASTIC AND RECONSTRUCTIVE SURGERY 2019; 144 (4): 552E–553E
Amputations versus Salvage: Reconciling the Differences.
Journal of reconstructive microsurgery
BACKGROUND: There are many factors to consider when choosing between amputations versus salvage in lower extremity reconstructive surgery. Postoperative functionality and survival benefit are critical factors when deciding between limb salvage and amputation.METHODS: In this review, we present the evidence and the risks and benefits between these two options in the setting of the acute, trauma population and the chronic, diabetes population.RESULTS: The trauma population is on average young without significant comorbidities and with robust vasculature and core strength for recovery. Therefore, these patients can often recover significant function with anamputation and prosthesis. Amputation can therefore be the more desirable in this patient population, especially in the case of complete traumatic disruption, unstable patients, high risk of extensive infection, and significant nerve injury. However, traumatic lower extremity reconstruction is also a viable option, especially in the case of young patients and those with intact plantar sensation and sufficient available tissue coverage. The diabetic population with lower extremity insult has on average a higher comorbidity profile and often lower core strength. These patients therefore often benefit most from reconstruction to preserve limb length and improve survival. However, amputation may be favored for diabetics that have no blood flow to the lower extremity, recalcitrant infection, high-risk comorbidities that preclude multiple operations, and those with end stage renal disease.CONCLUSION: Many patient-specific factors should be considered when deciding between amputation vs. salvage in the lower extremity reconstruction population.
View details for DOI 10.1055/s-0039-1696733
View details for PubMedID 31499559
Utility of a modified components separation for abdominal wall reconstruction in the liver and kidney transplant population
ARCHIVES OF PLASTIC SURGERY-APS
2019; 46 (5): 462–69
Incisional hernia is a common complication following visceral organ transplantation. Transplant patients are at increased risk of primary and recurrent hernias due to chronic immune suppression and large incisions. We conducted a retrospective review of patients with a history of liver or kidney transplantation who underwent hernia repair to analyze outcomes and hernia recurrence.This is a single center, retrospective review of 19 patients who received kidney and/or liver transplantation prior to presenting with an incisional hernia from 2011 to 2017. All hernias were repaired with open component separation technique (CST) with biologic mesh underlay.The mean age of patients was 61.0±8.3 years old, with a mean body mass index of 28.4±4.8 kg/m2, 15 males (78.9%), and four females (21.1%). There were seven kidney, 11 liver, and one combined liver and kidney transplant patients. The most common comorbidities were hypertension (16 patients, 84.2%), diabetes (9 patients, 47.4%), and tobacco use (8 patients, 42.1%). Complications occurred in six patients (31.6%) including hematoma (1/19), abscess (1/19), seroma (2/19), and hernia recurrence (3/19) at mean follow-up of 28.7±22.8 months. With the exception of two patients with incomplete follow-up, all patients healed at a median time of 27 days.This small, retrospective series of complex open CST in transplant patients shows acceptable rates of long-term hernia recurrence and healing. By using a multidisciplinary approach for abdominal wall reconstruction, we believe that modified open CST with biologic mesh is a safe and effective technique in the transplant population with complex abdominal hernias.
View details for DOI 10.5999/aps.2018.01361
View details for Web of Science ID 000487301500012
View details for PubMedID 31550752
View details for PubMedCentralID PMC6759439
The "String of Pearls" technique for increased surface area and lymphedematous fluid drainage in right gastroepiploic-vascularized lymph node transfer: A report of two cases
2019; 39 (6): 548–52
We present our "String of Pearls" technique for upper and lower extremity lymphedema based off the right gastroepiploic artery. The entire laprascopically harvested omentum is placed through a longitudinal incision at the lymphedematous area, and anastomosed proximally, with additional distal venous outflow. This approach preserves the native lymphaticovenous architecture, distributes free lymphatic tissue along the axis of the extremity, and allows for scar release. The additional vein serves to restore bidirectional physiologic drainage inherent in the omentum and providing further lymphaticovenous drainage. We present two cases of upper and lower extremity lymphedema as a result of malignancy treated using this method. The first case was a result of breast cancer in a 55-year-old female with orthotopically placed omentum, and the second case a result of malignant nodular fasciitis in the distal lower extremity in a 56-year-old female with distally placed omentum. No complications occurred. At 3 months follow up, there is a 25% and 28% reduction in lower and upper extremity volume, respectively, with no recurrent cellulitis episodes. The safety and feasibility of placement of the entire omentum longitudinally with additional venous anastomosis are apparent. However, long-term studies are required.
View details for DOI 10.1002/micr.30484
View details for Web of Science ID 000486171800010
View details for PubMedID 31225685
Does surgeon handedness or experience predict immediate complications after mastectomy? A critical examination of outcomes in a single health system
2020; 26 (3): 376–83
Surgeons often seek to perfect their technical dexterity, and hand dominance of the surgeon is an important factor given the constraints of operative field laterality. However, experience often dictates how surgeons are able to compensate. While surgeons have experienced preference for the ipsilateral breast, the impact of surgeon handedness, experience, and volume has not been directly examined in a single study. A retrospective chart review of five breast surgeons (2 LHD) at a single institution identified 365 mastectomy patients, totaling 594 breasts, between January 2015 and June 2018. The breasts were identified as ipsilateral or contralateral based on the surgeons' handedness. Surgeons were grouped based on length of surgical experience, three with ≥15 years and two with <15 years. Surgeons with greater experience were the highest volume surgeons in this series. Data included patient demographics, breast and oncologic history, surgical techniques, and surgical outcomes including complications. A total of 270 nonprophylactic and 324 prophylactic mastectomies were identified, of which 529 were performed by surgeons with greater than 15 years of experience and 65 by surgeons with less than 15 years. The overall complication rate was 33.5% (n = 199), of which 18.0% (n = 107) were on the ipsilateral breast and 15.5% (n = 92) were on the contralateral breast. 9.1% of complications required re-operation (n = 54). The odds of any complication on the ipsilateral breast were 2.9 times higher than complications on the contralateral breast when looking exclusively at surgeons with <15 years of experience (P = .0353, OR = 2.92, 1.06-8.03). Surgeons with <15 years of experience have a 2.71 (P = .05, OR 2.71, 1.361-5.373) increase in any ischemic complication and a 16 times (P < .0001, OR = 16.01, 5.038-50.933) increase in major operative ischemic complications. Our study finds that surgeons with less than 15 years of surgical experience have a 2.9 times higher rate of overall complication when operating on the ipsilateral breast. However, years of experience and surgeon volume have a much greater impact on any and ischemic complications after mastectomy.
View details for DOI 10.1111/tbj.13487
View details for Web of Science ID 000483390700001
View details for PubMedID 31448506
Venous thromboembolism in plastic surgery: the current state of evidence in risk assessment and chemoprophylactic options
JOURNAL OF PLASTIC SURGERY AND HAND SURGERY
2019; 53 (6): 370–80
The application of venous thromboembolism (VTE) prophylaxis has been the topic of intense debate in plastic surgery. The overall incidence of VTE is low in plastic surgery patients as compared to other surgical subspecialties but may be higher in the inpatient rather than outpatient plastic surgery populations. The Caprini Risk Assessment Model is the most highly studied and validated tool to assess VTE risk in plastic surgery patients. However, the Caprini model lacks procedure-specific risk assessment and patient-specific risk factor calculations. Due to these limitations, such as the low incidence and the heterogeneous nature of the specialty, trials lacked the power to capture proof of benefit, except in the highest-risk inpatient population. The emerging use of aspirin and novel oral anticoagulants may provide an alternative, as noninferiority in terms of efficacy and safety has been demonstrated in other fields. In this review, the authors intend to summarize the current state of evidence for prevention and explore the modalities available for prophylaxis, including novel oral anticoagulants.
View details for DOI 10.1080/2000656X.2019.1650057
View details for Web of Science ID 000485044900001
View details for PubMedID 31478782
Gabapentin Decreases Narcotic Usage: Enhanced Recovery after Surgery Pathway in Free Autologous Breast Reconstruction
PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN
2019; 7 (8): e2350
The opioid crisis is public health emergency, in part due to physician prescribing practices. As a result, there is an increased interest in reducing narcotic use in the postsurgical setting.From January 1, 2018, to October 31, 2018, we employed a multidisciplinary, multimodal Enhanced Recovery After Surgery (ERAS) pathway abdominally based free tissue transfer involving the rectus. Preoperative, intraoperative, and postoperative nonnarcotic modalities were emphasized. Factors in reducing narcotic consumption, pain scores, and antiemetic use were identified.Forty-two patients were included for a total of 66 free flaps, with a 98.4%(65/66) success rate. Average postoperative in-hospital milligram morphine equivalent (MME) use was 37.5, but decreased 85% from 80.9 MME per day to 12.9 MME per day during the study period. Average pain scores and antiemetic doses also decreased. Postoperative gabapentin was associated with a significant 59.8 mg decrease in postoperative MME use, 21% in self-reported pain, and a 2.5 fewer doses of antiemetics administered but increased time to ambulation by 0.89 days. Postoperative acetaminophen was associated with a significant 3.0 point decrease in self-reported pain.This study represents our early experience. A shift in the institutional mindset of pain control was necessary for adoption of the ERAS protocol. While the ERAS pathway functions to reduce stress and return patients to homeostasis following surgery, postoperative gabapentin resulted in the greatest reduction in postoperative opioid use, self-reported pain, and postoperative nausea vomiting compared to any other modality.
View details for DOI 10.1097/GOX.0000000000002350
View details for Web of Science ID 000486748300015
View details for PubMedID 31592040
View details for PubMedCentralID PMC6756647
- The Spare Parts Anastomosis: Branch Point Spatulation Technique to Alleviate SIEA Mismatch PLASTIC AND RECONSTRUCTIVE SURGERY 2019; 144 (1): 152E–153E
Pedicled and Free Tissue Transfers
CLINICS IN PODIATRIC MEDICINE AND SURGERY
2019; 36 (3): 441-+
Tissue defects that result from diabetic foot infections are often complex and necessitate reconstructive soft-tissue surgery to achieve closure. Intrinsic muscle flaps of the foot require attention to major vascular pedicles and are useful for closing smaller ulcerations. Microvascular free flaps are beneficial for large defects and provide long-term survivability. Perioperative planning is an important aspect of caring for diabetic patients requiring reconstructive surgery. These techniques are valuable tools for use in efforts to preserve a functional limb in this patient population.
View details for DOI 10.1016/j.cpm.2019.03.002
View details for Web of Science ID 000470805100010
View details for PubMedID 31079609
- The Hemirectus/Anterolateral Thigh Chimeric Flap: An Alternative in the Setting of Variable and Unfavorable Vascular Anatomy PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7 (5): e2238
Combining Abdominal Flaps and Implants in the Breast Reconstruction Patient: A Systematic and Retrospective Review of Complications and Outcomes
PLASTIC AND RECONSTRUCTIVE SURGERY
2019; 143 (3): 495E–503E
Implants offer a method for augmenting abdominal flaps in the setting of deficient volume in breast reconstruction. They may be placed immediately at the time of reconstruction or on a delayed basis. The authors seek to compare outcomes from a single surgeon and previously published studies.A systematic review was performed, querying multiple databases. A retrospective review was conducted for patients who underwent abdominally based flap breast reconstruction and implant placement between July of 2005 and August of 2015 performed by the senior author (M.Y.N.).A systematic review of the literature yielded four articles, for a total of 96 patients (142 breasts) included for systematic review. Eighty-seven breasts (61 percent) were reconstructed with immediate implant at the time of flap reconstruction and 55 breasts (39 percent) had a staged approach to implant placement. Complications were noted in 28 breasts (32 percent) following immediate placement and in 10 breasts (18 percent) following staged placement. A total of 53 patients (79 breasts) were retrospectively reviewed, all of whom underwent reconstruction in a staged manner. Twelve breasts (15 percent) were found to have a flap- or implant-related complication; 97.5 percent of implants/flap reconstructions were successful, with a 54 percent revision rate. When pooling systematic and retrospective data, there was a significant difference in complication rates between the staged and immediate reconstruction cohorts (p < 0.001) in favor of the staged approach.The literature supports a higher rate of implant-related complications following immediate implantation at the time of flap reconstruction. The authors' experience with implant placement highlights the safety and effectiveness of the staged approach.Therapeutic, IV.
View details for DOI 10.1097/PRS.0000000000005373
View details for Web of Science ID 000459804400004
View details for PubMedID 30589827
- What Does the Public Think? Examining Plastic Surgery Perceptions through the Twitterverse PLASTIC AND RECONSTRUCTIVE SURGERY 2019; 143 (2): 450E–452E
The Public's Preferences on Plastic Surgery Social Media Engagement and Professionalism: Demystifying the Impact of Demographics
PLASTIC AND RECONSTRUCTIVE SURGERY
2019; 143 (2): 619–30
Social media discussions are alive among plastic surgeons. This article represents a primer on beginning to understand how the public would seek out plastic surgeons and how demographics shape their preferences.An anonymous 31-question survey was crowdsourced by means of MTurk.There were a total of 527 respondents. Of these respondents, 33 percent follow plastic surgeons on social media, with those aged younger than 35 years 3.9 times more likely to do so. Google was the first place people would look for a plastic surgeon (46 percent). When asked what was the most influential of all online methods for selecting a surgeon, practice website ranked first (25 percent), but social media platforms ranked higher as a whole (35 percent). Those considering surgical or noninvasive procedures are thee times more likely to select social media platforms as the most influential online method in selecting a surgeon and five times more likely to follow a plastic surgeon on social media. The majority would prefer not seeing the surgeon's private life displayed on social media (39 percent). Respondents were evenly split regarding whether graphic surgical images would lead them to unfollow accounts. Ninety-six percent of the general public were unclear of the type of board certification a plastic surgeon should hold.Clear differences in engagement and perception exist in the public based on age, sex, parental status, and reported country of origin. Social media will soon become a critical strategy in outreach and engagement and a valuable tool in clearing misconceptions within plastic surgery.
View details for DOI 10.1097/PRS.0000000000005205
View details for Web of Science ID 000474573800083
View details for PubMedID 30688911
Solid organ transplantation in the 21st century
ANNALS OF TRANSLATIONAL MEDICINE
2018; 6 (20): 409
Solid organ transplantation (SOT) has emerged from an experimental approach in the 20th century to now being an established and practical definitive treatment option for patients with end-organ dysfunction. The evolution of SOT has seen the field progress rapidly over the past few decades with incorporation of a variety of solid organs-liver, kidney, pancreas, heart, and lung-into the donor pool. New advancements in surgical technique have allowed for more efficient and refined multi-organ procurements with minimal complications and decreased ischemic injury events. Additionally, immunosuppression therapy has also seen advancements with the expansion of immunosuppressive protocols to dampen the host immune response and improve short and long-term graft survival. However, the field of SOT faces new barriers, most importantly the expanding demand for SOT that is outpacing the current supply. Allocation protocols have been developed in an attempt to address these concerns. Other avenues for SOT are also being explored to increase the donor pool, including split-liver donor transplants, islet cell implantation for pancreas transplants, and xenotransplantation. The future of SOT is bright with exciting new research being explored to overcome current obstacles.
View details for DOI 10.21037/atm.2018.09.68
View details for Web of Science ID 000448472300014
View details for PubMedID 30498736
View details for PubMedCentralID PMC6230860
The Photosynthetic Eukaryote Nannochloris eukaryotum as an Intracellular Machine To Control and Expand Functionality of Human Cells
2014; 14 (5): 2720–25
To construct an intracellular machine, we sought a symbiotic relationship between a photosynthetic green alga and human cells. Human cells selectively take up the minimal eukaryote Nannochloris eukaryotum and the resulting symbionts are able to survive and proliferate. Host cells can utilize N. eukaryotum's photosynthetic apparatus for survival, and expression of cellular vascular endothelial growth factor can be controlled with input of photonic energy. This seemingly rare spontaneous association provides an opportunity to fabricate light-controlled, intracellular machines.
View details for DOI 10.1021/nl500655h
View details for Web of Science ID 000336074800075
View details for PubMedID 24766546