Gordon K. Lee, M.D.
Affiliate, Surgery - Plastic and Reconstructive Surgery
All Publications
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Dynamic insights into infection risk over time in two-stage implant-based breast reconstruction: a retrospective cohort study.
International journal of surgery (London, England)
2024
Abstract
Infections following postmastectomy implant-based breast reconstruction (IBR) can compromise surgical outcomes and lead to significant morbidity. This study aimed to discern the timing of infections in two-stage IBR and associated risk factors.A review of electronic health records was conducted on 1,096 breasts in 1,058 patients undergoing two-stage IBR at ** National University Hospital (2015-2020). Infections following the first-stage tissue expander (TE) insertion and second-stage TE exchange were analyzed separately, considering associated risk factors.Over a median follow-up of 53.5 months, infections occurred in 2.9% (32/1096) after the first stage and 4.1% (44/1070) after the second stage. Infections following the first-stage procedure exhibited a bimodal distribution across time, while those after the second-stage procedure showed a unimodal pattern. When analyzing risk factors for infection after the first-stage procedure, axillary lymph node dissection (ALND) was associated with early (≤7 weeks) infection, while both ALND and obesity were independent predictors of late (>7 weeks) infection. For infections following the second-stage procedure, obesity, postmastectomy radiotherapy, a history of expander infection, ALND, and the use of textured implants were identified as independent risk factors. Postmastectomy radiotherapy was related to non-salvaged outcomes after infection following both stages.Infections following first and second-stage IBR exhibit distinct timelines reflecting different pathophysiology. Understanding these timelines and associated risk factors will inform patient selection for IBR and aid in tailored postoperative surveillance planning. These findings contribute to refining patient suitability for IBR and optimizing personalized postoperative care strategies.
View details for DOI 10.1097/JS9.0000000000001235
View details for PubMedID 38489664
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Prioritizing Native Breast Skin Preservation or Scar Symmetry in Autologous Breast Reconstruction? Using Crowdsourcing to Assess Preference.
Eplasty
2023; 23: e75
Abstract
Recent literature on autologous breast reconstruction suggests that such factors as scar symmetry and skin paddle size impact patient preferences more than preservation of native breast skin. Since patient satisfaction with plastic surgery procedures can be largely influenced by beauty standards set by the general public, this study used a novel crowdsourcing method to evaluate laypeople's aesthetic preferences for different bilateral autologous breast reconstructions to determine the relative importance of scar and skin paddle symmetry and preservation of native skin.Using Amazon's Mechanical Turk crowdsourcing marketplace, participants ranked images of reconstructions based on overall aesthetic appearance. Images were digitally modified to reflect 4 types of reconstruction: immediate (IR), delayed symmetric (DS), delayed asymmetric (DA), or mixed (MR).DS was ranked most favorably (1.74), followed by IR (1.95), DA (2.93), and MR (3.34). Friedman rank sum and pairwise tests showed statistical significance for comparisons of all 4 reconstruction types. Likert ratings were higher for IR than for DA reconstructions for skin quality (P = .002), scar visibility (P < .001), scar position (P < .001), and breast symmetry, shape, and position (P < .001). Ratings increased for all aesthetic factors following nipple-areolar-complex reconstruction (P < .001).More symmetric breast scars were rated aesthetically higher than nonsymmetric scarring, and our participants preferred maintenance of scar symmetry over preservation of native breast skin. These findings are consistent with previous studies that surveyed non-crowdsourced participants, which demonstrates the potential for crowdsourcing to be used to better understand the general public's preferences in plastic surgery.
View details for PubMedID 38229965
View details for PubMedCentralID PMC10790140
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Safety and Sustainability: Optimizing Outcomes and Changing Paradigms in Global Health Endeavors.
Plastic and reconstructive surgery. Global open
2023; 11 (9): e5256
Abstract
The need to address inequities in global surgical care has garnered increased attention since 2015, after the Lancet Commission on Global Surgery underscored the importance of ensuring safe, accessible, affordable, and timely surgical and anesthetic care. The vast unmet global plastic surgery needs make plastic surgery care essential in reducing the global burden of disease. In the past, many nonprofit organizations undertook humanitarian activities within low- and middle-income countries that were primarily service-provision oriented. The Lancet Commission on Global Surgery report prompted a shift in focus from direct patient care models to sustainable global surgical models. The realization that 33% of deaths worldwide were due to unmet surgical needs led to a global shift of strategy toward the development of local systems, surgical capacity, and a focus on patient safety and quality of care within international global surgery partnerships.In this report, the authors explore some of the primary components of sustainable international global surgical partnerships discussed in a recent panel at the American Society of Plastic Surgeons Plastic Surgery The Meeting 2022, titled "Safety and Sustainability Overseas: Optimizing Outcomes and Changing Paradigms in Global Health Endeavors." A literature review elaborating the topics discussed was performed.This report focuses on cultural competence and humility, international collaboration, and the use of technology and innovation, all of which are needed to promote sustainability and patient safety, within global surgery efforts.The adoption of these components into international surgical collaborations will lead to greatly enhancing the development and sustainability of mutually beneficial relationships.
View details for DOI 10.1097/GOX.0000000000005256
View details for PubMedID 37691703
View details for PubMedCentralID PMC10489197
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Radiation-Induced Morphea of the Breast Treated With Wide Local Excision and Abdominal Free Flap Breast Reconstruction.
Eplasty
2023; 23: e50
Abstract
Radiation-induced morphea (RIM) associated with breast cancer treatment is a rare and underdiagnosed skin complication of radiotherapy that can lead to severe and painful contractures, resulting in disfigurement, failure of reconstruction, and poor quality of life in patients. The condition may present on a spectrum of local or more generalized forms involving skin over the breast and anterior chest wall. This diagnosis must be differentiated from post-radiation fibrosis, infection, cancer recurrence, inflammatory breast cancer, and other inflammatory conditions as the clinical course and treatment approaches differ. Various noninvasive and topical agents have been used; however, many cases are refractory to treatment. Surgery has been less commonly described in the management of generalized RIM. This report describes a case of RIM in a patient with breast cancer who experienced simultaneous resolution of symptoms as well as successful breast reconstruction using autologous free-tissue transfer.
View details for DOI 10.1097/01.SMJ.0000140866.97278.87
View details for PubMedID 37664810
View details for PubMedCentralID PMC10472431
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Paradigm Shifts in Alloplastic Breast Reconstruction: A Nationwide Analysis of Direct-To-Implant Trends.
Plastic and reconstructive surgery
2023
Abstract
Direct-to-implant breast reconstruction is an attractive choice for appropriately-selected patients, as a single-stage procedure can enhance global metrics of care. In an era of high-value healthcare, therefore, it is important to investigate utilization of such procedures. This study investigated direct-to-implant trends over the past decade on a nationwide basis.This was a retrospective investigation of direct-to-implant reconstruction between 2010-2018 in the United States, using the National Inpatient Sample (NIS) database. All study analyses were undertaken using Stata v15.0.The weighted sample included 287,093 women who underwent implant-based reconstruction between 2010-2018, of whom 43,064 (15%) underwent direct-to-implant reconstruction. Across the study period, the proportion of direct-to-implant procedures significantly increased (p=0.03), relative to staged and delayed implant-based procedures. While direct-to-implant patients were younger, more likely to be white and privately-insured, the proportion of non-white, publicly-insured patients undergoing direct-to-implant reconstruction significantly increased by 2018 (p<0.05). Furthermore, direct-to-implant utilization amongst Medicaid patients increased at 2.2 times the rate in Medicaid expansion states compared to non-expansion states. Direct-to-implant patients had significantly higher APR-DRG risk scores in 2018 than in 2010 (p=0.02), indicating expanding clinical indications for this procedure. Direct-to-implant reconstruction had significantly lower inpatient charges than staged procedures (p=0.03), when considering expander placement and expander-implant exchange.Overall, utilization of direct-to-implant breast reconstruction has significantly increased over the past decade, facilitated by expanding clinical indications and improved insurance coverage. However, certain disparities continue to exist. Further work should investigate drivers of disparities to allow continued expansion of direct-to-implant reconstruction as clinically appropriate.
View details for DOI 10.1097/PRS.0000000000010826
View details for PubMedID 37352460
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T-Line mesh as a safe and effective option for abdominal wall reinforcement with autologous breast reconstruction.
Journal of plastic, reconstructive & aesthetic surgery : JPRAS
2023; 84: 273-275
View details for DOI 10.1016/j.bjps.2023.06.028
View details for PubMedID 37356303
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Characterizing Clinical Trials in Plastic and Reconstructive Surgery: A Systematic Review of ClinicalTrials.gov From 2007 to 2020.
Annals of plastic surgery
2023; 90 (5S Suppl 3): S287-S294
Abstract
BACKGROUND: Clinical trials form the backbone of evidence-based medicine. ClinicalTrials.gov is the world's largest clinical trial registry, and the state of clinical trials in plastic and reconstructive surgery (PRS) within that database has not been comprehensively studied. To that end, we explored the distribution of therapeutic areas that are under investigation, impact of funding on study design and data reporting, and trends in research patterns of all PRS interventional clinical trials registered with ClinicalTrials.gov.METHODS: Using the ClinicalTrials.gov database, we identified and extracted all clinical trials relevant to PRS that were submitted between 2007 and 2020. Studies were classified based on anatomic locations, therapeutic categories, and specialty topics. Cox proportional hazard was used to calculate adjusted hazard ratios (HRs) for early discontinuation and results reporting.RESULTS: A total of 3224 trials that included 372,095 participants were identified. The PRS trials grew at an annual rate of 7.9%. The therapeutic classes most represented were wound healing (41.3%) and cosmetics (18.1%). Funding for PRS clinical trials is largely provided through academic institutions (72.7%), while industry and US government constituted a minority. Industry-funded studies were more likely to be discontinued early than those funded by academics (HR, 1.89) or government (HR, 1.92) and to be nonblinded and nonrandomized. Academic-funded studies were the least likely to report results data within 3 years of trial completion (odds ratio, 0.87).CONCLUSIONS: A gulf exists in the representation of different PRS specialties among clinical trials. We highlight the role of funding source in trial design and data reporting to identify a potential source of financial waste and to stress the need for continued appropriate oversight.
View details for DOI 10.1097/SAP.0000000000003227
View details for PubMedID 37227408
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A Systematic Review and Meta-Analysis Comparing the Clinical Outcomes of Profunda Artery Perforator Versus Gracilis Thigh Flap as a Second Choice for Autologous Breast Reconstruction.
Annals of plastic surgery
2023; 90 (5S Suppl 3): S256-S267
Abstract
Autologous breast reconstruction remains a versatile option to produce a natural appearing breast after mastectomy. The deep inferior epigastric perforator remains the most commonly used flap choice, but when this donor site is unsuitable or unavailable, the transverse upper gracilis (TUG) or profunda artery perforator (PAP) flaps are popular secondary alternatives. We conduct a meta-analysis to better understand patient outcomes and adverse events in secondary flap selection in breast reconstruction.A systematic search was conducted on MEDLINE and Embase for all articles published on TUG and/or PAP flaps for oncological breast reconstruction in postmastectomy patients. A proportional meta-analysis was conducted to statistically compare outcomes between PAP and TUG flaps.The TUG and PAP flaps were noted to have similar reported rates of success and incidences of hematoma, flap loss, and flap healing (P > 0.05). The TUG flap was noted to have significantly more vascular complications (venous thrombosis, venous congestion, and arterial thrombosis) than the PAP flap (5.0% vs 0.6%, P < 0.01) and significantly greater rates of unplanned reoperations in the acute postoperative period (4.4% vs 1.8%, P = 0.04). Infection, seroma, fat necrosis, donor healing complications, and rates of additional procedures all exhibited high degree of heterogeneity precluding mathematical synthesis of outcomes across studies.Compared with TUG flaps, PAP flaps have fewer vascular complications and fewer unplanned reoperations in the acute postoperative period. There is need for greater homogeneity in reported outcomes between studies to enable for synthesis of other variables important in determining flap success.
View details for DOI 10.1097/SAP.0000000000003226
View details for PubMedID 37227406
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Detecting flap compromise: an updated review of techniques to monitor microsurgical flaps postoperatively in breast reconstruction
PLASTIC AND AESTHETIC RESEARCH
2023; 10
View details for DOI 10.20517/2347-9264.2023.01
View details for Web of Science ID 001221532900025
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Outcomes of Biosynthetic and Synthetic Mesh in Ventral Hernia Repair.
Plastic and reconstructive surgery. Global open
2022; 10 (12): e4707
Abstract
The introduction of mesh for reinforcement of ventral hernia repair (VHR) led to a significant reduction in hernia recurrence rates. However, it remains controversial whether synthetic or biologic mesh leads to superior outcomes. Recently, hybrid mesh consisting of reinforced biosynthetic ovine rumen (RBOR) has been developed and aims to combine the advantages of biologic and synthetic mesh; however, outcomes after VHR with RBOR have not yet been compared with the standard of care.Methods: We performed a retrospective analysis on 109 patients, who underwent VHR with RBOR (n = 50) or synthetic polypropylene mesh (n = 59). Demographic characteristics, comorbidities, postoperative complications, and recurrence rates were analyzed and compared between the groups. Multivariate logistic regression models were fit to assess associations of mesh type with overall complications and surgical site occurrence (SSO).Results: Patients who underwent VHR with RBOR were older (mean age 63.7 versus 58.8 years, P = 0.02) and had a higher rate of renal disease (28.0 versus 10.2%, P = 0.01) compared with patients with synthetic mesh. Despite an unfavorable risk profile, patients with RBOR had lower rates of SSO (16.0 versus 30.5%, P = 0.12) and similar hernia recurrence rates (4.0 versus 6.78%, P = 0.68) compared with patients with synthetic mesh. The use of synthetic mesh was significantly associated with higher odds for overall complications (3.78, P < 0.05) and SSO (3.87, P < 0.05).Conclusion: Compared with synthetic polypropylene mesh, the use of RBOR for VHR mitigates SSO while maintaining low hernia recurrence rates at 30-month follow-up.
View details for DOI 10.1097/GOX.0000000000004707
View details for PubMedID 36530858
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Autologous reconstruction for partial mastectomy defects: outcomes of latissimus versus abdominal flaps
EUROPEAN JOURNAL OF PLASTIC SURGERY
2022
View details for DOI 10.1007/s00238-022-01998-3
View details for Web of Science ID 000866415700001
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Smooth versus textured tissue expanders in breast reconstruction - A retrospective review of post-operative surgical site infections.
Journal of plastic, reconstructive & aesthetic surgery : JPRAS
2022
Abstract
Textured tissue expanders (TTEs) were introduced to limit migration and reduce capsular contracture, which were inherent to smooth tissue expanders (STEs). Previous reports suggest that textured devices have increased rates of bacterial contamination and biofilm formation in comparison with smooth devices. Recently, the relative increased association of anaplastic large cell lymphoma (ALCL) with textured versus smooth devices has led to increased adoption of smooth devices. The aim of our study is to evaluate the post-operative surgical site infection (SSI) rates of STEs versus TTEs.A retrospective case series was conducted at a single academic teaching hospital from April 2016 to December 2019. The primary outcome variable was the development of a post-operative SSI.One hundred seventy-seven breasts underwent reconstruction with TTEs and 109 breasts underwent reconstruction with STE. In total, 54 SSIs were recorded (n = 34 TTE; n = 20 STE), with the majority of infections occurring within the first 30 post-operative days (TTE 65%, STE 70%). There was no statistically significant difference in overall post-operative infection rates between TTE and STE groups when broken down into the following time points: <30 day, 30-60 days, and >90 days (p = 0.924). There was no statistically significant difference between infection type (superficial vs. deep, p = 0.932), infection management (medical, surgical, or both, p = 0.409) or salvage results (p = 0.078) seen in STE versus TTE cohort. On multivariate analysis, seroma history was associated with SSI development (OR 3.18, p = 0.041).There was no significant difference in the rate of post-operative SSI following breast reconstruction with STE relative to TTE.
View details for DOI 10.1016/j.bjps.2022.04.087
View details for PubMedID 35768293
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Air versus Saline: The Effect of Tissue Expander Fill on Outcomes of Prepectoral Breast Reconstruction.
Plastic and reconstructive surgery
2022
Abstract
BACKGROUND: Traditionally, saline is used for intraoperative/postoperative expansion in two-stage alloplastic breast reconstruction. Recently, intraoperative expansion with air has been proposed, to reduce pressure on the mastectomy skin flap in the immediate postoperative setting. The authors examined whether the intraoperative tissue expansion medium (i.e., air versus saline) affected postmastectomy complications in two-stage prepectoral reconstruction.METHODS: This was a retrospective cohort study of 87 patients (144 breasts) undergoing prepectoral breast reconstruction at the authors' institution. Patient data were abstracted from medical records. Stepwise, multivariable-adjusted logistic regression using robust variances was used to identify predictors of postmastectomy complications. Statistical and power analyses were completed.RESULTS: Of the 87 study patients, 29 (33.3 percent) received intraoperative saline fill and 58 (66.7 percent) received air fill. Demographic/clinical data were well-matched between cohorts. Median follow-up was 165 days, and average patient age was 46.7 years. Initial tissue expander fill volumes were similar between study cohorts (p = 0.2). The crude association between air versus saline fill on overall complication rates suggested that air-filled tissue expanders may be protective (OR = 0.4; p = 0.03), and the suggested protective effect was maintained with borderline significance even after potential confounders (i.e., American Society of Anesthesiologists class III or higher, body mass index, diabetes, mastectomy specimen weight, smoking status) were added to the model (OR = 0.4; p = 0.05). In addition, fewer complications requiring salvage reoperation were observed with air-filled tissue expanders (adjusted OR = 0.3; p = 0.02).CONCLUSIONS: The medium used for immediate intraoperative tissue expansion impacted postmastectomy outcomes in patients undergoing two-stage prepectoral breast reconstruction. The results demonstrated that air-filled tissue expanders were associated with fewer postoperative complications/salvage reoperations relative to saline-filled tissue expanders.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
View details for DOI 10.1097/PRS.0000000000009191
View details for PubMedID 35499585
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The Price of Publishing: An Investigation of the Open Access Landscape in Plastic Surgery.
Plastic and reconstructive surgery
2022
Abstract
BACKGROUND: Open access publishing in plastic surgery has rapidly gained traction in the past decade. This study investigated the digital landscape of plastic surgery open access publishing.METHODS: This was a cross-sectional bibliometric investigation of plastic surgery-focused journals. Three publication models were investigated: subscription-only journals, hybrid journals offering both paywalled and open access publishing, and open access-only journals.RESULTS: Eighty-two journals were investigated. In 2010, open access journals comprised 18 percent of all plastic surgery journals online, subscription journals comprised 79 percent, and hybrid journals comprised 3 percent. Conversely, in 2020, open access journals comprised 55 percent of all journals, hybrid journals comprised 45 percent, and there were no subscription-only journals. Multivariable linear regression adjusting for article type/content demonstrated that open access articles from hybrid journals [beta coefficient, 1.3; F(4, 18) = 790; p = 0.05] and high-quality open access journals [beta coefficient, 0.9; F(4, 19) = 738; p = 0.04] were significantly positively associated with number of full-text views. Although impact factor and article processing charges were positively correlated [Pearson correlation coefficient: r(25) = 0.39, p = 0.04] for open access publishing, some high-quality open access journals were found to offer fee waivers/free publishing. Lastly, level of evidence offered by articles from open access versus hybrid journals differed.CONCLUSIONS: Overall, this study highlighted important distinctions between trustworthy and predatory journals offering open access publishing in plastic surgery. Open access publishing in trustworthy sources offers greater visibility and is not necessarily cost-prohibitive, but some open access journals can be limited in scope (i.e., less coverage of subspecialty topics) and quality of content. Study findings were used to generate recommendations for navigating open access publishing in plastic surgery.
View details for DOI 10.1097/PRS.0000000000009016
View details for PubMedID 35311801
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Reinforced Biologic Mesh Reduces Postoperative Complications Compared to Biologic Mesh after Ventral Hernia Repair.
Plastic and reconstructive surgery. Global open
2022; 10 (2): e4083
Abstract
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
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Combining Breast and Ovarian Operations Increases Complications.
Plastic and reconstructive surgery
2022
Abstract
Breast cancer resulting from a genetic mutation, such as BRCA1 or BRCA2, is seen in 5 to 10 percent of patients. More widespread genetic testing has increased the number of affected women undergoing prophylactic mastectomy and oophorectomy. Recent studies have yielded mixed results regarding complication rates after combined breast and ovarian operations. The authors compared surgical outcomes of breast operations performed in combination with salpingo-oophorectomies or as separate procedures.The authors retrospectively analyzed surgical complications and length of hospital stay in 145 female patients, from which 87 had undergone combined breast surgery and salpingo-oophorectomy, and 58 had undergone these procedures separately. Multivariate logistic regression models were used to calculate odds ratios and 95 percent confidence intervals.Patients undergoing combined breast and ovarian operations experienced higher rates of overall complications (46.5 percent versus 19 percent; p < 0.001), infections (22.2 percent versus 8.6 percent; p < 0.05), and delayed wound healing (13.2 percent versus 0 percent; p < 0.05) related to the breast surgery, when compared with patients undergoing separate procedures. Multivariate logistic regression analysis confirmed a significant association between combined surgery and overall postoperative complications (OR, 5.87; 95 percent CI, 2.03 to 16.91; p = 0.02). Patients undergoing tissue expander-based breast reconstruction combined with ovarian surgery had significantly longer hospital stays compared to patients undergoing separate procedures (3.5 days versus 1.8 days; p < 0.001).The authors' data indicate that combining breast and ovarian operations is associated with a higher risk of postoperative complications related to the breast procedure and increases the duration of hospital stay in patients with tissue expander-based reconstructions. The authors' study provides valuable information for preoperative counseling of patients considering both breast and ovarian surgery.Therapeutic, III.
View details for DOI 10.1097/PRS.0000000000008984
View details for PubMedID 35245249
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Single Institution's Plastic Surgery Case Trends and Considerations in the Midst of COVID-19.
Plastic and reconstructive surgery
2021
View details for DOI 10.1097/PRS.0000000000008657
View details for PubMedID 34878421
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The Plane of Mesh Placement Does Not Impact Abdominal Donor Site Complications in Microsurgical Breast Reconstruction.
Annals of plastic surgery
2021; 87 (5): 542-546
Abstract
BACKGROUND: Reinforcement of the abdominal wall with synthetic mesh in autologous breast reconstruction using abdominal free tissue transfer decreases the risk of bulging and herniation. However, the impact of the plane of mesh placement on donor site complications has not yet been investigated.METHODS: We performed a retrospective analysis of 312 patients who had undergone autologous breast reconstruction with muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps or deep inferior epigastric perforator (DIEP) flaps as well as polypropylene mesh implantation at the donor site. Donor site complications were compared among patients with different flap types and different mesh positions including overlay (n = 90), inlay and overlay (I-O; n = 134), and sublay (n = 88).RESULTS: Abdominal hernias occurred in 2.86% of patients who had undergone MS-TRAM reconstructions and in 2.63% of patients who had undergone DIEP reconstructions. When comparing patients with different mesh positions, donor site complications occurred in 14.4% of patients with overlay mesh, 13.4% of patients with I-O mesh, and 10.2% of patients with sublay mesh (P = 0.68). Abdominal hernias occurred in 4.44% of patients with overlay mesh, 2.24% of patients with I-O mesh, and 2.27% of patients with sublay mesh (P = 0.69). Multivariable logistic regression analysis did not identify a significant association between mesh position and hernia rates as well as wound complications.CONCLUSIONS: Our data indicate that the plane of synthetic mesh placement in relation to the rectus abdominis muscle does not impact the rate of postoperative donor site complications in patients undergoing breast reconstruction with MS-TRAM or DIEP flaps.
View details for DOI 10.1097/SAP.0000000000002897
View details for PubMedID 34699433
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Pyoderma Gangrenosum After Bilateral Total Knee Arthroplasty.
Arthroplasty today
2021; 11: 73-79
Abstract
Pyoderma gangrenosum is a neutrophilic dermatosis, which mimics both infection and necrotizing fasciitis, that can present after surgical interventions. We present the case of a 62-year-old male who underwent one-stage bilateral total knee arthroplasty. Nine days after the surgery, he presented with wound breakdown, high fever, and elevated white blood cell count. Repeated debridement was performed, and empiric antibiotics were given. All tissue cultures and aspirates remained negative throughout treatment course, and the patient remained unresponsive to therapy. The patient was eventually diagnosed with pyoderma gangrenosum after infectious etiologies were ruled out and after a skin biopsy and dermatologic consultation. His condition rapidly improved after treatment with corticosteroids, and soft-tissue defects were repaired with skin substitute and full-thickness skin grafting. In patients with aseptic wound breakdown after total knee arthroplasty, pyoderma gangrenosum is a rare but devastating complication and should be considered.
View details for DOI 10.1016/j.artd.2021.07.003
View details for PubMedID 34485653
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Examining the Effects of Postmastectomy Radiation Therapy in Prepectoral Versus Subpectoral Autologous Breast Reconstruction.
Annals of plastic surgery
2021; 86 (5S Suppl 3): S390–S394
Abstract
BACKGROUND: Postmastectomy radiation therapy (PMRT) is known to increase the risk of multiple adverse outcomes after breast reconstruction. In the context of delayed-immediate autologous breast reconstruction, PMRT is typically conducted after placement of subpectoral (SP) tissue expanders. With the re-emergence of prepectoral (PP) reconstruction, there are little data assessing the outcomes of PP reconstruction in breasts receiving PMRT. We compared postoperative outcomes of PMRT patients undergoing delayed-immediate, autologous breast reconstruction with placement of tissue expanders in either the PP or SP plane.METHODS: A retrospective chart review was conducted on all consecutive patients who underwent delayed-immediate autologous breast reconstruction and received PMRT at either the Stanford University or the Johns Hopkins University Hospitals between January 2009 and December 2018. Demographics, comorbidities, perioperative information, and oncologic data were collected for all patients. Complications were collected and analyzed after stage 1 surgery, between 30 days of stage 1 and up to stage 2 surgery, and after stage 2 surgery. Multivariable regressions were used to determine predictors of 1 or more complications.RESULTS: A total of 71 patients (73 breasts) were included. Prepectoral reconstruction comprised of 52.2% of the cohort, and the remaining 47.8% were SP reconstructions. Demographics and comorbidities were similar between groups, except for premastectomy radiation, which was more prevalent in the PP cohort (P = 0.010). Complications were similar between cohorts after stage 1 surgery (P = 0.420), between stages 1 and 2 (P = 0.100), and after stage 2 (P = 0.570). There were higher rates of skin necrosis in the SP cohort between stages 1 and 2 (PP: 2.6%, SP: 20%, P = 0.004). Multivariable analysis revealed body mass index to be the only predictor of complication (P = 0.041). The mean number of revisionary surgeries was higher in the SP cohort (PP: 0.8 vs SP: 1.9, P = 0.002). The mean follow-up was 385.5 days and similar between groups (P = 0.870).CONCLUSIONS: Rates of overall complication were similar between PP and SP expander placement. However, in SP reconstructions, skin necrosis was significantly higher between stages 1 and 2. The patients in the SP cohort also underwent a greater number of revisionary surgeries, although overall rates of pursuing any revisionary surgery were similar between groups.
View details for DOI 10.1097/SAP.0000000000002762
View details for PubMedID 33976068
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Comparing Outcomes of Flap-Based Salvage Reconstructions in the Radiated Breast.
Annals of plastic surgery
2021; 86 (5S Suppl 3): S403–S408
Abstract
INTRODUCTION: Chest wall irradiation significantly decreases the strength and quality of breast tissue supporting prostheses, increasing the risk of skin breakdown and implant or tissue expander extrusion. Autologous tissue, including the latissimus dorsi (LD) or abdominal-based flaps, including the muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps, may be used to salvage reconstructions. However, data comparing outcomes of the two flap options remains limited. We compare postoperative outcomes from both flap types after autologous salvage reconstruction in irradiated breasts.METHODS: Charts were retrospectively reviewed from patients who underwent either chest wall radiation or postmastectomy radiation therapy followed by salvage autologous reconstruction with either a LD and an implant or an abdominal-based flap (muscle-sparing transverse rectus abdominis myocutaneous or deep inferior epigastric perforator flaps). Patients with a history of tissue expander or implant failure requiring autologous salvage as part of 2-staged or delayed-immediate breast reconstruction that were operated on between January 2005 and November 2015 were included. Basic demographics, comorbidities, and recipient site complications (infection, wound dehiscence, seroma, hematoma, fat necrosis, and flap failure) were collected.RESULTS: A total of 72 patients met the inclusion criteria which included 72 flaps; 35 LD and 37 abdominally based flaps. Demographics and comorbidities did not vary significantly between patient groups. Mean follow-up was 767.6 weeks, and all reconstructions were unilateral. Nineteen (26.4%) patients had at least one complication, most commonly minor infections (9.7%). Overall complication rates were not significantly different between flap groups (P = 0.083). Wound dehiscence was significantly higher in the abdominal group (P = 0.045), and fat necrosis also trended higher in this group (P = 0.085). Major infection trended higher in the latissimus group (P = 0.069).CONCLUSIONS: When comparing outcomes of salvage flap-based reconstruction in radiated breast tissue, overall complication rates were similar when comparing postoperative outcomes between the LD- and abdominal-based flaps. Wound dehiscence was significantly higher when salvage reconstruction used an abdominal flap. Understanding the complications after salvage procedures can help inform decision making and optimize patient care to improve outcomes after breast reconstruction in the radiated breast.
View details for DOI 10.1097/SAP.0000000000002761
View details for PubMedID 33976069
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Response to: "Commentary on Delayed, two-staged autologous breast reconstruction: an approach to improving delayed reconstructive outcomes" by Mantelakis A, Kazzazi D, Bloom O, Gallagher M, Weale R & Geh J
EUROPEAN JOURNAL OF PLASTIC SURGERY
2021
View details for DOI 10.1007/s00238-021-01811-7
View details for Web of Science ID 000632787300001
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Revision Rates in Prepectoral Versus Subpectoral Delayed-Immediate Autologous Breast Reconstruction.
Annals of plastic surgery
2021
Abstract
INTRODUCTION: Breast reconstruction in the prepectoral plane has recently fallen into favor. Minimizing the number of revisionary procedures after reconstruction is an important factor in improving patient care, but long-term studies on the effects of prepectoral reconstruction are limited. In this study, we compare the revision rates after delayed-immediate, autologous reconstruction between prepectoral and subpectoral reconstructions.METHODS: Postoperative charts for all patients undergoing subpectoral or prepectoral delayed-immediate autologous breast reconstruction were retrospectively reviewed at our single tertiary-care institution between 2009 and 2018. Patient demographics, comorbidities, and oncologic history were recorded. Charts after second stage reconstruction were reviewed for up to eighteen months to determine if revisions were necessary. Data collected included the total number of surgeries performed, the average number of procedures performed during each surgery, and the type of revision that was performed. Statistical tests included the chi squared test, unpaired t-test, and logistic regressions.RESULTS: Data from 89 patients with 125 breast reconstructions were collected. There was a 41.6% of these that were prepectoral reconstructions (P), and 58.4% were subpectoral reconstructions (S). For both groups, nipple sparing, followed by skin sparing mastectomies were most common. Mastectomy rates were not statistically different. Fewer breasts in the prepectoral cohort required any revisions (P, 21.2% vs S, 47.9%; P = 0.002). The subpectoral cohort had higher rates of soft tissue rearrangement (P, 7.7% vs S, 21.9%, P = 0.032), fat grafting (P, 9.6% vs S, 27.4%; P = 0.014), and nipple reconstruction (P: 5.8% vs 20.5%, P = 0.020). Mean follow-up time was not significantly different between patient groups (P, 290.5 days vs S, 375.0 days, P = 0.142). Subpectoral expander placement was found to be the only variable independently predictive of requiring 1 or more revision (P = 0.034).CONCLUSIONS: Breast reconstruction performed in the prepectoral plane is associated with lower overall rates of revisionary surgery. Rates of soft tissue rearrangement, fat grafting, and nipple reconstruction after autologous reconstruction trended higher in subpectoral reconstructions.
View details for DOI 10.1097/SAP.0000000000002760
View details for PubMedID 33833169
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Autologous Fat Grafting and the Occurrence of Radiation-Induced Capsular Contracture.
Annals of plastic surgery
2021
Abstract
INTRODUCTION: Radiation therapy is a known risk factor for capsular contracture formation after implant-based breast reconstruction. Although autologous fat grafting (AFG) has been shown to reverse radiation-induced tissue fibrosis, its use as a prophylactic agent against capsular contraction has not been assessed in the clinical setting. In the setting of 2-stage implant-based reconstruction and postmastectomy radiation therapy, we explored the effect AFG has on the prevalence of capsular contracture.MATERIALS AND METHODS: A retrospective chart review of patients who underwent immediate tissue expander (TE) placement followed by postmastectomy radiation therapy and secondary implant-based reconstruction at our institution between January 2012 and December 2019 was performed. Patients were divided into 2 cohorts based on whether or not AFG was performed at the time of secondary reconstruction. The primary outcome of interest was the occurrence of capsular contracture after TE exchange.RESULTS: Overall 57 patients (57 breasts) were included, 33 of whom received AFG at the time of TE exchange. All but 1 patient underwent submuscular implant placement, and the mean follow-up was 1.96 years. There was no significant difference in the prevalence of medical comorbidities between the study groups.Capsular contracture occurred in 24 patients (42.1%). Seventeen of these patients had undergone AFG at the time of TE exchange (17/33 patients, 51.5%), and 7 of these patients had not (7/24 patients, 29.2%). Most of the capsular contracture cases were Baker grades III or IV (14 patients, 58.3%), and 50% of patients with capsular contracture of any grade ultimately required operative intervention. Multivariate logistic regression analysis demonstrated that AFG did not significantly influence the occurrence or severity of capsular contracture, or did not impact the need for operative intervention in this patient population.CONCLUSIONS: Implant-based reconstruction of the irradiated breast is associated with high postoperative capsular contracture rates. Although AFG has shown promise in reversing radiation-induced dermal fibrosis, no protective effect on the development of capsular contracture after stage 2 reconstruction was observed in this study population. Further investigation in the form of randomized, prospective studies is needed to better assess the utility of AFG in preventing capsular contracture in irradiated patients.
View details for DOI 10.1097/SAP.0000000000002817
View details for PubMedID 33833172
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Representation of Women on Plastic Surgery Journal Editorial Boards in the United States.
Aesthetic surgery journal
2021
Abstract
BACKGROUND: During the past decade, a growing number of women have pursued medical careers, including in plastic surgery. However, woman physicians have tended to be underrepresented in a variety of leadership roles in their respective specialties.OBJECTIVE: We sought to evaluate the representation of female plastic surgeons on the editorial boards of high impact plastic surgery journals.METHODS: The gender of editorial board members on three high impact plastic surgery journals was evaluated from 2009 and 2018. The number of women on each editorial board was than compared to the number of board certified female plastic surgeons (BCFPS) and board certified female academic plastic surgeons (BCFAPS), a subgroup of BCFPS.RESULTS: There were 555 unique editorial board members from Plastic & Reconstructive Surgery (PRS), Aesthetic Surgery Journal (ASJ), and Annals of Plastic Surgery (APS) from 2009 to 2018. During that period, 72 editors (13.0%) were women. At the beginning of the study, there were significantly fewer female editors than expected based on proportionate representation of BCFPS and BCFAPS to all board certified Plastic Surgeons (ABCPS) (p=0.007, 0.007 respectively). Over the course of the study there has been a 177% increase in women holding editorial board positions. At the end of the study period, women were adequately represented on all three editorial boards compared to their population data (BCFPS and BCFAPS).CONCLUSIONS: Over the ten year period of this study (2009-2018), editorial boards have overcome the underrepresentation of women on their editorial boards and female plastic surgeons are currently adequately represented on the top three high impact journal editorial boards.
View details for DOI 10.1093/asj/sjab034
View details for PubMedID 33491085
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Reply: Where Do We Look? Assessing Gaze Patterns in Cosmetic Face-Lift Surgery with Eye Tracking Technology.
Plastic and reconstructive surgery
2020; 146 (6): 821e-822e
View details for DOI 10.1097/PRS.0000000000007375
View details for PubMedID 33234991
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'What is Your Reality? - Virtual, Augmented, and Mixed Reality in Plastic Surgery Training, Education, and Practice '.
Plastic and reconstructive surgery
2020
Abstract
Virtual reality and other technological advancements both inside and outside the operating room have shown an exponential increase in the past two decades. Surgical techniques and finesse in delicate procedures has become ever more important and the onus is on plastic surgeons and plastic surgery residents to meet these needs to provide the best outcomes possible to patients. The ability to learn, simulate, and practice operating in a fashion that poses no harm to any patient is truly a gift from technology to surgery that any surgeon could benefit from, whether trainee or attending. This application of technology and simulation has been demonstrated in other fields such as in the airline industry with flight simulation. The ability to learn, synthesize, and incorporate learned materials and ideas through virtual, augmented, and mixed reality tools offers a great opportunity to put our field at the forefront of a paradigm shift in surgical education. The critical utility of digital education could not be further emphasized any more than in the unfortunate and infrequent situation of a world-wide pandemic. This article reviews some of the important recent technologies that have developed and their applications in plastic surgery education and offers a look into what we can expect in the future.
View details for DOI 10.1097/PRS.0000000000007595
View details for PubMedID 33235047
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A Protocol for Safe Head and Neck Reconstructive Surgery in the COVID-19 Pandemic.
Plastic and reconstructive surgery. Global open
2020; 8 (11): e3258
Abstract
The COVID-19 pandemic has had significant implications for citizens globally and for the healthcare system, including plastic surgeons. Operations of the upper aerodigestive tract, including head and neck reconstruction and craniomaxillofacial procedures, are of particularly high risk because they may aerosolize the virus and lead to severe surgeon and surgical team illness. Until the virus is eradicated or widespread vaccination occurs, we recommend certain precautions to safely perform these operations. We propose evolving algorithms for head and neck reconstruction and facial trauma surgeries to maintain provider safety. Central to these guidelines are preoperative COVID-19 testing, appropriate personal protective equipment, and operative techniques/principles that minimize operative time and aerosolization of the virus. We aim to provide efficient care to our patients throughout this pandemic, while maintaining the safety of plastic surgeons and other healthcare providers.
View details for DOI 10.1097/GOX.0000000000003258
View details for PubMedID 33299720
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The safety and efficacy of autologous fat grafting during second stage breast reconstruction.
Journal of plastic, reconstructive & aesthetic surgery : JPRAS
2020
Abstract
BACKGROUND: Patients often pursue revisions following implant-based breast reconstruction (IBR) to achieve their desired result. Fat grafting is a popular choice for patients and can be performed at second stage reconstruction or at a future date as a revisionary surgery. We investigate the best time to fat graft in IBR by comparing the outcomes of patients who received fat grafting during implant placement with those who pursued fat grafting during a tertiary procedure.METHODS: We retrospectively reviewed the charts of 157 patients (270 breasts) who underwent immediate two-stage IBR and fat grafting over a five-year period (2012-2016) at our institution. Two cohorts were created based on timing of first fat grafting procedure: immediate (IFG) and delayed (DFG). Charts were reviewed for postoperative complications or revisions.RESULTS: Complication rates were lower when fat grafting was performed during the second stage (p = 0.0331). Patients in the DFG cohort required more than one additional revision (p < 0.001) until the completion of reconstruction. Patients in the IFG cohort completed their reconstruction and revisions more than one year earlier than the DFG cohort (p < 0.001). Multivariable regressions showed IFG to be associated with decreased revisions (p < 0.001) and total fat grafting procedures (p = 0.008).CONCLUSIONS: These results indicate that fat grafting at the second stage does not increase overall complication rates, require fewer additional surgeries, and enables patients to reach their desired aesthetic appearance in a shorter time frame. Fewer total surgeries translate not only to a more economical option but also obviate the risk of complications that come with additional surgeries.
View details for DOI 10.1016/j.bjps.2020.10.008
View details for PubMedID 33189618
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Air vs Saline: Effect of Tissue Expander Fill Prepectoral Breast Reconstruction Postoperative Complication
ELSEVIER SCIENCE INC. 2020: E81
View details for Web of Science ID 000582798100160
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Postoperative Complication Rates after Combined Breast and Gynecologic Surgeries
ELSEVIER SCIENCE INC. 2020: S39–S40
View details for Web of Science ID 000582792300051
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Development of a Classification Tree to Predict Implant-Based Reconstruction Failure with or without Postmastectomy Radiation Therapy for Breast Cancer.
Annals of surgical oncology
2020
Abstract
PURPOSE: The aim of this study was to determine the complications, incidence, and predictors of implant-based reconstruction failure (RF) among patients treated with mastectomy for breast cancer.METHODS: We retrospectively reviewed 108 patients who underwent mastectomy, tissue expander, and implant-based breast reconstruction with or without radiation therapy (RT) at our institution (2000-2014). Descriptive statistics determined complication incidences, with major complications defined as any complications requiring surgical intervention or inpatient management. Chi square and Fisher's exact tests determined differences in RF incidences, defined as implant loss. Logistic regression analyses identified predictors of RF.RESULTS: Median follow-up was 42.5months. Sixty patients (55.6%) experienced major complications. Overall, 27 patients (25%) experienced RF. Incidences of RF were significantly increased in patients who had any major complication (43.3% vs. 2.1%; p<0.0001), especially infection (61.3% vs. 10.4%; p<0.0001), delayed wound healing (83.3% vs. 21.7%; p=0.004), and implant exposure (80.0% vs. 19.4%; p=0.0002). Receiving RT, but not timing of RT, significantly predicted RF [odds ratio (OR) 4.00, 95% confidence interval (CI) 1.11-14.47; p=0.03]. On multivariable analysis, infection (OR 7.69, 95% CI 2.12-27.89; p=0.002) and delayed wound healing (OR 17.86, 95% CI 1.59-200.48; p=0.02) independently predicted for RF. Our newly developed classification tree, which includes stepwise assessment of major infection, delayed wound healing, implant exposure, age ≥50years, and total number of lymph nodes removed ≥10, accurately predicted 74% of RF events and 75% of non-RF events.CONCLUSIONS: Infection or delayed wound healing requiring surgical intervention or hospitalization and receipt of RT, but not radiation timing, were significant predictors of RF. Our classification tree demonstrated >70% accuracy for stepwise prediction of RF.
View details for DOI 10.1245/s10434-020-09068-3
View details for PubMedID 32875465
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A 20-year tertiary cancer center's experience utilizing the pedicled gracilis myocutaneous flap
EUROPEAN JOURNAL OF PLASTIC SURGERY
2020
View details for DOI 10.1007/s00238-020-01692-2
View details for Web of Science ID 000535380200003
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European Attitudes and Outcomes Regarding Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Multinational Survey.
Aesthetic plastic surgery
2020
Abstract
BACKGROUND: Breast implants have been related to breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). While some research has been conducted to study BIA-ALCL incidence, little is known regarding surgeon concern about the disease.OBJECTIVES: This study aims to determine surgeon concern about BIA-ALCL within the European plastic surgeon community as related to their practice of breast plastic surgery.METHODS: A 27-question online survey was sent to 2353 members of the European Plastic Surgery Society and EURAPS. 240 surgeons responded (10.2%) from 18 different societies. Questions were related to demographics, exposure to BIA-ALCL cases, clinical practices, awareness, and concern. Univariate and multivariable analyses were used.RESULTS: Of surveyed surgeons, 8% had encountered a case of BIA-ALCL, while 73% were concerned about the disease. The rate of concern seemed to be influenced by seven of the variables studied. However, multivariate analysis demonstrated that none of the combined variables analyzed predicted concern or disclosure of the risks of BIA-ALCL to patients. Textured silicone-filled implants were implicated in the disease (56.5% of cases, P=0.005). Mentor and Polytech were the two brands involved in most of the reported cases (20% each).CONCLUSIONS: Consistent with epidemiological reports worldwide, this study confirms that BIA-ALCL is more prevalent in patients undergoing placement of textured silicone implants, the use of which was greater among surgeons not concerned about the risks of BIA-ALCL. Surgeons appear to approach their patients with similar risk disclosures regardless of practice pattern and type of breast implant used, but not regardless of their concern about the disease.LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
View details for DOI 10.1007/s00266-020-01736-9
View details for PubMedID 32367324
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Surgical Treatment of Lymphedema.
JAMA surgery
2020
View details for DOI 10.1001/jamasurg.2020.0015
View details for PubMedID 32211838
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Reply: Where Do We Look? Assessing Gaze Patterns in Cosmetic Face-Lift Surgery with Eye Tracking Technology.
Plastic and reconstructive surgery
2020; 145 (2): 451e–452e
View details for DOI 10.1097/PRS.0000000000006437
View details for PubMedID 31985679
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Analysis and Interpretation of Google Trends Data on Public Interest in Cosmetic Body Procedures
AESTHETIC SURGERY JOURNAL
2020; 40 (1): NP34–NP43
View details for DOI 10.1093/asj/sjz051
View details for Web of Science ID 000562332200007
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Global Health Microsurgery Training With Cell Phones.
Annals of plastic surgery
2020; 84 (5S Suppl 4): S273–S277
Abstract
Lack of surgical care for trauma, burns, congenital anomalies, and other surgical diseases is a growing portion of global disability and death accounting for 30% of the global disease burden. Global surgical and anesthesia care aim to achieve excellence and equality of clinical care through leadership, innovation, teaching, research, and advocacy. Stanford University Division of Plastic Surgery faculty partnered with ReSurge International to teach reconstructive microsurgery in low- and middle-income countries.Global surgery teaching and training are challenged by limited resources. Surgical loupes and operating microscopes used to perform complex microsurgery magnify the surgical field are very expensive. Our goal was to identify low-cost alternatives to teach and practice microsurgery suturing.Use cell phone camera with zoom capacity to teach and practice microsurgery suturing.Cell phones with zoom feature are widely available even in low- and middle-income countries. A cell phone was placed on a stand over a microsurgery practice station. The camera was used to zoom and focus on the suturing station to mimic a surgical field with loupes or microscope magnification. Nine attending surgeons and 7 residents practiced microsurgery with microsurgical instruments and 9-0 nylon suture under the magnification of a cell phone camera. The Stanford Microsurgery and Resident Training Scale was used to track their progress. A feedback survey was given to the participants to identify the usefulness of the cell phone setup for microsurgery suture practice.Global surgery teaching and training face many challenges especially limited resources. Identifying low-cost alternative is crucial. Cell phone camera with zoom is a low-cost alternative to loupes or operating microscope for microsurgical teaching and training.
View details for DOI 10.1097/SAP.0000000000002403
View details for PubMedID 32294075
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Comparing Prepectoral Versus Subpectoral Tissue Expander Placement Outcomes in Delayed-Immediate Autologous Breast Reconstruction.
Annals of plastic surgery
2020; 84 (5S Suppl 4): S329–S335
Abstract
Delayed-immediate breast reconstruction has traditionally involved placement of tissue expanders (TE) in the subpectoral (SP) position. Development of acellular dermal matrices has renewed interest in the prepectoral (PP) pocket, which avoids extensive muscle manipulation. We compare complication rates between PP and SP TE placement in autologous delayed-immediate breast reconstruction.A retrospective chart review of patients undergoing autologous, delayed-immediate breast reconstruction at our institution (June 2009 to December 2018) was performed. Demographics, comorbidities, perioperative information, and complication incidence ≤12 months' follow-up were collected from first- and second-stage surgeries. Complications were modeled using univariable and multivariable binary logistic regressions.A total of 89 patients met the inclusion criteria, and data from 125 breast reconstructions were evaluated. Complication rates following TE placement trended lower in the PP cohort (28.8% vs 37%, P = 0.34). Overall complication rates following autologous reconstruction were significantly lower for PP reconstructions (7.7% vs 23.3%, P = 0.02). Multivariable regression showed TE position (P = 0.01) was a significant predictor of ≥1 complication following autologous reconstruction. Time delay between first- and second-stage surgeries was greater for SP reconstructions (199.7 vs 324.8 days, P < 0.001). Postoperative drains were removed earlier in the PP cohort (8.6 vs 12.0 days, P < 0.001). Mean follow-up time was 331.3 days.Prepectoral reconstruction in the delayed-immediate autologous reconstruction patient leads to significantly lower complication rates, shorter duration between first- and second-stage surgeries, and shorter times before removal of breast drains compared with SP reconstructions.
View details for DOI 10.1097/SAP.0000000000002402
View details for PubMedID 32294076
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Where Do We Look? Assessing Gaze Patterns in Cosmetic Facelift Surgery with Eye Tracking Technology.
Plastic and reconstructive surgery
2020
View details for DOI 10.1097/PRS.0000000000007375
View details for PubMedID 32947525
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Reply: Where Do We Look? Assessing Gaze Patterns in Cosmetic Face-Lift Surgery with Eye Tracking Technology.
Plastic and reconstructive surgery
2020; 145 (6): 1104e
View details for DOI 10.1097/PRS.0000000000006825
View details for PubMedID 32464032
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Assessing the Accuracy of a 3-Dimensional Surface Imaging System in Breast Volume Estimation.
Annals of plastic surgery
2020
Abstract
Preoperative prediction of breast volume can guide patient expectations and aid surgical planning in breast reconstruction. Here, we evaluate the accuracy of a portable surface imager (Crisalix S.A., Lausanne, Switzerland) in predicting breast volume compared with anthropomorphic estimates and intraoperative specimen weights.Twenty-five patients (41 breasts) undergoing mastectomy were scanned preoperatively with the Crisalix surface imager, and 1 of 3 attending plastic surgeons provided an anthropomorphic volume estimate. Intraoperative mastectomy weights were used as the gold standard. Volume conversions were performed assuming a density of 0.958 g/cm.The Pearson correlation coefficient between imager estimates and intraoperative volumes was 0.812. The corresponding value for anthropomorphic estimates and intraoperative volumes was 0.848. The mean difference between imager and intraoperative volumes was -233.5 cm, whereas the mean difference between anthropomorphic estimates and intraoperative volumes was -102.7 cm. Stratifying by breast volume, both surface imager and anthropomorphic estimates closely matched intraoperative volumes for breast volumes 600 cm and less, but the 2 techniques tended to underestimate true volumes for breasts larger than 600 cm. Stratification by plastic surgeon providing the estimate and breast surgeon performing the mastectomy did not eliminate this underestimation at larger breast volumes.For breast volumes 600 cm and less, the accuracy of the Crisalix surface imager closely matches anthropomorphic estimates given by experienced plastic surgeons and true volumes as measured from intraoperative specimen weights. Surface imaging may potentially be useful as an adjunct in surgical planning and guiding patient expectations for patients with smaller breast sizes.
View details for DOI 10.1097/SAP.0000000000002244
View details for PubMedID 32032116
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Commentary on: The Impact of Mastectomy on Women's Visual Perception of Breast Aesthetics and Symmetry: A Pilot Eye-Tracking Study.
Aesthetic surgery journal
2019
View details for DOI 10.1093/asj/sjz332
View details for PubMedID 31886480
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Response to Letter to the Editor: Where Do We Look? Assessing Gaze Patterns in Cosmetic Facelift Surgery with Eye Tracking Technology.
Plastic and reconstructive surgery
2019
View details for DOI 10.1097/PRS.0000000000006437
View details for PubMedID 31834272
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A Quantitative Analysis of Online Plastic Surgeon Reviews for Abdominoplasty.
Plastic and reconstructive surgery
2019; 144 (6): 1110e-1111e
View details for DOI 10.1097/PRS.0000000000006213
View details for PubMedID 31764685
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Clinical outcomes of a low-cost single-channel myoelectric-interface three-dimensional hand prosthesis.
Archives of plastic surgery
2019; 46 (5): 491
View details for DOI 10.5999/aps.2019.01256
View details for PubMedID 31550753
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Google Trends as a Tool for Evaluating Public Interest in Facial Cosmetic Procedures
AESTHETIC SURGERY JOURNAL
2019; 39 (8): 908–18
View details for DOI 10.1093/asj/sjy267
View details for Web of Science ID 000475855200028
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The Sternocleidomastoid Myocutaneous Flap: A Laryngeal Preservation Option for Total Hypopharyngoesophageal Stenosis
SAGE PUBLICATIONS LTD. 2019: 186–89
View details for DOI 10.1177/0194599819835784
View details for Web of Science ID 000473507100026
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Clinical outcomes of a low-cost single-channel myoelectric-interface three-dimensional hand prosthesis.
Archives of plastic surgery
2019; 46 (4): 303–10
Abstract
BACKGROUND: Prosthetic hands with a myoelectric interface have recently received interest within the broader category of hand prostheses, but their high cost is a major barrier to use. Modern three-dimensional (3D) printing technology has enabled more widespread development and cost-effectiveness in the field of prostheses. The objective of the present study was to evaluate the clinical impact of a low-cost 3D-printed myoelectric-interface prosthetic hand on patients' daily life.METHODS: A prospective review of all upper-arm transradial amputation amputees who used 3D-printed myoelectric interface prostheses (Mark V) between January 2016 and August 2017 was conducted. The functional outcomes of prosthesis usage over a 3-month follow-up period were measured using a validated method (Orthotics Prosthetics User Survey-Upper Extremity Functional Status [OPUS-UEFS]). In addition, the correlation between the length of the amputated radius and changes in OPUS-UEFS scores was analyzed.RESULTS: Ten patients were included in the study. After use of the 3D-printed myoelectric single electromyography channel prosthesis for 3 months, the average OPUS-UEFS score significantly increased from 45.50 to 60.10. The Spearman correlation coefficient (r) of the correlation between radius length and OPUS-UEFS at the 3rd month of prosthetic use was 0.815.CONCLUSIONS: This low-cost 3D-printed myoelectric-interface prosthetic hand with a single reliable myoelectrical signal shows the potential to positively impact amputees' quality of life through daily usage. The emergence of a low-cost 3D-printed myoelectric prosthesis could lead to new market trends, with such a device gaining popularity via reduced production costs and increased market demand.
View details for DOI 10.5999/aps.2018.01375
View details for PubMedID 31336417
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Applying a value-based care framework to post-mastectomy reconstruction
BREAST CANCER RESEARCH AND TREATMENT
2019; 175 (3): 547–51
View details for DOI 10.1007/s10549-019-05212-0
View details for Web of Science ID 000469014200002
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Health-Related Quality of Life After Ventral Hernia Repair With Biologic and Synthetic Mesh
LIPPINCOTT WILLIAMS & WILKINS. 2019: S332–S338
Abstract
Quality of life (QOL) is an important outcome measure after ventral hernia repair (VHR). The Hernia-Related QOL Survey (HerQLes) is a specific survey tool for QOL after VHR. Studies comparing QOL in patients with biologic mesh repairs (BMRs) and synthetic mesh repairs (SMRs) are lacking.A survey based on the HerQLes was administered via e-mail to 974 patients who had undergone VHR at Stanford Medical Center. From 175 patients who were included in the study, the mean HerQLes scores and postoperative complications were compared between patients with suture repairs (SR), BMR, SMR, with and without component separation, and different types of SMR.Quality of life was lower in patients with hernias of 50 cm or greater, obesity, history of tobacco use, previous abdominal surgeries, hernia recurrences, and postoperative complications (P < 0.05). Patients with SR and SMR had a comparable QOL (71.58 vs 70.12, P = 0.75). In patients with Modified Ventral Hernia Working Group grade 2 hernias, a significantly lower QOL was found after BMR compared with SMR. Postoperative complications did not significantly differ between the groups. Recurrence rates were comparable between MR (10.4%) and SR (8.3%, P = 0.79), but higher in BMR (21.7%) compared with SMR (6.6%, P < 0.05).Previous abdominal surgeries, previous hernia repairs, tobacco use, and hernia sizes of 50 cm or greater negatively affect QOL after VHR. Our data indicate that QOL is comparable between patients with SMR and SR, however, is lower in patients with Modified Ventral Hernia Working Group grade 2 and BMR compared with SMR, raising the benefit of BMR in light of its higher cost into question.
View details for DOI 10.1097/SAP.0000000000001768
View details for Web of Science ID 000473280700012
View details for PubMedID 30633027
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The Power of Patient Norms: Postoperative Pathway Associated With Shorter Hospital Stay After Free Autologous Breast Reconstruction.
Annals of plastic surgery
2019; 82 (5S Suppl 4): S320–S324
Abstract
INTRODUCTION: Enhanced recovery after surgery pathways designed to optimize postoperative care have become increasingly popular across multiple surgical specialties with proven benefits. In this retrospective cohort study, we present a comparative evaluation of the impact of protocol-based postoperative care on free autologous breast reconstruction patients.METHODS: With institutional review board approval, we performed a chart review of patients who underwent breast reconstruction with free autologous tissue transfer by a single surgeon from 2006 to 2017. Patients were managed according to a postoperative protocol since 2006 that initially called for discharge home on postoperative day (POD) 4 for unilateral cases and POD 5 for bilateral cases. In May 2015, the protocol was revised to discharge home on POD 3 for all cases. Patients who underwent reconstruction before (2006 to April 2015) and after (May 2015 to 2017) the change in postoperative protocol were compared.RESULTS: A total of 432 patients (647 breasts) underwent free autologous breast reconstruction during the study period. Flaps were predominantly muscle-sparing transverse rectus abdominis myocutaneous (56.3%) or deep inferior epigastric perforator (30.3%) flaps. Average patient age was 51.6 years (range, 29.7-80.3 years). Unilateral reconstructions were performed for 167 patients before and 50 patients after the protocol change; average hospital length of stay (LOS) was 4.5 and 3.4 days, respectively (P < 0.001). Bilateral reconstructions were performed for 153 patients before and 62 patients after the protocol change; average hospital LOS was 5.1 and 3.5 days, respectively (P < 0.001). There was no significant increase in patients with major or minor complications.CONCLUSIONS: Revising our postoperative protocol to reduce expected LOS was associated with an overall faster time to discharge without negative consequences in patients who underwent unilateral and bilateral free autologous breast reconstruction. Use of protocols to guide behavior not only can improve the patient experience by promoting a quicker return home, but may also have the added benefit of decreasing healthcare expenditures through reduced inpatient utilization.
View details for PubMedID 30973838
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The Utility of Google Trends Data for Analyzing Public Interest in Breast Procedures
ANNALS OF PLASTIC SURGERY
2019; 82: S325–S331
View details for DOI 10.1097/SAP.0000000000001806
View details for Web of Science ID 000473280700011
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The Power of Patient Norms Postoperative Pathway Associated With Shorter Hospital Stay After Free Autologous Breast Reconstruction
LIPPINCOTT WILLIAMS & WILKINS. 2019: S320–S324
View details for DOI 10.1097/SAP.0000000000001767
View details for Web of Science ID 000473280700010
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Assessing the Fisher, Mohler, and Millard Techniques of Cleft Lip Repair Surgery With Eye-Tracking Technology
ANNALS OF PLASTIC SURGERY
2019; 82: S313–S319
View details for DOI 10.1097/SAP.0000000000001911
View details for Web of Science ID 000473280700009
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Where Do We Look? Assessing Gaze Patterns in Cosmetic Facelift Surgery with Eye Tracking Technology.
Plastic and reconstructive surgery
2019
Abstract
PURPOSE: Aesthetics plays a central role in determining success in plastic surgery. Understanding perceptions of favorable aesthetics is critical to ensure patient satisfaction. Eye-tracking technology offers an objective way to evaluate attention and understand how viewers direct their focus in patients who undergo cosmetic facelift procedures.METHODS: Thirty-six subjects ranging from layperson to attending plastic surgeon viewed 15 sets of photos before and after patients underwent an elective facelift procedure. They were instructed to evaluate the aesthetic quality on a Likert scale, while eye-tracking equipment tracked their gaze and analyzed their distribution of attention.RESULTS: Post-operative images showed a Likert score improvement of 0.51±0.26, with the greatest difference in attending cosmetic plastic surgeons (1.36±0.22; p<0.05). The nose was the most common first fixation location (31% of first fixations) and the most viewed area (16±3% of fixation time) for all subjects. Experienced subjects spent less time in non-relevant areas (30±11% for attending cosmetic plastic surgeons and 37±10% for attending non-cosmetic plastic surgeons) compared to less experienced subjects (50±15% for laypersons).CONCLUSIONS: This study demonstrates that viewers with greater experience in cosmetic surgery focus quickly on the cheeks, chin, and neck and have evenly distributed gaze across the entire face. These results suggest that laypersons' gaze are drawn to the center of the face - due to both unfamiliarity with the facelift procedure and the natural tendency to look at the central face - while attending plastic surgeons exhibit holistic gaze patterns and are more aware of the impact of the procedure.
View details for PubMedID 30998662
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Fat Grafting into Younger Recipients Improves Volume Retention in an Animal Model
PLASTIC AND RECONSTRUCTIVE SURGERY
2019; 143 (4): 1067–75
View details for DOI 10.1097/PRS.0000000000005483
View details for Web of Science ID 000474582600052
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Applying a value-based care framework to post-mastectomy reconstruction.
Breast cancer research and treatment
2019
Abstract
PURPOSE: Reconstructive breast surgeons, like all procedural care providers, face a transition from volume reimbursement (i.e., per unit of service) to value-based care. Value can be defined as the relationship between outcomes and costs, or more specifically healthcare outcomes per unit cost. Although the definition of a meaningful outcome for a particular treatment can vary, some weighted average of survival, function, complications, process measures, and patient-reported outcomes (PROs) comprise the numerator, while the total cost of a complete care cycle is the denominator. We aim to construct a value-based care framework for reconstructive surgery using post-mastectomy reconstruction as an organizing element.METHODS: A preexisting value framework was applied to breast reconstruction using expert opinion and literature review. Domains and associated realization strategies were constructed based on established health economic principles.RESULTS: Seven domains were identified including: implementing an inclusive and transparent process for stakeholder engagement, practicing clear and explicit treatment goals, anchoring care delivery to the patient perspective, maximizing value across the entire continuum of care, optimizing operation efficiency, and scaling best practices with implementation science.CONCLUSIONS: In the near future, reconstructive plastic surgeons may be asked to solve clinical problems for fixed reimbursement (i.e. bundled payments). Considering breast reconstruction through a value lens provides surgeons with an opportunity to adapt and thrive in an evolving healthcare landscape. Lastly, we hope this document helps promote value assessment within the specialty.
View details for PubMedID 30937659
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The Sternocleidomastoid Myocutaneous Flap: A Laryngeal Preservation Option for Total Hyopharyngoesophageal Stenosis.
Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery
2019: 194599819835784
Abstract
Complete hypopharyngoesophageal (HPE) stenosis is rare and a challenging condition to treat. When endoscopic therapy fails, total laryngectomy with or without pharyngeal reconstruction is usually performed. We present a retrospective case series involving 3 patients with complete HPE stenosis who failed endoscopic repair and were gastrostomy dependent. All were managed successfully with the sternocleidomastoid myocutaneous (SCM) flap. A temporary fistula occurred in 1 patient. Hospitalization ranged from 5 to 15 days, patients resumed oral intake from 21 to 82 days postoperatively, and their gastrostomy tubes were removed from 28 to 165 days postoperatively. We suggest that the SCM flap is a laryngeal preservation option for reconstruction of complete HPE stenosis when endoscopic techniques fail. This flap allows HPE repair and reconstruction within the same surgical field, imposes no significant donor site morbidity, and affords good functional and cosmetic outcomes.
View details for PubMedID 30909812
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Assessing the Fisher, Mohler, and Millard Techniques of Cleft Lip Repair Surgery With Eye-Tracking Technology.
Annals of plastic surgery
2019
Abstract
BACKGROUND: Cleft lip repair is essential to restoring physiologic function and ensuring social and psychological well-being in children with orofacial clefts. It is important to critically study various techniques to understand the elements of the lip and nasal repair that contribute to favorable results. Here, we use eye-tracking technology to evaluate how viewers analyze images of cleft lips repaired by the Fisher, Millard, or Mohler techniques.METHODS: Thirty viewers were shown 5 images without deformity and 5 images each of unilateral cleft lips repaired by the Fisher, Millard, or Mohler techniques. Viewers assessed the esthetic quality of images on a Likert scale while eye-tracking technology analyzed their gaze patterns.RESULTS: Of the 3 repair techniques, viewers found Fisher repairs most esthetically pleasing (mean ± standard error, 6.91 ± 0.13). Mohler repairs were next most attractive at (6.47 ± 0.13), followed by Millard repairs at (5.60 ± 0.14). The proportion of time spent in fixed gaze on the nose and upper lip was greatest for Millard repairs (58.3% ± 0.4%) and least for Fisher repairs (51.9% ± 0.5%). Viewers fixated most frequently on the nose and upper lip in Millard repairs (83.2% ± 0.5%) and least frequently in Fisher repairs (75.3% ± 0.5%). When examining the Millard compared with Fisher and Mohler repairs, viewers spent more time and fixations on the ipsilateral lip, nose, and repair scar than on the contralateral lip.CONCLUSIONS: The esthetics of the Fisher repair appear to be favored as measured by Likert scores and gaze data. Eye-tracking technology may be a useful tool to assess outcomes in plastic surgery.
View details for PubMedID 30882421
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The Utility of Google Trends Data for Analyzing Public Interest in Breast Procedures.
Annals of plastic surgery
2019
Abstract
BACKGROUND: Google Trends (GT) is a free, open-source tool that permits customizable analysis of search term volumes entered into the Google search engine. Google Trends data may offer useful and actionable insight to plastic surgeons pertaining to worldwide, national, and regional evolution of patient interest for breast procedures and other common surgeries.METHODS: Search terms were generated using the "related queries" feature of GT. Google Trends data were collected for breast lift, breast reduction, breast reconstruction, and male breast reduction from January 2004 to September 2017. Case volumes for respective procedures were obtained from the American Society of Plastic Surgeons (ASPS) annual statistics reports for the calendar year 2006 to 2016. Trend analysis was performed using univariate linear regression analysis of ASPS statistics and GT search data.RESULTS: Total search volume varied geographically and temporally during the study period. Statistically significant positive correlations between GT and ASPS data were as follows: breast lift: "mastopexy" (R = 0.445, P = 0.025); male breast reduction: "gynecomastia surgery" (R = 0.45, P = 0.024); and breast reconstruction: "tissue expander" (R = 0.806, P ≤ 0.001) and "TRAM flap reconstruction" (R = 0.764, P = 0.002). For several search terms, no significant correlation was detected, highlighting the importance for careful selection of terms.
View details for PubMedID 30870175
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Analysis and Interpretation of Google Trends Data on Public Interest in Cosmetic Body Procedures.
Aesthetic surgery journal
2019
Abstract
BACKGROUND: Several online resources such as Google Trends (GT) enable plastic surgeons to track search volume trends for cosmetic procedures. Understanding these data may allow surgeons to better anticipate patients' interests and meet their needs.OBJECTIVES: Evaluate the correlation between GT search volumes and annual surgery volumes.METHODS: Search terms were generated using the "related queries" feature of GT. Data were obtained for the terms breast augmentation, buttock augmentation, buttock implants, buttock lift, calf augmentation, liposuction, lower body lift, thighplasty, abdominoplasty, and brachioplasty from January 2004 to November 2017. Annual volumes for respective procedures were obtained from statistics reports of the American Society of Plastic Surgeons (ASPS) from 2006 to 2017 and American Society of Aesthetic Plastic Surgery (ASAPS) from 2004 to 2017. Correlations were evaluated using univariate linear regression of GT data to both ASPS and ASAPS data.RESULTS: Geographical and temporal variations in search volume were detected during the study. Search volume trends that correlated significantly with both ASPS and ASAPS surgery volume trends were: were: "butt implants surgery" (ASPS R2=0.366, p=0.049; ASAPS R2=0.380, p=0.019); "liposuction" (ASPS R2=0.690, p=0.002; ASAPS R2=0.578, p=0.002); and "liposuction surgery" (ASPS R2=0.672, p=0.002; ASAPS R2=0.476, p=0.006). Several search terms demonstrated no significant relationships, negative correlations, or were significant with only one database.CONCLUSIONS: Our study characterizes GT as a convenient and informative data set for plastic surgeons to analyze patient interest in cosmetic body-sculpting procedures. GT represents a useful instrument for tailoring marketing strategies and addressing the needs of our patient population.
View details for PubMedID 30810161
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Fat Grafting into Younger Recipients Improves Volume Retention in an Animal Model.
Plastic and reconstructive surgery
2019
Abstract
BACKGROUND: Soft tissue deficits associated with various craniofacial anomalies can be addressed by fat grafting, although outcomes remain unpredictable. Furthermore, consensus does not exist for timing of these procedures. While some advocate approaching soft tissue reconstruction after the underlying skeletal foundation has been corrected, other studies have suggested earlier grafting may exploit a younger recipient niche that is more conducive for fat graft survival. As there is a dearth of research investigating effects of recipient age on fat graft volume retention, this study compared the effectiveness of fat grafting in younger versus older animals through a longitudinal, in vivo analysis.METHODS: Human lipoaspirate from three healthy female donors was grafted subcutaneously over the calvarium of immunocompromised mice. Volume retention over 8 weeks was evaluated using micro-computed tomography in three experimental ages - 3-weeks old, 6-months old, and 1-year old. Histology was performed on explanted grafts to evaluate graft health and vascularity. Recipient site vascularity was also evaluated by confocal microscopy.RESULTS: Greatest retention of fat graft volume was noted in the youngest group compared to both older groups (*p < 0.05) at 6 and 8 weeks following grafting. Histological and immunohistochemical analyses revealed that improved retention in younger groups was associated with greater fat graft integrity and more robust vascularization.CONCLUSION: Our study provides evidence that grafting fat into a younger recipient site correlates with improved volume retention over time, suggesting that beginning soft tissue reconstruction with fat grafting in patients at an earlier age may be preferable to late correction.
View details for PubMedID 30730498
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A Quantitative Analysis of Online Plastic Surgeon Reviews for Abdominoplasty.
Plastic and reconstructive surgery
2019
View details for DOI 10.1097/PRS.0000000000006213
View details for PubMedID 31490810
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Radiation-Induced Skin Fibrosis: Pathogenesis, Current Treatment Options, and Emerging Therapeutics.
Annals of plastic surgery
2019; 83 (4S Suppl 1): S59–S64
Abstract
Radiotherapy (RT) has become an indispensable part of oncologic treatment protocols for a range of malignancies. However, a serious adverse effect of RT is radiodermatitis; almost 95% of patients develop moderate to severe skin reactions following radiation treatment. In the acute setting, these can be erythema, desquamation, ulceration, and pain. Chronically, soft tissue atrophy, alopecia, and stiffness can be noted. Radiodermatitis can delay oncologic treatment protocols and significantly impair quality of life. There is currently a paucity of effective treatment options and prevention strategies for radiodermatitis. Importantly, recent preclinical and clinical studies have suggested that fat grafting may be of therapeutic benefit, reversing detrimental changes to soft tissue following RT. This review outlines the damaging effects of RT on the skin and soft tissue as well as discusses available treatment options for radiodermatitis. Emerging strategies to mitigate detrimental, chronic radiation-induced changes are also presented.
View details for DOI 10.1097/SAP.0000000000002098
View details for PubMedID 31513068
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A dual padding method for ischial pressure sore reconstruction with an inferior gluteal artery perforator fasciocutaneous flap and a split inferior gluteus maximus muscle flap.
Archives of plastic surgery
2019; 46 (5): 455–61
Abstract
Various surgical management methods have been proposed for ischial sore reconstruction, yet it has the highest recurrence rate of all pressure ulcer types. A novel approach combining the advantages of a perforator-based fasciocutaneous flap and a muscle flap is expected to resolve the disadvantages of previously introduced surgical methods.Fifteen patients with ischial pressure ulcers with chronic osteomyelitis or bursitis, who underwent reconstructive procedures with an inferior gluteal artery perforator (IGAP) fasciocutaneous flap and a split inferior gluteus maximus muscle flap from January 2011 to June 2016, were analyzed retrospectively. The split muscle flap was rotated to obliterate the deep ischial defect, managing the osteomyelitis or bursitis, and the IGAP fasciocutaneous flap was rotated or advanced to cover the superficial layer. The patients' age, sex, presence of bursitis or osteomyelitis, surgical details, complications, follow-up period, and ischial sore recurrence were reviewed.All ischial pressure ulcers were successfully reconstructed without any flap loss. The mean duration of follow-up was 12.9 months (range, 3-35 months). Of 15 patients, one had a recurrent ulcer 10 months postoperatively, which was repaired by re-advancing the previously elevated fasciocutaneous flap.The dual-flap procedure with an IGAP fasciocutaneous flap and split inferior gluteus maximus muscle flap for ischial pressure ulcer reconstruction is a useful method that combines the useful characteristics of perforator and muscle flaps, providing thick dual padding with sufficient vascularization while minimizing donor morbidity and vascular pedicle injury.
View details for DOI 10.5999/aps.2019.00031
View details for PubMedID 31550751
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Where Do We Look? Assessing Gaze Patterns in Cosmetic Face-Lift Surgery with Eye Tracking Technology.
Plastic and reconstructive surgery
2019; 144 (1): 63–70
Abstract
Aesthetics plays a central role in determining success in plastic surgery. Understanding perceptions of favorable aesthetics is critical to ensure patient satisfaction. Eye-tracking technology offers an objective way of evaluating attention and understanding how viewers direct their focus on patients who undergo cosmetic face-lift procedures.Thirty-six subjects ranging from layperson to attending plastic surgeon viewed 15 sets of photographs before and after patients underwent an elective face-lift procedure. They were instructed to evaluate the aesthetic quality on a Likert scale while eye-tracking equipment tracked their gaze and analyzed their distribution of attention.Postoperative images showed a Likert score improvement of 0.51 ± 0.26, with the greatest difference in attending cosmetic plastic surgeons (1.36 ± 0.22; p < 0.05). The nose was the most common first fixation location (31 percent of first fixations) and the most viewed area (16 ± 3 percent of fixation time) for all subjects. Experienced subjects spent less time in nonrelevant areas (30 ± 11 percent for attending cosmetic plastic surgeons and 37 ± 10 percent for attending noncosmetic plastic surgeons) compared with less experienced subjects (50 ± 15 percent for laypersons).This study demonstrates that viewers with greater experience in cosmetic surgery focus quickly on the cheeks, chin, and neck and have evenly distributed gaze across the entire face. These results suggest that a layperson's gaze is drawn to the center of the face (because of both unfamiliarity with the face-lift procedure and the natural tendency to look at the central face), whereas attending plastic surgeons exhibit holistic gaze patterns and are more aware of the impact of the procedure.
View details for DOI 10.1097/PRS.0000000000005700
View details for PubMedID 31246802
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Discussion: Tips for Making a Successful Online Microsurgery Educational Platform: The Experience of International Microsurgery Club.
Plastic and reconstructive surgery
2019; 143 (1): 234e–235e
View details for PubMedID 30589816
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The quality of systematic reviews addressing peripheral nerve repair and reconstruction.
Journal of plastic, reconstructive & aesthetic surgery : JPRAS
2018
Abstract
While systematic reviews are regarded as the strongest level of medical evidence, inconsistency in the quality and rigor of systematic reviews raises concerns about their use as a tool in guiding quality delivery in evidence-based clinical practice. The objective of this present study was to assess methodological soundness of systematic reviews with a particular focus on peripheral nerve repair and reconstruction. We performed a comprehensive search using PubMed and Scopus to identify all systematic reviews published on peripheral nerve reconstruction in 9 high-impact surgical journals. Two authors independently performed literature searches, screened abstracts, and extracted data. Discrepancies were resolved by discussion and consensus. The quality of systematic reviews was assessed using AMSTAR criteria. Initial search retrieved 184 articles. After screening duplicates, titles, abstracts, and conducting full text reviews, 26 studies met inclusion criteria. Of those, 18 (65%) were published by Plastic Surgery, 7 (27%) by Orthopedic Surgery, and 1 (4%) by Occupational Therapy. The total number of systematic reviews published on peripheral nerves each year has shown an increasing trend from 2004 through 2015. The overall median AMSTAR score was 5, reflecting a "fair" quality. There was no evidence of AMSTAR score improvement over time. Although the number of systematic reviews published on peripheral nerve repair has risen over the last decade, their quality has not exhibited the same increase. This highlights the necessity to increase familiarity with and conform to methodological quality criteria in order to improve the integrity of evidence-based medicine in peripheral nerve repair and reconstruction.
View details for PubMedID 30655242
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Google Trends as a Tool for Evaluating Public Interest in Facial Cosmetic Procedures.
Aesthetic surgery journal
2018
Abstract
Background: The utility of Google Trends (GT) in analyzing worldwide and regional patient interest for plastic surgery procedures is becoming invaluable to plastic surgery practices. GT data may offer practical information to plastic surgeons pertaining to seasonal and geographic trends in interest in facial cosmetic procedures.Objective: The authors sought to analyze geographic and temporal trends between GT search volumes and US surgery volumes using univariate analysis.Methods: The "related queries" feature of GT generated potential search terms. GT data were compiled for cheek implants, mentoplasty, otoplasty, blepharoplasty, rhytidectomy, forehead lift, hair transplantation, lip augmentation, lip reduction, platysmaplasty, and rhinoplasty from January 2004 to December 2017. Annual volumes for respective procedures were obtained from annual statistics reports of the American Society of Plastic Surgeons (ASPS) from 2006 to 2017 and American Society of Aesthetic Plastic Surgery (ASAPS) from 2004 to 2017.Results: Geographical and temporal variations in search volume were detected during the study. Search volume trends that correlated significantly with both ASPS and ASAPS surgery volume trends were: "eyelid plastic surgery" (ASPS R2=0.336, P=0.048; ASAPS R2=0.661, P=0.001); "facelift" (ASPS R2=0.767, P≤0.001; ASAPS R2=0.767, P=0.001); "lip injections" (ASPS R2=0.539, P=0.007; ASAPS R2=0.461, P=0.044); and "rhinoplasty surgery" (ASPS R2=0.797, P≤0.001; ASAPS R2=0.441, P=0.01). Several search terms demonstrated no significant relationships or were significant with only one database.Conclusions: GT may provide a high utility for informing plastic surgeons about the interest expressed by our patient population regarding certain cosmetic search terms and procedures. GT may represent a convenient tool for optimizing marketing and advertising decisions.
View details for PubMedID 30304356
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Breast Reconstruction Following Breast Cancer Treatment-2018.
JAMA
2018
View details for PubMedID 30178060
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Response: Where Do We Look? Assessing Gaze Patterns in Reconstructive Surgery with Eye Tracking Technology.
Plastic and reconstructive surgery
2018
View details for PubMedID 30222674
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Using Mesh to Reinforce the Abdominal Wall in Abdominal Free Flaps for Breast Reconstruction: Is There a Benefit? What are the Risks?
Annals of plastic surgery
2018; 80 (5S Suppl 5): S295–S298
Abstract
INTRODUCTION: Abdominal wall integrity may be compromised after abdominal flap harvest for breast reconstruction, leading to bulging or herniation due to weakening of the abdominal wall and dissection through the rectus muscle. Mesh can be used to reinforce the abdominal wall to reduce the risk of hernia formation postoperatively, especially in patients who may be at high risk. In this study, we describe this institution's experience with the use of mesh in the abdominal wall and critically evaluate its impact on patient outcomes and complications.METHODS: We retrospectively reviewed all patients with an abdominal free flap harvested for breast reconstruction at Stanford Health Care from 2005 to 2015. Multivariate-adjusted logistic regression analysis was used to compare the odds of abdominal complications-infection, bulging, and herniation-between patients with and without an abdominal mesh implanted during breast reconstruction.RESULTS: Three hundred eighty patients met inclusion criteria. One hundred sixty-one patients received mesh, whereas 219 received no reinforcement. In the mesh group, there were 7 (4.3%) cases of postoperative abdominal bulging, 11 (6.8%) cases of abdominal infection, and no (0.0%) cases of herniation. In the group without mesh, there were 17 (7.8%) cases of abdominal bulging, 11 (5.0%) cases of abdominal infection, and 5 (2.3%) cases of herniation. There was a significant difference in the odds of bulging (odds ratio [OR], 0.30; P = 0.01). There was not a significant difference in the odds of herniation (OR, 2.26E-10; P = 0.99) or infection (OR, 1.21; P = 0.69).CONCLUSIONS: In our current treatment algorithm, patients who received mesh were selected based upon several criteria, including obesity, weak fascia identified during surgery, and extensive muscle dissection. We confirm that the risk of bulging and herniation is decreased in patients receiving mesh. Furthermore, the risk of wound infection was not associated with the use of mesh; instead, a patient's elevated body mass index, as well as tension of closure, and other comorbidities are more likely causes of superficial wound complications. We find the use of mesh to be safe and beneficial in select patients undergoing abdominal free flap breast reconstruction who are at risk for hernias and bulges.
View details for PubMedID 29596090
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Age-associated differences in infection of human skin in the SCID mouse model of varicella-zoster virus pathogenesis.
Journal of virology
2018
Abstract
Varicella-zoster virus (VZV) is the skin-tropic human alphaherpesvirus responsible for both varicella and herpes zoster. Varicella and herpes zoster skin lesions have similar morphology but herpes zoster occurs disproportionally in older individuals and is often associated with a more extensive local rash and severe zoster-related neuralgia. We hypothesized that skin aging could also influence the outcome of the anterograde axonal transport of VZV to skin. We utilized human skin xenografts maintained in immunodeficient (SCID) mice to study VZV-induced skin pathology in vivo in fetal and adult skin xenografts. Here we find that VZV replication is enhanced in skin from older compared to younger adults, correlating with clinical observations. In addition to measures of VZV infection, we examined the expression of type I interferon (IFN) pathway components in adult skin and investigated elements of the cutaneous proliferative and inflammatory response to VZV infection in vivo Our results demonstrated that VZV infection of adult skin triggers intrinsic IFN-mediated responses as we have described in VZV-infected fetal skin xenografts, including MxA as well as PML, in skin cells surrounding lesions. Further, we observed that VZV elicited altered cell-signaling, proliferative and inflammatory responses that are involved in wound healing, driven by follicular stem cells. These cellular changes are consistent with VZV-induced activation of STAT3 and suggest that VZV exploits the wound healing process to ensure efficient delivery of the virus to keratinocytes. Adult skin xenografts offer an approach to further investigate VZV-induced skin pathologies in vivoIMPORTANCE Varicella-zoster virus (VZV) is the agent responsible for both varicella and herpes zoster. Herpes zoster occurs disproportionally in older individuals and is often associated with a more extensive local rash and severe zoster-related neuralgia. To examine the effect of skin aging on VZV skin lesions, we utilized fetal and adult human skin xenografts maintained in immunodeficient (SCID) mice. We measured VZV-induced skin pathology, examined the expression of type I interferon (IFN) pathway components in adult skin, and investigated elements of the cutaneous proliferative and inflammatory response to VZV infection in vivo Our results demonstrate that characteristics of aging skin are preserved in xenografts, that VZV replication is enhanced in skin from older compared to younger adults, correlating with clinical observations, and that VZV infection elicits altered cell-signaling and inflammatory responses. Adult skin xenografts offer an approach to further investigate VZV-induced skin pathologies in vivo.
View details for PubMedID 29563288
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Evaluating Resident Perspectives on International Humanitarian Missions
LIPPINCOTT WILLIAMS & WILKINS. 2018: 279–85
Abstract
Opportunities for international missions are highly sought after by medical students, residents, and attending plastic surgeons. The educational benefits and ethical considerations of trainees participating in these ventures have been extensively debated. At the time of this writing, many surgical training programs lack the necessary infrastructure or funds to support missions of this sort. Despite the increasing interest, the perceived benefit of international work has not yet been well studied. The authors seek to evaluate residents' perspectives on the personal and educational benefits of international mission work.A 24-item online questionnaire was designed to measure residents' perspectives on humanitarian missions. Residents' perceptions on how participation in these missions may have influenced their career path were also evaluated. This questionnaire was disseminated to the plastic surgery residents in Accreditation Council for Graduate Medical Education (ACGME) accredited programs in the United States during the 2015 to 2016 academic year.Of the 123 responses collected, 49 (40%) indicated that they had participated in international mission work prior to beginning residency, while 74 (60%) had not. Fifty-seven percent (n = 25) of those who had participated agreed that this experience impacted their choice to pursue plastic surgery as a specialty. Twenty-nine (24%) participated in 1 or more missions during residency. The most common type of mission work focused on cleft lip/palate repairs (n = 24) followed by nonsurgical medical relief (n = 18) and general plastics/combined (n = 6). Most respondents reported trips lasting 6 to 8 days (n = 29, 48%), though several reported trips lasting 9 to 10 days (n = 6, 10%) and 11 days or more (n = 16, 27%). When asked about the volume of procedures performed, 32 (65%) reported participating in more than 15 procedures, with 15 (31%) residents reporting participation in 26 procedures or more. When asked to evaluate the educational benefits in light of the 6 core competencies from the ACGME, there was an overwhelmingly positive response.Residents perceive international mission experiences to be valuable for professional development as well as an effective tool for surgical education, particularly in the setting of competency-based education goals and these ventures should be supported by training programs. An appropriately planned mission experience can impact the professional and educational development of the trainee.
View details for PubMedID 29283950
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Where Do We Look? Assessing Gaze Patterns in Breast Reconstructive Surgery with Eye-Tracking Technology
PLASTIC AND RECONSTRUCTIVE SURGERY
2018; 141 (3): 331E–340E
Abstract
Aesthetics plays a large role in determining a successful outcome in plastic and reconstructive surgery. As such, understanding perceptions of favorable aesthetics is crucial for optimizing patient satisfaction. Eye-tracking technology offers an unbiased way of measuring how viewers evaluate breast reconstructions.Twenty-nine raters with varied plastic surgery experience were shown 20 images of breast reconstruction at various stages. Breasts were divided into those with nipples and no reconstruction scars, those with nipples and reconstruction scars, and those with reconstruction scars and no nipples. Raters viewed each image for 8 seconds to evaluate aesthetic outcomes. Eye-tracking equipment and software were used to track raters' gaze and analyze the distribution of attention.In breasts with reconstruction scars and no nipples, viewers spent 53.9 percent of the view time examining scars, whereas viewers' attention was divided evenly in breasts with both reconstruction scars and nipples, spending 27.5 percent and 27.7 percent of view time examining the nipples and reconstruction scars, respectively. When examining complete reconstructions, viewers spent more time scanning the entire image before fixating on scars and spent less time on single-site fixation.Complete reconstructions, which notably include the final nipple-areola complex, appear to play an important role in restoring normal viewing parameters. In essence, completed breast reconstructions with nipple-areola complexes divert attention from extraneous surgical scars and lead viewers to assess the breasts more holistically. Eye-tracking technology provides a powerful link between objective gaze and viewer attention that may potentially be used to predict subjective aesthetic preferences.
View details for PubMedID 29481389
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Deferoxamine Preconditioning of Irradiated Tissue Improves Perfusion and Fat Graft Retention
PLASTIC AND RECONSTRUCTIVE SURGERY
2018; 141 (3): 655–65
Abstract
Radiation therapy is a mainstay in the treatment of many malignancies, but collateral damage to surrounding tissue, with resultant hypovascularity, fibrosis, and atrophy, can be difficult to reconstruct. Fat grafting has been shown to improve the quality of irradiated skin, but volume retention of the graft is significantly decreased. Deferoxamine is a U.S. Food and Drug Administration-approved iron-chelating medication for acute iron intoxication and chronic iron overload that has also been shown to increase angiogenesis. The present study evaluates the effects of deferoxamine treatment on irradiated skin and subsequent fat graft volume retention.Mice underwent irradiation to the scalp followed by treatment with deferoxamine or saline and perfusion and were analyzed using laser Doppler analysis. Human fat grafts were then placed beneath the scalp and retention was also followed up to 8 weeks radiographically. Finally, histologic evaluation of overlying skin was performed to evaluate the effects of deferoxamine preconditioning.Treatment with deferoxamine resulted in significantly increased perfusion, as demonstrated by laser Doppler analysis and CD31 immunofluorescent staining (p < 0.05). Increased dermal thickness and collagen content secondary to irradiation, however, were not affected by deferoxamine (p > 0.05). Importantly, fat graft volume retention was significantly increased when the irradiated recipient site was preconditioned with deferoxamine (p < 0.05).The authors' results demonstrated increased perfusion with deferoxamine treatment, which was also associated with improved fat graft volume retention. Preconditioning with deferoxamine may thus enhance fat graft outcomes for soft-tissue reconstruction following radiation therapy.
View details for PubMedID 29135894
View details for PubMedCentralID PMC5826842
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Three-Dimensional Ultrasound Versus Computerized Tomography in Fat Graft Volumetric Analysis
ANNALS OF PLASTIC SURGERY
2018; 80 (3): 293–96
Abstract
Studies evaluating fat grafting in mice have frequently used micro-computed tomography (micro-CT) as an accurate radiographic tool to measure longitudinal volume retention without killing the animal. Over the past decade, however, microultrasonography has emerged as an equally powerful preclinical imaging tool. Given their respective strengths in 3-dimensional reconstruction, there is no study to our knowledge that directly compares micro-CT with microultrasound in volumetric analysis. In this study, we compared the performance of micro-CT with microultrasound in the evaluation of adipose tissue graft volume in a murine model. Fifteen immunodeficient mice were given 200 μL of adipose tissue grafts. In vivo volumetric analysis of the grafts by micro-CT and microultrasound was conducted at discrete time points up to postoperative day 105. Three mice were killed at multiple time points, and explanted grafts were reimaged by CT and ultrasound, as mentioned previously. Analysis revealed that in vivo graft volumes measured by micro-CT do not differ significantly from those of microultrasound. Furthermore, both micro-CT and microultrasound were capable of accurately measuring fat grafts as in vivo volumes closely correlated with explanted volumes. Finally, ultrasound was found to yield improved soft tissue contrast compared with micro-CT. Therefore, either modality may be used, depending on experimental needs.
View details for DOI 10.1097/SAP.0000000000001183
View details for Web of Science ID 000425352000021
View details for PubMedID 28678028
View details for PubMedCentralID PMC5752634
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Outcomes after Phalloplasty: Do Transgender Patients and Multiple Urethral Procedures Carry a Higher Rate of Complication?
PLASTIC AND RECONSTRUCTIVE SURGERY
2018; 141 (2): 220E–229E
Abstract
Phalloplasty is associated with improved quality-of-life in those with penile defects, and in female-to-male transgender (transmale) patients seeking gender-confirming surgery. However, aggregate complication and outcome data are sparse. This study compares phalloplasty outcomes between transmale and cismale patients and between those with primary versus staged urethroplasty.A comprehensive literature search of PubMed, MEDLINE, and Google Scholar databases was conducted for studies relating to phalloplasty. Data on techniques, complications, outcomes, and patient demographics were collected. Analysis using the random-effects model with subgroup analyses was performed.A total of 50 studies (1351 patients) were included: 19 studies (869 patients) for transmale patients and 31 studies (482 patients) for cismale patients. The urethral complication rate in the transmale group was 39.4 percent (95 percent CI, 30.6 to 48.9 percent; p = 0.028) compared to 24.8 percent (95 percent CI, 16.5 to 35.4 percent; p < 0.001) in the cismale group. The overall flap complication rates for transmale and cismale patients were 10.8 percent (95 percent CI, 7.0 to 16.2 percent; p < 0.001) and 8.1 percent (95 percent CI, 5.5 to 11.7 percent; p < 0.001), respectively. Twenty-three studies (723 patients) used primary urethroplasty and 13 studies (210 patients) performed staged urethroplasty procedures. Flap complication rates of primary and staged urethroplasty were 8.6 percent (95 percent CI, 5.3 to 13.8 percent; p < 0.001) and 16.7 percent (95 percent CI, 10.7 to 24.9 percent; p < 0.001), respectively. Primary urethroplasty had superior outcomes of voiding while standing, sexual function, and patient satisfaction compared with staged urethroplasty.Cismale patients undergoing phalloplasty had lower urethral and flap complication rates compared with transmale patients. Staged urethroplasty had more flap complications, and worse outcomes and patient satisfaction compared with primary urethroplasty.
View details for PubMedID 29019859
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Perianal Extramammary Paget's Disease: More Than Meets the Eye.
Digestive diseases and sciences
2018
View details for PubMedID 29696480
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Bioengineered Viral Platform for Intramuscular Passive Vaccine Delivery to Human Skeletal Muscle.
Molecular therapy. Methods & clinical development
2018; 10: 144–55
Abstract
Skeletal muscle is ideal for passive vaccine administration as it is easily accessible by intramuscular injection. Recombinant adeno-associated virus (rAAV) vectors are in consideration for passive vaccination clinical trials for HIV and influenza. However, greater human skeletal muscle transduction is needed for therapeutic efficacy than is possible with existing serotypes. To bioengineer capsids with therapeutic levels of transduction, we utilized a directed evolution approach to screen libraries of shuffled AAV capsids in pools of surgically resected human skeletal muscle cells from five patients. Six rounds of evolution were performed in various muscle cell types, and evolved variants were validated against existing muscle-tropic serotypes rAAV1, 6, and 8. We found that evolved variants NP22 and NP66 had significantly increased primary human and rhesus skeletal muscle fiber transduction from surgical explants ex vivo and in various primary and immortalized myogenic lines in vitro. Importantly, we demonstrated reduced seroreactivity compared to existing serotypes against normal human serum from 50 adult donors. These capsids represent powerful tools for human skeletal muscle expression and secretion of antibodies from passive vaccines.
View details for PubMedID 30101152
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Practical Applications of Delayed-Immediate Autologous Breast Reconstruction: A Flexible and Safe Operative Strategy.
Annals of plastic surgery
2018; 80 (5S Suppl 5): S299–S302
Abstract
Timing is an important consideration in patients undergoing mastectomy for breast cancer. While immediate reconstruction results in superior aesthetic outcomes, the need for postmastectomy radiation can often only be ascertained after review of surgical pathology. Delayed-immediate autologous reconstruction (DIAR) is a reconstructive approach that consists of mastectomy with tissue expander placement in the first stage and flap-based breast reconstruction in the second stage. We describe our institution's experience with DIAR to characterize the reasons in which patients opt for this reconstructive approach and analyze its ultimate outcomes.We conducted an institutional review board-approved retrospective chart review of all consecutive patients undergoing DIAR performed by the senior author from 2007 to 2016. Data gathered included demographics, operative techniques, and postoperative outcomes.In our study, 17 patients and 26 breasts underwent DIAR. Seven patients initially planned for and eventually underwent DIAR. Ten patients initially planned for implant-based reconstructions but ultimately underwent DIAR instead. Flap types included deep inferior epigastric perforator (n = 6), superficial inferior epigastric artery (n = 2), and muscle-sparing free transverse rectus abdominis myocutaneous (n = 18). The mean time between mastectomy and reconstruction was 208 days. Complications included tissue expander infection, vascular compromise, abscess formation, hematoma, and skin necrosis.The delayed-immediate approach allows for breast reconstruction with aesthetic and psychosocial benefits, while enabling postmastectomy radiation in patients with advanced disease. We describe modifications to DIAR, including use of a flap skin paddle and prolonged time between stages, which allow for broader applicability. We show that DIAR accommodates a range of patient preferences with few complications.
View details for DOI 10.1097/SAP.0000000000001380
View details for PubMedID 29620551
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Analysis of Aesthetic Outcomes and Patient Satisfaction After Delayed-Immediate Autologous Breast Reconstruction.
Annals of plastic surgery
2018; 80 (5S Suppl 5): S303–S307
Abstract
Patients with breast cancer frequently opt to undergo breast reconstruction after mastectomy. The timing and aesthetic outcome of the breast reconstruction may be affected by the need for radiation therapy (RT). Delayed-immediate autologous reconstruction (DIAR) is a novel surgical approach for patients in whom the need for adjuvant RT after mastectomy is preoperatively unknown.We sought to evaluate the difference in clinical outcomes, patient satisfaction, and cosmetic results between DIAR and patients who underwent delayed autologous reconstruction.A total of 19 DIAR and 19 delayed patients were retrospectively included.Patient demographics, surgical characteristics, and complications were obtained from patient files. Patients scored their satisfaction using the breast-Q questionnaire, and independent reviewers scored cosmetic outcomes, including skin quality/color, scar formation, symmetry, breast contour/size/position, and overall aesthetic outcome. The DIAR patients were matched to delayed patients based on age, body mass index, and unilateral or bilateral reconstruction.The median age in the delayed group was 48 years (range, 31-61 years) and 46 years (range, 29-64 years) in the DIAR group, with a median body mass index of 28.8 (range, 21.4-40.5) and 28.6 (range, 24-1.9), respectively.There were no significant differences in demographics between the two groups. In total, 16 patients underwent unilateral reconstruction and 22 patients bilateral reconstruction. Delayed-immediate autologous reconstruction was associated with a higher infection rate compared with delayed reconstruction, 8 and 1, respectively (P = 0.026). All infections in the DIAR group were tissue expander-related. The DIAR patients had significantly better breast contour/size/position and overall aesthetics compared with the delayed reconstruction group (P = 0.001). In addition, patients who did not receive RT had significant better cosmetic outcome (P < 0.001). There were no significant differences in patient satisfaction between the DIAR and delayed group.Delayed-immediate autologous reconstruction should be considered as an option for patients wanting autologous reconstruction when the need for RT remains unknown. Delayed-immediate autologous reconstruction demonstrates better breast contour/size/position and overall aesthetic outcome.
View details for PubMedID 29553980
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Complications After Two-Stage Expander Implant Breast Reconstruction Requiring Reoperation: A Critical Analysis of Outcomes.
Annals of plastic surgery
2018; 80 (5S Suppl 5): S292–S294
Abstract
Two-stage expander implant breast reconstruction is commonly performed after mastectomy. Salvage and long-term outcomes after development of complications have not been well described. We examined a single surgeon's experience to study the rate of reoperation secondary to complications after first-stage expander placement and to evaluate their outcomes. Better understanding of salvage techniques may help guide future management.We performed a retrospective analysis of consecutive patients who underwent placement of a tissue expander (TE) for breast reconstruction between December 2006 and August 2015 with the senior author. Patient demographics including age, body mass index, medical comorbidities, history of smoking, and history of radiation to the breast were collected. Surgical factors including timing of reconstruction (immediate vs delayed) and location of TE (total submuscular vs with acellular dermal matrix) were recorded. Complications were analyzed, as were patients who underwent reoperation in the setting of developing a complication.We analyzed 282 patients who underwent 453 implant-based breast reconstructions. Of these, 39 patients and 45 breasts required a reoperation after development of a postoperative complication. Return to the operating room was associated with higher body mass index (29 vs 24, P < 0.001), higher TE initial fill volume (299 mL vs 169 mL, P < 0.001), and preoperative radiation (31% vs 13%, P = 0.001). Complications resulting in reoperation included infection (60%), mastectomy skin necrosis (27%), and TE extrusion through thin mastectomy skin (11%). The affected TE was removed and exchanged in 17 patients (38%), autologous flap reconstruction occurred in 16 patients (36%), and TE was explanted without replacement in 12 patients (27%).Infectious complications including cellulitis and abscess formation accounted for most cases requiring reoperation after TE placement for breast reconstruction. More than a quarter of patients who underwent a reoperation ultimately lost their implants. Patients undergoing two-stage expander implant breast reconstruction should be appropriately counseled regarding the possibility of requiring a reoperation in the setting of developing a complication.
View details for DOI 10.1097/SAP.0000000000001382
View details for PubMedID 29489547
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Mastectomy Skin Necrosis After Breast Reconstruction: A Comparative Analysis Between Autologous Reconstruction and Implant-Based Reconstruction.
Annals of plastic surgery
2018; 80 (5S Suppl 5): S285–S287
Abstract
Mastectomy skin necrosis is a significant problem after breast reconstruction. We sought to perform a comparative analysis on this complication between patients undergoing autologous breast reconstruction and patients undergoing 2-stage expander implant breast reconstruction.A retrospective review was performed on consecutive patients undergoing autologous breast reconstruction or 2-stage expander implant breast reconstruction by the senior author from 2006 through 2015. Patient demographic factors including age, body mass index, history of diabetes, history of smoking, and history of radiation to the breast were collected. Our primary outcome measure was mastectomy skin necrosis. Fisher exact test was used for statistical analysis between the 2 patient cohorts. The treatment patterns of mastectomy skin necrosis were then analyzed.We identified 204 patients who underwent autologous breast reconstruction and 293 patients who underwent 2-stage expander implant breast reconstruction. Patients undergoing autologous breast reconstruction were older, heavier, more likely to have diabetes, and more likely to have had prior radiation to the breast compared with patients undergoing implant-based reconstruction. The incidence of mastectomy skin necrosis was 30.4% of patients in the autologous group compared with only 10.6% of patients in the tissue expander group (P < 0.001). The treatment of this complication differed between these 2 patient groups. In general, those with autologous reconstructions were treated with more conservative means. Although 37.1% of patients were treated successfully with local wound care in the autologous group, only 3.2% were treated with local wound care in the tissue expander group (P < 0.001). Less than half (29.0%) of patients in the autologous group were treated with an operative intervention for this complication compared with 41.9% in the implant-based group (P = 0.25).Mastectomy skin necrosis is significantly more likely to occur after autologous breast reconstruction compared with 2-stage expander implant-based breast reconstruction. Patients with autologous reconstructions are more readily treated with local wound care compared with patients with tissue expanders, who tended to require operative treatment of this complication. Patients considering breast reconstruction should be counseled appropriately regarding the differences in incidence and management of mastectomy skin necrosis between the reconstructive options.
View details for DOI 10.1097/SAP.0000000000001379
View details for PubMedID 29489546
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Quality Measures in Breast Reconstruction: A Systematic Review.
Annals of plastic surgery
2017
Abstract
The importance of providing quality care over quantity of care, and its positive effects on health care expenditure and health, has motivated a transition toward value-based payments. The Centers for Medicare and Medicaid Services and private payers are establishing programs linking financial incentives and penalties to adherence to quality measures. As payment models based on quality measures are transitioned into practice, it is beneficial to identify current quality measures that address breast reconstruction surgery as well as understand gaps to inform future quality measure development.We performed a systematic review of quality measures for breast reconstruction surgery by searching quality measure databases, professional society clinical practice guidelines, and the literature. Measures were categorized as structure, process, or outcome according to the Donabedian domains of quality.We identified a total of 27 measures applicable to breast reconstruction: 5 candidate quality measures specifically for breast reconstruction surgery and 22 quality measures that relate broadly to surgery. Of the breast reconstruction candidate measures, 3 addressed processes and 2 addressed outcomes. Seventeen of the general quality measures were process measures and 5 were outcome measures. We did not identify any structural measures.Currently, an overrepresentation of process measures exists, which addresses breast reconstruction surgery. There is a limited number of candidate measures that specifically address breast reconstruction. Quality measure development efforts on underrepresented domains, such as structure and outcome, and stewarding the measure development process for candidate quality measures can ensure breast reconstruction surgery is appropriately evaluated in value-based payment models.
View details for DOI 10.1097/SAP.0000000000001088
View details for PubMedID 28570449
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Immunological Effect of Skin Allograft in Burn Treatment: Impact on Future Vascularized Composite Allotransplantation
JOURNAL OF BURN CARE & RESEARCH
2017; 38 (3): 169-173
Abstract
Skin allografts are the benchmark in temporary burn wound coverage, but allografts are hypothesized to place a high antigenic load on recipients. This project aims to determine the degree of human leukocyte antigen sensitization in burn patients treated with allografts. Serum was obtained from nine adult, nontransfused, and nontransplanted burn patients treated with allografts. Group 1 included patients tested in the acute burn period, while group 2 included different patients tested months to years after injury. A calculated panel reactive antibody (cPRA) percent was assessed for each patient, and data for a control group of 92 adult nontransplanted males were used for comparison. Each patient received allografts from an average 3.55 ± 1.24 different donors. cPRA in group 1 was lower than in group 2 (6 ± 12% vs 42 ± 33%, P = .08). cPRA in the study group was significantly higher than in the control group (26 ± 31% vs 8 ± 17%, P = .0075). Burn patients who receive skin allograft demonstrate increased immunological sensitization compared with unsensitized controls. Detection of human leukocyte antigen antibody is lower in the acute burn period than months to years after injury. Increased sensitization may ultimately limit burn patients' candidacy for vascularized composite allotransplantation or decrease success of these procedures.
View details for DOI 10.1097/BCR.0000000000000458
View details for Web of Science ID 000399817800007
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Management of Mastectomy Skin Necrosis in Implant Based Breast Reconstruction.
Annals of plastic surgery
2017; 78 (5): S208-S211
Abstract
Mastectomy skin necrosis is a significant problem after breast reconstruction. This complication may lead to poor wound healing and need for implant removal, which may delay subsequent oncologic treatment. We sought to characterize factors associated with mastectomy skin necrosis and propose a management algorithm.A retrospective review was performed on consecutive patients undergoing implant-based breast reconstruction by the senior author from 2006 through 2015. Patient-level factors including age, race, body mass index, history of hypertension, history of diabetes, history of smoking, and history of radiation were collected. Surgical factors including type of mastectomy, location of implant placement, and immediate versus delayed reconstruction were collected. The incidence and treatment of mastectomy skin necrosis were analyzed.A total of 293 patients underwent either unilateral or bilateral implant-based breast reconstructions after mastectomy with a total of 471 reconstructed breasts. Mastectomy skin necrosis was observed in 8.1% of reconstructed breasts. Skin necrosis was not associated with age, hypertension, diabetes, prior radiation, or type of mastectomy. The incidence of skin necrosis was higher among smokers (17.9% vs 5.0%, P < 0.001), among patients with higher body mass index (11.4% vs 6.1%, P = 0.05), patients who underwent immediate reconstruction compared to delayed (9.6% vs 0%, P = 0.004), placement of expander under acellular dermal matrix compared with submuscular placement (12.0% vs 5.2%, P = 0.02), and use of higher initial expander fill volume compared with lower fill volume (11.4% vs 5.4%, P = 0.02).The median necrosis size was 8 cm. The median time to treatment was 15 days postoperatively. In 55% of patients minor necrosis was treated with clinic debridement, whereas 43% had larger areas of necrosis requiring operative debridement. The median size treated with clinic debridement was 5.5 cm, compared to 15 cm for operative debridement. All necrosis was treated in a timely fashion and did not delay adjuvant therapy.Mastectomy skin necrosis occurred in 8.1% of breasts after implant-based reconstruction. Necrosis less than 10 cm can be treated successfully with local debridement in the clinic setting. Timely and appropriate treatment of skin necrosis with debridement and primary closure expedites wound healing and facilitates tissue expander breast reconstruction.
View details for DOI 10.1097/SAP.0000000000001045
View details for PubMedID 28301366
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The Effects of Music on Microsurgical Technique and Performance: A Motion Analysis Study.
Annals of plastic surgery
2017; 78 (5): S243-S247
Abstract
Music is commonly played in operating rooms (ORs) throughout the country. If a preferred genre of music is played, surgeons have been shown to perform surgical tasks quicker and with greater accuracy. However, there are currently no studies investigating the effects of music on microsurgical technique. Motion analysis technology has recently been validated in the objective assessment of plastic surgery trainees' performance of microanastomoses. Here, we aimed to examine the effects of music on microsurgical skills using motion analysis technology as a primary objective assessment tool.Residents and fellows in the Plastic and Reconstructive Surgery program were recruited to complete a demographic survey and participate in microsurgical tasks. Each participant completed 2 arterial microanastomoses on a chicken foot model, one with music playing, and the other without music playing. Participants were blinded to the study objectives and encouraged to perform their best. The order of music and no music was randomized. Microanastomoses were video recorded using a digitalized S-video system and deidentified. Video segments were analyzed using ProAnalyst motion analysis software for automatic noncontact markerless video tracking of the needle driver tip.Nine residents and 3 plastic surgery fellows were tested. Reported microsurgical experience ranged from 1 to 10 arterial anastomoses performed (n = 2), 11 to 100 anastomoses (n = 9), and 101 to 500 anastomoses (n = 1). Mean age was 33 years (range, 29-36 years), with 11 participants right-handed and 1 ambidextrous. Of the 12 subjects tested, 11 (92%) preferred music in the OR. Composite instrument motion analysis scores significantly improved with playing preferred music during testing versus no music (paired t test, P <0.001). Improvement with music was significant even after stratifying scores by order in which variables were tested (music first vs no music first), postgraduate year, and number of anastomoses (analysis of variance, P < 0.01).Preferred music in the OR may have a positive effect on trainees' microsurgical performance; as such, trainees should be encouraged to participate in setting the conditions of the OR to optimize their comfort and, possibly, performance. Moreover, motion analysis technology is a useful tool with a wide range of applications for surgical education and outcomes optimization.
View details for DOI 10.1097/SAP.0000000000001047
View details for PubMedID 28399026
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Penile Replantation: A Retrospective Analysis of Outcomes and Complications
JOURNAL OF RECONSTRUCTIVE MICROSURGERY
2017; 33 (4): 227-232
Abstract
Purpose Penile replantation is an uncommonly performed procedure, which can alleviate physical and psychosocial sequelae of penile amputation. This study critically appraises the current literature on penile replantation. Methods A comprehensive literature search of the Medline, PubMed, and Google Scholar databases was conducted with multiple search terms related to penile replantation. Data on outcomes, complications, and patient satisfaction were collected. Results A total of 74 articles met inclusion criteria. One hundred and six patients underwent penile replantation, but outcome, complication, and satisfaction data were not standardized across all patients. Penile amputation most often resulted from self-mutilation or trauma. The majority were complete amputations (74.8%). Full sensation was maintained in 68.4% of patients. Most reported adequate urinary function (97.4%) and normal erection (77.5%). Skin necrosis (54.8%) and venous congestion (20.2%) were the most common complications. Urethral stricture (11.0%) and fistula (6.6%) were common urethral complications. Most (91.6%) patients reported overall satisfaction although there was a lack of patient-reported outcomes. Multivariate analysis suggested that complete amputation (β = 3.15, 95% CI 0.41-5.89, p = 0.024), anastomosis of the superficial dorsal artery (β = 9.88, 95% CI 0.74-19.02, p = 0.034), and increasing number of nerves coapted (β = 1.75, 95% CI 0.11-3.38, p = 0.036) were associated with favorable sexual, urinary, and sensation outcomes. Increasing number of vessels anastomosed (β = -3.74, 95% CI -7.15 to -0.32, p = 0.032) was associated with unfavorable outcomes. Conclusion Although penile replantation is associated with complications, it has a high rate of satisfaction and efficacy. Coaptation of multiple nerves and anastomosis of the superficial dorsal artery should be completed.
View details for DOI 10.1055/s-0036-1597567
View details for Web of Science ID 000399586200001
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Transversus Abdominis Plane Block and Free Flap Abdominal Tissue Breast Reconstruction Is There a True Reduction in Postoperative Narcotic Use?
ANNALS OF PLASTIC SURGERY
2017; 78 (3): 254-259
Abstract
The use of the transversus abdominis plane (TAP) block is increasing in abdominally based autologous tissue breast reconstruction as a method to provide postoperative donor site analgesia. The purpose of this study was to evaluate the efficacy of the TAP block in the immediate postoperative period.A retrospective analysis of all patients who underwent autologous microsurgical breast reconstruction over a 2-year period (2013-2015) was conducted. Only patients with an abdominal donor site were included. Patients were grouped based on the presence or absence of TAP blocks. Primary endpoints included patient-reported pain score, daily and total narcotic use during the hospitalization, antiemetic use, as well as complications.We identified 40 patients that had undergone abdominal-based free flap breast reconstruction and TAP block catheter placement for postoperative analgesia that met inclusion criteria. This group was then compared with a matched cohort of 40 patients without TAP blocks. There were no complications associated with using the TAP catheters. There was no statistically significant difference in postoperative pain scores, daily or total narcotic use during the hospitalization, or antiemetic use between the 2 groups. Although not statistically significant, linear regression analysis identified trends of improved donor site analgesia in select groups, such as unilateral immediate reconstructions, body mass index greater than 30 kg/m, and those without abdominal mesh placed at the time of donor site closure in the TAP block group.Constant delivery of local anesthetic through the TAP block appears to be safe; however, it did not reduce narcotic requirements or postoperative pain scores in patients undergoing abdominal-based free flap breast reconstruction.
View details for DOI 10.1097/SAP.0000000000000873
View details for Web of Science ID 000394386700004
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Transversus Abdominis Plane Block and Free Flap Abdominal Tissue Breast Reconstruction: Is There a True Reduction in Postoperative Narcotic Use?
Annals of plastic surgery
2017; 78 (3): 254-259
Abstract
The use of the transversus abdominis plane (TAP) block is increasing in abdominally based autologous tissue breast reconstruction as a method to provide postoperative donor site analgesia. The purpose of this study was to evaluate the efficacy of the TAP block in the immediate postoperative period.A retrospective analysis of all patients who underwent autologous microsurgical breast reconstruction over a 2-year period (2013-2015) was conducted. Only patients with an abdominal donor site were included. Patients were grouped based on the presence or absence of TAP blocks. Primary endpoints included patient-reported pain score, daily and total narcotic use during the hospitalization, antiemetic use, as well as complications.We identified 40 patients that had undergone abdominal-based free flap breast reconstruction and TAP block catheter placement for postoperative analgesia that met inclusion criteria. This group was then compared with a matched cohort of 40 patients without TAP blocks. There were no complications associated with using the TAP catheters. There was no statistically significant difference in postoperative pain scores, daily or total narcotic use during the hospitalization, or antiemetic use between the 2 groups. Although not statistically significant, linear regression analysis identified trends of improved donor site analgesia in select groups, such as unilateral immediate reconstructions, body mass index greater than 30 kg/m, and those without abdominal mesh placed at the time of donor site closure in the TAP block group.Constant delivery of local anesthetic through the TAP block appears to be safe; however, it did not reduce narcotic requirements or postoperative pain scores in patients undergoing abdominal-based free flap breast reconstruction.
View details for DOI 10.1097/SAP.0000000000000873
View details for PubMedID 28118232
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Hospital Transfer of Open Tibial Fractures Requiring Microsurgical Reconstruction Negatively Impacts Clinical Outcomes.
Annals of plastic surgery
2017
Abstract
Open tibial fractures are orthopedic emergencies that may present with severe soft tissue damage. Free tissue transfer is often required when local tissues are insufficient and patients may require hospital transfer to tertiary care centers for this purpose. Although the negative impact of inter-facility transfer has been well demonstrated in trauma patients, less is known regarding transfers for lower extremity injury patients. This study investigates differences in outcomes based on transfer status after open tibial fracture.Thirty-four consecutive open tibial fractures requiring free tissue transfer over a 13-year period (2001-2014) were retrospectively reviewed. Patients transferred from outside facilities were compared to non-transferred patients in regards to demographics, injury, surgical characteristics, and outcomes (mean follow-up of 2.5 years). Student t tests and chi square analysis were used to compare means and proportions, respectively.One-half of patients were transferred from an outside hospital. Transferred and nontransferred patients were not significantly different in regard to age, sex, comorbidities, mechanism of injury, and Gustilo grade. There was no significant difference in the method of bony fixation or free flap used for soft tissue coverage. The time to wound vacuum-assisted closure placement was longer in transferred patients, though this difference was not found to be significant (2.4 vs 3.3 days, P = 0.55). Time to definitive bony fixation was delayed in the transfer group by 9 days (5.2 vs 14.1 days, P = 0.05) and to tissue coverage by 7 days (14.2 vs 20.9 days, P = 0.13). Rates of flap loss and amputation did not differ between the groups. However, transferred patients were more likely to develop osteomyelitis (risk ratio [RR], 3.0; P = 0.03), nonunion (RR, 5.0; P = 0.09), and require hardware removal (RR, 3.3; P = 0.01).Transferred and nontransferred patients were not significantly different in their demographics or presentation. However, an analysis of clinical outcomes showed that transfer was associated with increased rates of osteomyelitis, nonunion, and hardware removal. Although likely multifactorial, this study suggests that a delay to definitive fixation and soft tissue coverage contributes to the increased rate of complications and poorer prognosis.
View details for DOI 10.1097/SAP.0000000000000972
View details for PubMedID 28118229
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Critical Evaluation of Risk Factors of Infection Following 2-Stage Implant-Based Breast Reconstruction.
Plastic and reconstructive surgery. Global open
2017; 5 (7): e1386
Abstract
Infection is a dreaded complication following 2-stage implant-based breast reconstruction that can prolong the reconstructive process and lead to loss of implant. This study aimed to characterize outcomes of reconstructions complicated by infection, identify patient and surgical factors associated with infection, and use these to develop an infection management algorithm.We performed a retrospective review of all consecutive implant-based breast reconstructions performed by the senior author (2006-2015) and collected data regarding patient demographics, medical history, operative variables, presence of other complications (necrosis, seroma, hematoma), and infection characteristics. Univariate and multivariate binomial logistic regression analyses were performed to identify independent predictors of infection.We captured 292 patients who underwent 469 breast reconstructions. In total, 14.1% (n = 66) of breasts were complicated by infection, 87.9% (n = 58) of those were admitted and given intravenous antibiotics, 80.3% (n = 53) of all infections were cleared after the first attempt, whereas the remaining recurred at least once. The most common outcome was explantation (40.9%; n = 27), followed by secondary implant insertion (21.2%; n = 14) and operative salvage (18.2%; n = 12). Logistic regression analysis demonstrated that body mass index (P = 0.01), preoperative radiation (P = 0.02), necrosis (P < 0.001), seroma (P < 0.001), and hematoma (P = 0.03) were independent predictors of infection.We observed an overall infectious complication rate of 14.1%. Heavier patients and patients who received preoperative radiation were more likely to develop infectious complications, suggesting that closer monitoring of high risk patients can potentially minimize infectious complications. Further, more aggressive management may be warranted for patients whose operations are complicated by necrosis, seroma, or hematoma.
View details for PubMedID 28831338
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Penile Replantation: A Retrospective Analysis of Outcomes and Complications.
Journal of reconstructive microsurgery
2016
Abstract
Purpose Penile replantation is an uncommonly performed procedure, which can alleviate physical and psychosocial sequelae of penile amputation. This study critically appraises the current literature on penile replantation. Methods A comprehensive literature search of the Medline, PubMed, and Google Scholar databases was conducted with multiple search terms related to penile replantation. Data on outcomes, complications, and patient satisfaction were collected. Results A total of 74 articles met inclusion criteria. One hundred and six patients underwent penile replantation, but outcome, complication, and satisfaction data were not standardized across all patients. Penile amputation most often resulted from self-mutilation or trauma. The majority were complete amputations (74.8%). Full sensation was maintained in 68.4% of patients. Most reported adequate urinary function (97.4%) and normal erection (77.5%). Skin necrosis (54.8%) and venous congestion (20.2%) were the most common complications. Urethral stricture (11.0%) and fistula (6.6%) were common urethral complications. Most (91.6%) patients reported overall satisfaction although there was a lack of patient-reported outcomes. Multivariate analysis suggested that complete amputation (β = 3.15, 95% CI 0.41-5.89, p = 0.024), anastomosis of the superficial dorsal artery (β = 9.88, 95% CI 0.74-19.02, p = 0.034), and increasing number of nerves coapted (β = 1.75, 95% CI 0.11-3.38, p = 0.036) were associated with favorable sexual, urinary, and sensation outcomes. Increasing number of vessels anastomosed (β = -3.74, 95% CI -7.15 to -0.32, p = 0.032) was associated with unfavorable outcomes. Conclusion Although penile replantation is associated with complications, it has a high rate of satisfaction and efficacy. Coaptation of multiple nerves and anastomosis of the superficial dorsal artery should be completed.
View details for DOI 10.1055/s-0036-1597567
View details for PubMedID 28002849
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Reconstruction following abdominoperineal resection (APR): Indications and complications from a single institution experience
JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY
2016; 69 (11): 1506-1512
Abstract
Abdominoperineal resection (APR) is the surgical treatment of low-lying rectal cancers and other pelvic malignancies. Plastic surgery offers a means to close these complicated defects through obliterating dead space, providing tension-free closure, and introducing vascularized tissue into a radiated field. The indications for reconstructive surgery and choice of reconstruction are debatable. This study aims to identify when and which reconstruction is preferred.A retrospective comparative analysis was performed on all patients undergoing APR at Stanford Hospital between 2007 and 2013. Data points included demographics, disease, operative positioning, and postoperative complications. Univariate analysis and multivariate logistic regression analysis were performed to identify markers of flap reconstruction and complications.A total of 178 APRs were performed, of which 51 underwent flap reconstruction. The odds ratio of all complications between flap and primary closure was not significant at 1.36 (0.69-2.66). Independent predictors for flap reconstruction included prone positioning, anal squamous cell carcinoma (SCC), prior smoking, and neoadjuvant chemoradiation therapy. Univariate predictors of flap reconstruction included female gender and combined vaginectomy. Independent predictors of complications included current and prior smoking. Muscle flap closure had lower recipient site complications than V-to-Y advancement closure (20% vs. 50%, p = 0.039).Flap reconstruction following APR is associated with prone positioning, neoadjuvant chemoradiation, female gender, prior smoking, and anal SCC resections. Pedicled muscle flaps had a significantly lower rate of recipient site complications than V-to-Y advancement flaps and therefore should be the flap reconstruction of choice. The vertical rectus abdominis myocutaneous flap was superior to the gracilis flap in terms of the overall reduction of complications.
View details for DOI 10.1016/j.bjps.2016.06.024
View details for Web of Science ID 000388293400012
View details for PubMedID 27538340
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Cleft Lip Standardized Patient Examinations: The Role in Plastic Surgery Resident Education
CLEFT PALATE-CRANIOFACIAL JOURNAL
2016; 53 (6): 634-639
Abstract
Our institution has incorporated the use of objective structured clinical examinations (OSCE) in our residency curriculum. The OSCE provides trainee education and evaluation while addressing the six Accreditation Council for Graduate Medical Education (ACGME) core competencies required within training programs. We report our program's experience with the first cleft OSCE ever conducted. A validated method for administration of OSCEs currently used at our medical school was utilized for residents in postgraduate years (PGYs) 3 through 6. The video-recorded patient encounter involved a 1-month-old newborn with a unilateral cleft lip and palate and used standardized patient actors as parents. A post-encounter written exam assessed medical knowledge. A questionnaire regarding the utility of the exercise was administered to residents after the OSCE. Results were evaluated using analysis of variance (P < .05). There was a positive correlation with increasing level of training in terms of medical knowledge (P < .04). Residents in PGY-3 and PGY-4 demonstrated lower understanding of the surgical markings and details of the lip repair compared with those in PGY-5 and PGY-6 (P < .03). All residents performed similarly on evaluation of the remaining ACGME core competencies. All residents agreed that this was a realistic and useful encounter. Results of our cleft OSCE demonstrate that medical knowledge regarding the evaluation, management, and surgical repair of patients is less in midlevel residents. All residents expressed an interest in earlier exposure to pediatric patients in the training period. Although a cleft OSCE does not replace clinical rotations, it is a valuable adjunct to training and evaluation of trainees, particularly for junior residents.
View details for DOI 10.1597/15-121
View details for Web of Science ID 000388005700004
View details for PubMedID 26720521
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Immunological Effect of Skin Allograft in Burn Treatment: Impact on Future Vascularized Composite Allotransplantation.
Journal of burn care & research
2016: -?
Abstract
Skin allografts are the benchmark in temporary burn wound coverage, but allografts are hypothesized to place a high antigenic load on recipients. This project aims to determine the degree of human leukocyte antigen sensitization in burn patients treated with allografts. Serum was obtained from nine adult, nontransfused, and nontransplanted burn patients treated with allografts. Group 1 included patients tested in the acute burn period, while group 2 included different patients tested months to years after injury. A calculated panel reactive antibody (cPRA) percent was assessed for each patient, and data for a control group of 92 adult nontransplanted males were used for comparison. Each patient received allografts from an average 3.55 ± 1.24 different donors. cPRA in group 1 was lower than in group 2 (6 ± 12% vs 42 ± 33%, P = .08). cPRA in the study group was significantly higher than in the control group (26 ± 31% vs 8 ± 17%, P = .0075). Burn patients who receive skin allograft demonstrate increased immunological sensitization compared with unsensitized controls. Detection of human leukocyte antigen antibody is lower in the acute burn period than months to years after injury. Increased sensitization may ultimately limit burn patients' candidacy for vascularized composite allotransplantation or decrease success of these procedures.
View details for PubMedID 27801681
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Phalloplasty: A Review of Techniques and Outcomes.
Plastic and reconstructive surgery
2016; 138 (3): 594-615
Abstract
Acquired or congenital absence of the penis can lead to severe physical limitations and psychological outcomes. Phallic reconstruction can restore various functional aspects of the penis and reduce psychosocial sequelae. Moreover, some female-to-male transsexuals desire creation of a phallus as part of their gender transition. Because of the complexity of phalloplasty, there is not an ideal technique for every patient. This review sets out to identify and critically appraise the current literature on phalloplasty techniques and outcomes.A comprehensive literature search of the MEDLINE, PubMed, and Google Scholar databases was conducted for studies published through July of 2015 with multiple search terms related to phalloplasty. Data on techniques, outcomes, complications, and patient satisfaction were collected.A total of 248 articles were selected and reviewed from the 790 identified. Articles covered a variety of techniques on phalloplasty. Three thousand two hundred thirty-eight patients underwent phalloplasty, with a total of 1753 complications reported, although many articles did not explicitly comment on complications. One hundred four patients underwent penile replantation and two underwent penile transplantation. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction.Phalloplasty techniques are evolving to include a number of different flaps, and most techniques have high reported satisfaction rates. Penile replantation and transplantation are also options for amputation or loss of phallus. Further studies are required to better compare different techniques to more robustly establish best practices. However, based on these studies, it appears that phalloplasty is highly efficacious and beneficial to patients.
View details for DOI 10.1097/PRS.0000000000002518
View details for PubMedID 27556603
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Rhinoplasty Education Using a Standardized Patient Encounter.
Archives of plastic surgery
2016; 43 (5): 451-456
Abstract
Comprehensive aesthetic surgery training continues to be a challenge for residency programs. Our residency program developed a rhinoplasty-based objective structured clinical examination (OSCE) based upon validated methods as part of the residency education curriculum. We report our experience with the rhinoplasty-based OSCE and offer guidance to its incorporation within residency programs.The encounter involved resident evaluation and operative planning for a standardized patient desiring a rhinoplasty procedure. Validated OSCE methods currently used at our medical school were implemented. Residents were evaluated on appropriate history taking, physical examination, and explanation to the patient of treatment options. Examination results were evaluated using analysis of variance (statistical significance P<0.05).Twelve residents completed the rhinoplasty OSCE. Medical knowledge assessment showed increasing performance with clinical year, 50% versus 84% for postgraduate year 3 and 6, respectively (P<0.005). Systems-based practice scores showed that all residents incorrectly submitted forms for billing and operative scheduling. All residents confirmed that the OSCE realistically represents an actual patient encounter. All faculty confirmed the utility of evaluating resident performance during the OSCE as a useful assessment tool for determining the Next Accreditation System Milestone level.Aesthetic surgery training for residents will require innovative methods for education. Our examination showed a program-educational weakness in billing/coding, an area that will be improved upon by topic-specific lectures. A thoroughly developed OSCE can provide a realistic educational opportunity to improve residents' performance on the nonoperative aspects of rhinoplasty and should be considered as an adjunct to resident education.
View details for DOI 10.5999/aps.2016.43.5.451
View details for PubMedID 27689053
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Cross-Leg Flap-Sharing Technique Using an Anterolateral Thigh Perforator Flap
ARCHIVES OF PLASTIC SURGERY-APS
2016; 43 (4): 384-+
View details for PubMedID 27462575
View details for PubMedCentralID PMC4959985
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Clinical Significance of Internal Mammary Lymph Node Biopsy during Microsurgical Breast Reconstruction: Review of 264 Cases
PLASTIC AND RECONSTRUCTIVE SURGERY
2016; 137 (6): 917E-922E
Abstract
Despite the knowledge of alternate lymphatic draining patterns of the breast, routine evaluation of the internal mammary lymph node basin is still not considered standard of care. The advent of microsurgical breast reconstruction using the internal mammary vessels as recipients, however, has allowed sampling of internal mammary lymph nodes with technical ease, thus revisiting their role in breast cancer management. In the present study, the authors reviewed their experience with this practice.A retrospective analysis of patients who underwent internal mammary lymph node biopsy at the time of autologous breast reconstruction using the internal mammary vessels between 2004 and 2012 was performed. Parameters of interest included patient age, timing of reconstruction (immediate versus delayed), disease stage, and pathologic findings of internal mammary lymph nodes.A total of 264 autologous breast reconstructions using the internal mammary vessels were performed in 204 patients with a median age of 44.5 years. The majority of reconstructions were immediate [n = 211 (79.9 percent)]. Seventy-two percent of patients had either stage I [72 patients (35.3 percent)] or stage II disease [75 patients (36.8 percent)]. Six patients were found to have internal mammary lymph node metastasis. Stage migration and alteration in adjuvant therapy occurred in all patients.Internal mammary lymph node sampling at the time of autologous breast reconstruction using the internal mammary system should become routine practice, as the morbidity associated with internal mammary lymph node harvest is low and the impact in cases of nodal involvement is quite substantial.Therapeutic, IV.
View details for DOI 10.1097/PRS.0000000000002174
View details for Web of Science ID 000377098100001
View details for PubMedID 27219258
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Effects of A Novel Decision Aid for Breast Reconstruction: A Randomized Prospective Trial.
Annals of plastic surgery
2016; 76: S249-54
Abstract
The choice to undergo mastectomy and breast reconstruction is a highly personal decision with profound psychosocial effects, and ultimately, the decision between implant- and autologous tissue-based reconstruction should be made based on a combination of factual information and the patient's personal values and preferences. Unfortunately, patients undergoing breast reconstruction surgery may experience decision regret. Decision aids promote patient involvement in decision making by not only providing standard information about options, but also emphasizing comparative risks, benefits, and alternatives, and most importantly by providing clarification exercises regarding personal values to guide patients toward an individualized decision.We developed a novel decision aid to provide decision support and structured guidance for prosthetic, autologous, and combined prosthetic-autologous breast reconstruction surgery. New breast reconstruction patients of one surgeon at our institution were randomized by week to either receive the decision aid or standard preconsultation material. Immediately preceding their new patient consultation clinic visit, patients were asked to complete the validated Decisional Conflict Scale and the BREAST-Q Preoperative survey. After 3 to 5 months following breast mound reconstruction, patients were asked to complete the Decision Regret Scale, BREAST-Q Postoperative survey, and the Hospital Anxiety and Depression Scale.Patients who received the decision aid demonstrated a trend toward decreased preoperative decisional conflict (mean of 13.3 ± 5.5, compared to 26.2 ± 4.2; n = 8 per group, P = 0.069), with similar preoperative BREAST-Q scores. Most patients desired to know "everything" regarding their reconstruction surgery (75%), and to be "very involved" in the decisions in their care (81%), with remaining patients wanting to know "as much as I need to be prepared" and to be "somewhat involved." Postoperatively, patients who received the decision aid demonstrated significantly less decision regret (P < 0.001), although there was no significant difference in anxiety, depression, or quality of life-related outcomes as measured by the BREAST-Q.The use of decision aids in breast reconstruction surgery may help decrease decisional conflict and regret through promoting improved information sharing and shared decision making, which are highly important in this particular setting, patient population, and in our move toward greater patient-centered care.
View details for DOI 10.1097/SAP.0000000000000722
View details for PubMedID 27070681
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Should We Excise Native Breast Skin Envelope to Achieve Symmetric Scars in Bilateral Autologous Breast Reconstruction?-A Survey of Surgeon and Patient Preference.
Annals of plastic surgery
2016; 76: S175-8
Abstract
Given the multiple possible scar patterns in autologous breast reconstruction and combinations of such patterns in bilateral reconstruction, the present study aimed to determine the importance of scar symmetry in achieving aesthetically pleasing results.A survey was administered to 128 participants including plastic surgeons and female breast reconstruction patients. In part A of the survey, participants were provided with photos of bilateral autologous breast reconstructions, and scar placement was varied to represent bilateral (1) immediate, (2) delayed symmetric, (3) delayed asymmetric, and (4) a mixture of immediate and delayed free flap reconstructions. Participants were asked to rank the photos in order of best to worst aesthetic outcome. In part B, pairs of the same reconstruction before and after nipple-areolar complex (NAC) reconstruction were presented, and participants were asked to assign a score to each photo according to aesthetic outcome.In part A, immediate reconstructions that included the smallest flap skin paddles ranked best among 52.5% ± 30% of participants, followed by delayed symmetric reconstructions that ranked best in 46.7% ± 29.6%. Mixed reconstructions ranked worst among 53.6% ± 37.6% of participants, followed by delayed asymmetric reconstructions (42.5% ± 37.9%). When NAC reconstruction was added to 1 set of the photos in part A, the same immediate reconstruction was ranked best, a significantly higher proportion of the time (36.3% increase, P < 0.001). This was accompanied by a significant decrease in top ranking for the delayed symmetric reconstruction (37.9% decrease, P < 0.001). In part B, addition of NAC increased each reconstruction's score by an average of 1.36 points on a 5-point scale with patients citing less improvement between the conditions (0.93 ± 0.03) than plastic surgeons (1.13 ± 0.49) (P = 0.03).More symmetric breast scars led to higher aesthetic ranking of bilateral autologous breast reconstructions. Participants in our survey preferred symmetric scars, even if achieving such a scar pattern would require excision of native breast skin and inclusion of more flap skin. Furthermore, NAC reconstruction alone improves aesthetic outcome, and improvement was most notable among immediate reconstructions.
View details for DOI 10.1097/SAP.0000000000000775
View details for PubMedID 26954739
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World's First Baby Born Through Natural Insemination by Father With Total Phalloplasty Reconstruction
ANNALS OF PLASTIC SURGERY
2016; 76: S179-S183
Abstract
Techniques for neophallus reconstruction have become increasingly refined, fulfilling more criteria for what is considered to be the ideal penis reconstruction. For both trauma and transgender populations, the radial forearm free flap remains the gold standard, although the pedicled or free anterolateral thigh flap is becoming a favored alternative. Despite the remarkably high rates of sexual activity reported by patients having benefited from these techniques, sexual function remains a significant challenge due to frequent complications including autologous and prosthetic stiffener failure, fistula formation, and inadequate erogenous sensation. Perhaps the ultimate criterion for neophallus reconstruction is one which not only avoids these complications by meeting the immediate goals of a competent neourethra, sensitivity, bulk, and aesthetic form but also successfully combines them into their true overarching function: procreation. In this article, we report the case of a pedicled anterolateral thigh flap neophallus reconstruction which allowed a patient to naturally conceive a child through penetrative intercourse without use of a stiffener, and led to pregnancy and subsequent birth of a baby son. We review the surgical techniques and factors that led to this patient's successful progeny.
View details for DOI 10.1097/SAP.0000000000000769
View details for Web of Science ID 000375061200009
View details for PubMedID 27070679
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Superior Gluteal Artery Perforator Flap: The Beauty of the Buttock.
Annals of plastic surgery
2016; 76: S191-5
Abstract
The superior gluteal artery perforator (SGAP) flap is a useful technique for breast reconstruction. This perforator flap allows for the transfer of the patient's own skin and subcutaneous tissue with minimal donor-site morbidity. Despite its usefulness, the SGAP flap is not widely used among reconstructive surgeons. The challenging perforator dissection and need for microsurgery may contribute to the reluctant use of the flap by many reconstructive surgeons. The ability to perform a single-stage breast reconstruction with buttock tissue when abdominal or thigh tissue are unavailable provides a significant service to the patient desiring an autologous breast reconstruction.The authors performed a retrospective review and outcomes analysis of a single surgeon's surgical technique and experience. Consecutive patients, who underwent SGAP flaps for breast reconstruction during a 7-year period from 2007 to 2014, were compared to a matched cohort of consecutive patients undergoing deep inferior epigastric perforator (DIEP) flaps and clinical outcomes were analyzed.Thirteen patients underwent SGAP flap breast reconstruction for a total of 16 flaps during the study period compared to 34 consecutive DIEP flaps for breast reconstruction. There was no significant difference in flap or donor-site complications between the 2 groups. There was no statistically significant difference between the average operative time for unilateral breast reconstruction in the SGAP and DIEP flap groups. In 4 patients, a bipedicled SGAP flap was used due to perforator anatomy. All SGAP patients returned to full activity. Average follow-up time was 1 year.Although utilization of buttock tissue for breast reconstruction can be challenging and requires microsurgical expertise, in the hands of experienced microsurgeons the SGAP flap is a safe and reliable option for autologous breast reconstruction with minimal donor-site morbidity and excellent aesthetic results.
View details for DOI 10.1097/SAP.0000000000000723
View details for PubMedID 26808742
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The Use of the Sternocleidomastoid Flap Helps Reduce Complications After Free Jejunal Flap Reconstructions in Total Laryngectomy and Cervical Esophagectomy Defects.
Annals of plastic surgery
2016; 76: S209-12
Abstract
Esophageal reconstruction after tumor extirpation or ingestion injury is a difficult problem for the reconstructive plastic surgeon. Free tubed fasciocutaneous flaps and intestinal flaps have become the mainstay for reconstruction. The free jejunal flap has the advantage of replacing like-with-like tissue and having lower fistula rates. Additionally, the "mesenteric wrap" modification and prophylactic pectoralis major muscle have been described to further decrease anastomotic leaks and fistulae. The purpose of this study was to describe the use of the prophylactic pedicled sternocleidomastoid (SCM) flap for prevention of anastomotic leaks and fistulae.A retrospective review of patients who underwent reconstruction of circumferential pharyngoesophageal defects with a free jejunal flap by a single surgeon from 2008 to 2012 was performed. Those who received a prophylactic pedicled SCM flap to reinforce one of their jejunal anastomoses were selected for this study, and their outcomes were analyzed. Patients' demographics, comorbidities, complications, and clinical outcomes were collected and analyzed.Three patients underwent reinforcement of one jejunal anastomosis with a pedicled SCM flap. The mean age was 60 years, and average follow-up was 27 months. Two patients received postoperative radiation, and one patient received both preoperative and postoperative radiation. The recipient vessels included the facial artery, internal jugular vein, and facial vein. The flap survival rate was 100%. There was 1 stricture and 1 fistula that occurred at the anastomoses without the SCM muscle reinforcement. There were no complications at the jejunal anastomotic sites that were reinforced with the SCM muscle. Of the 6 anastomotic sites in 3 patients, there was a 0% fistula rate and 0% stricture rate at the sites reinforced with the SCM muscle versus a 33% fistula rate and a 33% stricture rate at the sites without the SCM muscle flap. One patient was diagnosed with local tumor recurrence and eventually succumbed to the progression of their disease. All patients were able to tolerate an oral diet without supplemental feeds. All patients were able to achieve intelligible speech via an electrolarynx or esophageal speech.Reconstruction of pharyngoesophageal defects can be technically challenging and requires extensive planning and careful execution. The free jejunal flap restores alimentary continuity with good functional outcomes. Fistula rates may be decreased with the use of a prophylactic SCM flap to reinforce the jejunal anastomosis.
View details for DOI 10.1097/SAP.0000000000000724
View details for PubMedID 26849282
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Cell-Assisted Lipotransfer Improves Volume Retention in Irradiated Recipient Sites and Rescues Radiation-Induced Skin Changes
STEM CELLS
2016; 34 (3): 668-673
Abstract
Radiation therapy is not only a mainstay in the treatment of many malignancies but also results in collateral obliteration of microvasculature and dermal/subcutaneous fibrosis. Soft tissue reconstruction of hypovascular, irradiated recipient sites through fat grafting remains challenging; however, a coincident improvement in surrounding skin quality has been noted. Cell-assisted lipotransfer (CAL), the enrichment of fat with additional adipose-derived stem cells (ASCs) from the stromal vascular fraction, has been shown to improve fat volume retention, and enhanced outcomes may also be achieved with CAL at irradiated sites. Supplementing fat grafts with additional ASCs may also augment the regenerative effect on radiation-damaged skin. In this study, we demonstrate the ability for CAL to enhance fat graft volume retention when placed beneath the irradiated scalps of immunocompromised mice. Histologic metrics of fat graft survival were also appreciated, with improved structural qualities and vascularity. Finally, rehabilitation of radiation-induced soft tissue changes were also noted, as enhanced amelioration of dermal thickness, collagen content, skin vascularity, and biomechanical measures were all observed with CAL compared to unsupplemented fat grafts. Supplementation of fat grafts with ASCs therefore shows promise for reconstruction of complex soft tissue defects following adjuvant radiotherapy. Stem Cells 2016;34:668-673.
View details for DOI 10.1002/stem.2256
View details for Web of Science ID 000372552600013
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Cell-Assisted Lipotransfer Improves Volume Retention in Irradiated Recipient Sites and Rescues Radiation-Induced Skin Changes.
Stem cells
2016; 34 (3): 668-673
Abstract
Radiation therapy is not only a mainstay in the treatment of many malignancies but also results in collateral obliteration of microvasculature and dermal/subcutaneous fibrosis. Soft tissue reconstruction of hypovascular, irradiated recipient sites through fat grafting remains challenging; however, a coincident improvement in surrounding skin quality has been noted. Cell-assisted lipotransfer (CAL), the enrichment of fat with additional adipose-derived stem cells (ASCs) from the stromal vascular fraction, has been shown to improve fat volume retention, and enhanced outcomes may also be achieved with CAL at irradiated sites. Supplementing fat grafts with additional ASCs may also augment the regenerative effect on radiation-damaged skin. In this study, we demonstrate the ability for CAL to enhance fat graft volume retention when placed beneath the irradiated scalps of immunocompromised mice. Histologic metrics of fat graft survival were also appreciated, with improved structural qualities and vascularity. Finally, rehabilitation of radiation-induced soft tissue changes were also noted, as enhanced amelioration of dermal thickness, collagen content, skin vascularity, and biomechanical measures were all observed with CAL compared to unsupplemented fat grafts. Supplementation of fat grafts with ASCs therefore shows promise for reconstruction of complex soft tissue defects following adjuvant radiotherapy. Stem Cells 2016;34:668-673.
View details for DOI 10.1002/stem.2256
View details for PubMedID 26661694
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Coverage of defect over toes after failure of microsurgical replantation with medial sural artery perforator flap: A case report
MICROSURGERY
2016; 36 (2): 161–64
Abstract
In this report, we present a case of toe reconstruction with a medial sural artery perforator free flap after failure of replantation. A 35-year-old male suffered a crush injury from a heavy object falling over the left 1st, 2nd, and 3rd toes and underwent microsurgical replantation of the toes at an outside facility. Over the next 2 weeks, ischemic necrosis of all the toes developed. This condition was very frustrating for the patient who had very high expectations of preserving the toes, and also for the surgeon to determine the optimal method to reconstruct the distal foot and toes. After debridement of non-viable tissues, the defect over the toes was resurfaced using a medial sural artery perforator free flap and full thickness skin graft. Subsequently, several minor operations, including interdigitation, excision of neuromas, and defatting procedure were performed to complete his reconstruction. Eighteen months later, the patient had very aesthetically pleasing and fully functional toes. A medial sural artery perforator free flap may be used to repair the soft tissue defect on the toes after failed replantation, and provides sufficient skin.
View details for PubMedID 25867277
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Clinical outcomes in breast cancer expander-implant reconstructive patients with radiation therapy
JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY
2016; 69 (1): 14-22
Abstract
Immediate expander-implant breast reconstruction (EIBR) with external beam radiation therapy (XRT) is pursued by many breast cancer patients; however, there is still a lack of consensus on the expected clinical outcomes. We performed a critical analysis of postoperative outcomes in EIBR patients with XRT exposure through a retrospective review from January 2007 to December 2013. Patients were stratified into three groups: exposure to preoperative XRT (XRT-pre), postoperative XRT (XRT-post), or no XRT (control). A subset of XRT patients with bilateral EIBR was assessed using a matched-pair analysis with the patients serving as their own controls. A total of 76 patients were included in the study. Major complications were observed in 6 of 8, 26 of 38, and 14 of 30 patients in the XRT-pre, XRT-post, and control groups, respectively, and were not statistically different (p > 0.05). EIBR failure rates were 13.3% in the control group compared to 50.0% in the XRT-pre group (p = 0.044) and 26.3% in the XRT-post group (p > 0.05). In the matched-pair analysis, 16 of 26 irradiated breasts developed complications compared to only 7 of 26 contralateral non-irradiated breasts (p = 0.043). In conclusion, we detected a significantly increased risk of complications in patients with pre-mastectomy radiotherapy. Patients with this history of XRT should strongly consider autologous reconstruction instead of EIBR to avoid the high risk of developing complications and subsequently losing their implant. Increased complications in irradiated breasts when compared to the contralateral non-irradiated breasts in bilateral EIBR patients confirmed the detrimental role of XRT in the setting of EIBR.
View details for DOI 10.1016/j.bjps.2015.08.032
View details for Web of Science ID 000367236800007
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Clinical outcomes in breast cancer expander-implant reconstructive patients with radiation therapy.
Journal of plastic, reconstructive & aesthetic surgery : JPRAS
2016; 69 (1): 14-22
Abstract
Immediate expander-implant breast reconstruction (EIBR) with external beam radiation therapy (XRT) is pursued by many breast cancer patients; however, there is still a lack of consensus on the expected clinical outcomes. We performed a critical analysis of postoperative outcomes in EIBR patients with XRT exposure through a retrospective review from January 2007 to December 2013. Patients were stratified into three groups: exposure to preoperative XRT (XRT-pre), postoperative XRT (XRT-post), or no XRT (control). A subset of XRT patients with bilateral EIBR was assessed using a matched-pair analysis with the patients serving as their own controls. A total of 76 patients were included in the study. Major complications were observed in 6 of 8, 26 of 38, and 14 of 30 patients in the XRT-pre, XRT-post, and control groups, respectively, and were not statistically different (p > 0.05). EIBR failure rates were 13.3% in the control group compared to 50.0% in the XRT-pre group (p = 0.044) and 26.3% in the XRT-post group (p > 0.05). In the matched-pair analysis, 16 of 26 irradiated breasts developed complications compared to only 7 of 26 contralateral non-irradiated breasts (p = 0.043). In conclusion, we detected a significantly increased risk of complications in patients with pre-mastectomy radiotherapy. Patients with this history of XRT should strongly consider autologous reconstruction instead of EIBR to avoid the high risk of developing complications and subsequently losing their implant. Increased complications in irradiated breasts when compared to the contralateral non-irradiated breasts in bilateral EIBR patients confirmed the detrimental role of XRT in the setting of EIBR.
View details for DOI 10.1016/j.bjps.2015.08.032
View details for PubMedID 26453182
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Flow-through omental flap to free anterolateral thigh flap for complex chest wall reconstruction: Case report and review of the literature.
Microsurgery
2016; 36 (1): 70-76
Abstract
Despite the options currently available for chest wall reconstruction, patients with complex composite defects may still pose a significant challenge for the reconstructive surgeon when only using conventional methods. In particular, prior radiotherapy and/or large en bloc resection may leave inadequate regional flaps and recipient vessels for free tissue transfer. Here, we describe a case in which we reconstruct a 14 cm × 18 cm complex chest wall defect, secondary to tumor resection and infected sternum debridement, with a pedicled flow-through omental flap to a 14 cm × 22 cm free anterolateral thigh flap using the omental gastroepiploic vessels as recipient vessels. Reconstruction was successful with excellent flap viability, and no complications at recipient or donor sites. We review the literature on complex chest wall reconstruction and introduce this valuable option of utilizing a pedicled omental flap as a flow-through flap to a free flap for patients without viable recipient vessels or local flaps.
View details for DOI 10.1002/micr.22444
View details for PubMedID 26140609
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Ex Vivo Expansion and In Vivo Self-Renewal of Human Muscle Stem Cells
STEM CELL REPORTS
2015; 5 (4): 621-632
Abstract
Adult skeletal muscle stem cells, or satellite cells (SCs), regenerate functional muscle following transplantation into injured or diseased tissue. To gain insight into human SC (huSC) biology, we analyzed transcriptome dynamics by RNA sequencing of prospectively isolated quiescent and activated huSCs. This analysis indicated that huSCs differentiate and lose proliferative potential when maintained in high-mitogen conditions ex vivo. Further analysis of gene expression revealed that p38 MAPK acts in a transcriptional network underlying huSC self-renewal. Activation of p38 signaling correlated with huSC differentiation, while inhibition of p38 reversibly prevented differentiation, enabling expansion of huSCs. When transplanted, expanded huSCs differentiated to generate chimeric muscle and engrafted as SCs in the sublaminar niche with a greater frequency than freshly isolated cells or cells cultured without p38 inhibition. These studies indicate characteristics of the huSC transcriptome that promote expansion ex vivo to allow enhanced functional engraftment of a defined population of self-renewing huSCs.
View details for DOI 10.1016/j.stemcr.2015.08.004
View details for PubMedID 26344908
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Motion Analysis for Microsurgical Training: Objective Measures of Dexterity, Economy of Movement, and Ability.
Plastic and reconstructive surgery
2015; 136 (2): 231e-40e
Abstract
Evaluation of skill acquisition in microsurgery has traditionally relied on subjective opinions of senior faculty, but is shifting toward early competency-based training using validated models. No objective measures of dexterity, economy of movement, and ability exist. The authors propose a novel video instrument motion analysis scoring system to objectively measure motion.Video of expert microsurgeons was analyzed and used to develop a resident motion analysis scoring system based on a mathematical model. Motion analysis scores were compared to blinded, global rating scores of the same videos using the Stanford Microsurgery and Resident Training scale.Eighty-five microsurgical anastomoses from 16 residents ranging from postgraduate years 1 through 6 were analyzed. Composite motion analysis scores for each segmented video correlated positively to arterial anastomotic experience (rho, +0.77; p < 0.001). Stanford Microsurgery and Resident Training scale interrater reliability was consistent between expert assessors, and mean composite motion analysis overall performance and Stanford scores were well matched for each level of experience. Composite motion analysis scores correlated significantly with combined Stanford Microsurgery and Resident Training [instrument handling (rho, +0.66; p < 0.01), efficiency (rho, +0.59; p < 0.01), suture handling (rho, +0.83; p < 0.001), operative flow (rho, +0.67; p < 0.001), and overall performance (rho, +89; p < 0.001)] motion components of the scale.Instrument motion analysis provides a novel, reliable, and consistent objective assessment for microsurgical trainees. It has an associated cost, but is timely, repeatable, and senior physician independent, and exposes patients to zero risk.
View details for DOI 10.1097/PRS.0000000000001469
View details for PubMedID 26218398
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Video-Based Self-Review Comparing Google Glass and GoPro Technologies
ANNALS OF PLASTIC SURGERY
2015; 74: S71-S74
Abstract
Professionals in a variety of specialties use video-based review as a method of constant self-evaluation. We believe critical self-reflection will allow a surgical trainee to identify methods for improvement throughout residency and beyond. We have used 2 new popular technologies to evaluate their role in accomplishing the previously mentioned objectives.Our group investigated Google Glass and GoPro cameras. Medical students, residents, and faculty were invited to wear each of the devices during a scheduled operation. After the case, each participant was asked to comment on a number of features of the device including comfort, level of distraction/interference with operating, ease of video acquisition, and battery life. Software and hardware specifications were compiled and compared by the authors. A "proof-of-concept" was also performed using the video-conferencing abilities of Google Glass to perform a simulated flap check.The technical specifications of the 2 cameras favor GoPro over Google Glass. Glass records in 720p with 5-MP still shots, and the GoPro records in 1080p with 12-MP still shots. Our tests of battery life showed more than 2 hours of continuous video with GoPro, and less than 1 hour for Glass. Favorable features of Google Glass included comfort and relative ease of use; they could not comfortably wear loupes while operating, and would have preferred longer hands-free video recording. The GoPro was slightly more cumbersome and required a nonsterile team member to activate all pictures or video; however, loupes could be worn. Google Glass was successfully used in the hospital for a simulated flap check, with overall audio and video being transmitted-fine detail was lost, however.There are benefits and limitations to each of the devices tested. Google Glass is in its infancy and may gain a larger intraoperative role in the future. We plan to use Glass as a way for trainees to easily acquire intraoperative footage as a means to "review tape" and will use the GoPro to amass a video library of commonly performed operations.
View details for DOI 10.1097/SAP.0000000000000423
View details for Web of Science ID 000360629600017
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Algorithmic Approach to the Design and Harvest of Abdominal Flaps for Microvascular Breast Reconstruction in Patients With Abdominal Scars
ANNALS OF PLASTIC SURGERY
2015; 74: S33-S40
Abstract
Risk of abdominal free flaps complications and the risk of abdominal wound complications from surgery are significantly increased in patients with previous abdominal surgeries. Previous scars can limit the vascularized territories suitable for transfer and can lead to significant partial flap necrosis.A retrospective review of abdominal free flap breast reconstructions performed by the senior author (GKL) over 5 years (2008-2013). Patients were grouped based on the presence or absence of abdominal scars and specific type/location of scar(s). In addition, we analyzed patient information. including demographics, body mass index, smoking history, comorbid conditions, and most importantly, surgical techniques to optimize vascular perfusion.We identified 169 patients that underwent abdominal perforator free flap breast reconstruction. One hundred nine patients underwent previous abdominal surgery. Within this group, we had 2 complete flap losses, 5 major flap complications, 9 minor flap complications, and 9 donor site complications. Sixty patients had no previous abdominal surgery. Of these patients, we had no complete flap losses, 2 major flap complications, 1 minor flap complication, and 4 donor site complications. Patients with previous abdominal surgeries undergoing abdominal free flap breast reconstruction had a statistically significant higher rate of flap complications (P=0.02). Donor site wound healing complications were not statistically significant (P=0.5). The subgroup of patients that had both a previous intra-abdominal surgery scar and Pfannenstiel scar (21 patients) were at greatest risk for both free flap (19% of patients) and donor site wound healing (19% of patients) complications.Abdominal scars increase the risk of complications to the free flap. Unlike previous studies, patients with abdominal scars do not appear to have a statistically significant increase for donor site complications. Using the data from our study, we developed an algorithm for abdominal flap harvest in patients with abdominal scars. The algorithm emphasizes the importance of bipedicled perforator flaps and supercharging/turbocharging when blood flow is required across scars or when a large volume of tissue is needed crossing the midline. In specific cases, where perforator viability is in question because of a previous abdominal surgical procedure, we recommend the inclusion of muscle (Muscle-Sparing-transverse rectus abdominis musculocutaneous vs transverse rectus abdominis musculocutaneous).
View details for DOI 10.1097/SAP.0000000000000509
View details for Web of Science ID 000360629600010
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Algorithmic approach to the design and harvest of abdominal flaps for microvascular breast reconstruction in patients with abdominal scars.
Annals of plastic surgery
2015; 74: S33-40
Abstract
Risk of abdominal free flaps complications and the risk of abdominal wound complications from surgery are significantly increased in patients with previous abdominal surgeries. Previous scars can limit the vascularized territories suitable for transfer and can lead to significant partial flap necrosis.A retrospective review of abdominal free flap breast reconstructions performed by the senior author (GKL) over 5 years (2008-2013). Patients were grouped based on the presence or absence of abdominal scars and specific type/location of scar(s). In addition, we analyzed patient information. including demographics, body mass index, smoking history, comorbid conditions, and most importantly, surgical techniques to optimize vascular perfusion.We identified 169 patients that underwent abdominal perforator free flap breast reconstruction. One hundred nine patients underwent previous abdominal surgery. Within this group, we had 2 complete flap losses, 5 major flap complications, 9 minor flap complications, and 9 donor site complications. Sixty patients had no previous abdominal surgery. Of these patients, we had no complete flap losses, 2 major flap complications, 1 minor flap complication, and 4 donor site complications. Patients with previous abdominal surgeries undergoing abdominal free flap breast reconstruction had a statistically significant higher rate of flap complications (P=0.02). Donor site wound healing complications were not statistically significant (P=0.5). The subgroup of patients that had both a previous intra-abdominal surgery scar and Pfannenstiel scar (21 patients) were at greatest risk for both free flap (19% of patients) and donor site wound healing (19% of patients) complications.Abdominal scars increase the risk of complications to the free flap. Unlike previous studies, patients with abdominal scars do not appear to have a statistically significant increase for donor site complications. Using the data from our study, we developed an algorithm for abdominal flap harvest in patients with abdominal scars. The algorithm emphasizes the importance of bipedicled perforator flaps and supercharging/turbocharging when blood flow is required across scars or when a large volume of tissue is needed crossing the midline. In specific cases, where perforator viability is in question because of a previous abdominal surgical procedure, we recommend the inclusion of muscle (Muscle-Sparing-transverse rectus abdominis musculocutaneous vs transverse rectus abdominis musculocutaneous).
View details for DOI 10.1097/SAP.0000000000000509
View details for PubMedID 25875909
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Video-based self-review: comparing Google Glass and GoPro technologies.
Annals of plastic surgery
2015; 74: S71-4
Abstract
Professionals in a variety of specialties use video-based review as a method of constant self-evaluation. We believe critical self-reflection will allow a surgical trainee to identify methods for improvement throughout residency and beyond. We have used 2 new popular technologies to evaluate their role in accomplishing the previously mentioned objectives.Our group investigated Google Glass and GoPro cameras. Medical students, residents, and faculty were invited to wear each of the devices during a scheduled operation. After the case, each participant was asked to comment on a number of features of the device including comfort, level of distraction/interference with operating, ease of video acquisition, and battery life. Software and hardware specifications were compiled and compared by the authors. A "proof-of-concept" was also performed using the video-conferencing abilities of Google Glass to perform a simulated flap check.The technical specifications of the 2 cameras favor GoPro over Google Glass. Glass records in 720p with 5-MP still shots, and the GoPro records in 1080p with 12-MP still shots. Our tests of battery life showed more than 2 hours of continuous video with GoPro, and less than 1 hour for Glass. Favorable features of Google Glass included comfort and relative ease of use; they could not comfortably wear loupes while operating, and would have preferred longer hands-free video recording. The GoPro was slightly more cumbersome and required a nonsterile team member to activate all pictures or video; however, loupes could be worn. Google Glass was successfully used in the hospital for a simulated flap check, with overall audio and video being transmitted-fine detail was lost, however.There are benefits and limitations to each of the devices tested. Google Glass is in its infancy and may gain a larger intraoperative role in the future. We plan to use Glass as a way for trainees to easily acquire intraoperative footage as a means to "review tape" and will use the GoPro to amass a video library of commonly performed operations.
View details for DOI 10.1097/SAP.0000000000000423
View details for PubMedID 25664407
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Abdominal compartment syndrome as a rare complication following component separation repair: case report and review of the literature
HERNIA
2015; 19 (2): 293-299
Abstract
One of the most feared complications following a massive ventral hernia repair is abdominal compartment syndrome (ACS). ACS is caused by an acute increase in intra-abdominal pressure (IAP), which can lead to multi-organ dysfunction and ultimately result in death. Component separation repair (CST) has been successful for most large hernia repairs in reducing the risk of ACS by increasing abdominal volume and reducing abdominal wall tension during a tight closure. However, reduction of a large hernia can lead to elevated IAP and possible progression to ACS. Here, we describe the detailed intra-operative and post-operative course of a patient who developed abdominal compartment syndrome following CST repair.
View details for DOI 10.1007/s10029-015-1362-9
View details for PubMedID 25739715
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Systematic Reviews Addressing Microsurgical Head and Neck Reconstruction
JOURNAL OF CRANIOFACIAL SURGERY
2015; 26 (1): 214-217
Abstract
Systematic reviews frequently form the basis for clinical decision making and guideline development. Yet, the quality of systematic reviews has been variable, thus raising concerns about the validity of their conclusions. In the current study, a quality analysis of systematic reviews was performed, addressing microsurgical head and neck reconstruction.A PubMed search was performed to identify all systematic reviews published up to and including December 2012 in 12 surgical journals. Two authors independently reviewed the literature and extracted data from the included reviews. Discrepancies were resolved by consensus. Quality assessment was performed using AMSTAR.The initial search retrieved 1020 articles. After screening titles and abstracts, 987 articles were excluded. Full-text review of the remaining 33 articles resulted in further exclusion of 18 articles, leaving 15 systematic reviews for final analysis. A marked increase in the number of published systematic reviews over time was noted (P = 0.07). The median AMSTAR score was 5, thus reflecting a "fair" quality. No evidence for improvement in methodological quality over time was noted.The trend to publish more systematic reviews in microsurgical head and neck reconstruction is encouraging. However, efforts are indicated to improve the methodological quality of systematic reviews. Familiarity with criteria of methodological quality is critical to ensure future improvements in the quality of systematic reviews conducted in microsurgery.
View details for DOI 10.1097/SCS.0000000000001248
View details for Web of Science ID 000347954400083
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Reconstruction With Pedicled Anterolateral Thigh Flap After Wide Local Excision of Penoscrotal Extramammary Paget's Disease: A Case Report and Comprehensive Literature Review.
Eplasty
2015; 15
Abstract
The clinical characteristics, management, and prognostic indicators of penoscrotal extramammary Paget's disease are not clearly defined. Surgical excision is often an effective treatment modality but results in a large wound after resection of all involved tissues.Reconstruction of large penoscrotal soft-tissue defects after wide local excision remains a challenge to the reconstructive surgeon. The use of the anterolateral thigh flap for penoscrotal reconstruction after resection of extramammary Paget's disease is infrequent as a reconstruction tool throughout the literature.We discuss a case where the anterolateral thigh flap was effectively used for reconstruction of a large penoscrotal defect after wide local excision of penoscrotal extramammary Paget's disease and present a comprehensive literature review of extramammary Paget's disease key features, diagnosis, prognosis, and treatment.The anterolateral thigh flap is a useful tool for penoscrotal defect reconstruction.
View details for PubMedID 26171098
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Systematic reviews addressing microsurgical head and neck reconstruction.
journal of craniofacial surgery
2015; 26 (1): 210-213
Abstract
Systematic reviews frequently form the basis for clinical decision making and guideline development. Yet, the quality of systematic reviews has been variable, thus raising concerns about the validity of their conclusions. In the current study, a quality analysis of systematic reviews was performed, addressing microsurgical head and neck reconstruction.A PubMed search was performed to identify all systematic reviews published up to and including December 2012 in 12 surgical journals. Two authors independently reviewed the literature and extracted data from the included reviews. Discrepancies were resolved by consensus. Quality assessment was performed using AMSTAR.The initial search retrieved 1020 articles. After screening titles and abstracts, 987 articles were excluded. Full-text review of the remaining 33 articles resulted in further exclusion of 18 articles, leaving 15 systematic reviews for final analysis. A marked increase in the number of published systematic reviews over time was noted (P = 0.07). The median AMSTAR score was 5, thus reflecting a "fair" quality. No evidence for improvement in methodological quality over time was noted.The trend to publish more systematic reviews in microsurgical head and neck reconstruction is encouraging. However, efforts are indicated to improve the methodological quality of systematic reviews. Familiarity with criteria of methodological quality is critical to ensure future improvements in the quality of systematic reviews conducted in microsurgery.
View details for DOI 10.1097/SCS.0000000000001248
View details for PubMedID 25478976
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Motion Analysis for Microsurgical Training: Objective Measures of Dexterity, Economy of Movement, and Ability
Plastic and Reconstructive Surgery
2015; 136 (2): 231e–240e
Abstract
Evaluation of skill acquisition in microsurgery has traditionally relied on subjective opinions of senior faculty, but is shifting toward early competency-based training using validated models. No objective measures of dexterity, economy of movement, and ability exist. The authors propose a novel video instrument motion analysis scoring system to objectively measure motion.Video of expert microsurgeons was analyzed and used to develop a resident motion analysis scoring system based on a mathematical model. Motion analysis scores were compared to blinded, global rating scores of the same videos using the Stanford Microsurgery and Resident Training scale.Eighty-five microsurgical anastomoses from 16 residents ranging from postgraduate years 1 through 6 were analyzed. Composite motion analysis scores for each segmented video correlated positively to arterial anastomotic experience (rho, +0.77; p < 0.001). Stanford Microsurgery and Resident Training scale interrater reliability was consistent between expert assessors, and mean composite motion analysis overall performance and Stanford scores were well matched for each level of experience. Composite motion analysis scores correlated significantly with combined Stanford Microsurgery and Resident Training [instrument handling (rho, +0.66; p < 0.01), efficiency (rho, +0.59; p < 0.01), suture handling (rho, +0.83; p < 0.001), operative flow (rho, +0.67; p < 0.001), and overall performance (rho, +89; p < 0.001)] motion components of the scale.Instrument motion analysis provides a novel, reliable, and consistent objective assessment for microsurgical trainees. It has an associated cost, but is timely, repeatable, and senior physician independent, and exposes patients to zero risk.
View details for DOI 10.1097/PRS.0000000000001469
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Restoration of oral competence in double free flap reconstructions of massive lower facial defects with fascia lata slings - Case series and review of the literature
CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY
2015; 2 (3-4): 67–72
Abstract
Restoration of adequate oral competence is especially challenging in double free flap reconstructions of massive head and neck defects resulting from composite resections. Our report illustrates that oral competence in double free flap reconstructions of extensive oromandibular defects can be successfully restored with tensor fascia lata suspension slings.
View details for PubMedID 27252975
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Design and Focus Test of a Preconsultation Decision Aid for Breast Cancer Reconstruction Patients: A Quality Improvement Initiative.
Eplasty
2015; 15
Abstract
To design, develop, and evaluate via focus group a preconsultation decision aid to improve patient satisfaction for breast reconstruction.The design of the decision aid was based on perceived patient needs, literature, existing decision aids, and current standard of breast cancer reconstruction treatment and consultation at Stanford. Our decision aid was designed to (1) reducing fear of the unknown in patients via providing a knowledge base that they can rely on, (2) helping patients identify their key breast reconstruction concerns, (3) addressing common patient concerns, (4) providing a framework to help patients identify the treatment option that may be right for them, and (5) promoting shared decision making. Physicians were consulted on the decision aid, following which a focus group was conducted for patient feedback.Interviewed patients (n = 12) were supportive of the decision aid initiative. Participants were especially pleased with the side-by-side comparison of surgical options and the parsimonious way information was represented. All patients before undergoing reconstruction (n = 3) requested the decision guide to reference at home. All interviewed patients believed information level was "about right."Decision aid was well received by patients in the focus group. As the initiative is for quality improvement, we saw no need to further delay the distribution of the decision aid. A pilot study will be conducted to evaluate whether our decision aid has an effect on patients' decision regret, stress, and anxiety.
View details for PubMedID 26171096
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Cloud-Based Applications for Organizing and Reviewing Plastic Surgery Content.
Eplasty
2015; 15
Abstract
Cloud-based applications including Box, Dropbox, Google Drive, Evernote, Notability, and Zotero are available for smartphones, tablets, and laptops and have revolutionized the manner in which medical students and surgeons read and utilize plastic surgery literature. Here we provide an overview of the use of Cloud computing in practice and propose an algorithm for organizing the vast amount of plastic surgery literature. Given the incredible amount of data being produced in plastic surgery and other surgical subspecialties, it is prudent for plastic surgeons to lead the process of providing solutions for the efficient organization and effective integration of the ever-increasing data into clinical practice.
View details for PubMedID 26576208
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Modified Transconjunctival Lower Lid Approach for Orbital Fractures in East Asian Patients: The Lateral Paracanthal Incision Revisited
PLASTIC AND RECONSTRUCTIVE SURGERY
2014; 134 (5): 1023-1030
Abstract
Optimal repair of an orbital fracture requires adequate exposure into the orbit. The transconjunctival approach with lateral canthotomy is a valid option in East Asian patients, who are especially sensitive to the appearance of an external skin scar, although one must also recognize the potential complications associated with eyelid aperture mechanics. The authors report the modification of the transconjunctival approach, in which a lateral paracanthal incision is made along with division of the lateral tarsal plate but not at the lateral canthus. This was developed to overcome the complications of traditional lateral cantholysis.A retrospective chart review was performed for all patients who had received the modified transconjunctival incision. Patient demographics, injury characteristics, and surgical outcomes were evaluated.The baseline demographics of 30 patients in this study was typical of orbital fractures in the Korean population. A take-back operation was required in one case of preseptal hematoma. The mean follow-up period was 6 months, and no long-term functional complications were identified. Of the 30 total patients, 29 showed excellent aesthetic outcome. One patient did present with postoperative notch deformity but did not feel the need for a revision operation.The transconjunctival approach with a lateral paracanthal incision is an alternative approach to the orbital wall. The decoupling of the lower eyelid through the lateral portion of the tarsal plate provides excellent exposure of the orbital floor and provides a reliable and consistent landmark by which the anatomy of the eyelid can be restored. The aesthetic and functional outcomes are excellent.Therapeutic, IV.
View details for DOI 10.1097/PRS.0000000000000639
View details for Web of Science ID 000344546000053
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Modified transconjunctival lower lid approach for orbital fractures in East Asian patients: the lateral paracanthal incision revisited.
Plastic and reconstructive surgery
2014; 134 (5): 1023-30
Abstract
Optimal repair of an orbital fracture requires adequate exposure into the orbit. The transconjunctival approach with lateral canthotomy is a valid option in East Asian patients, who are especially sensitive to the appearance of an external skin scar, although one must also recognize the potential complications associated with eyelid aperture mechanics. The authors report the modification of the transconjunctival approach, in which a lateral paracanthal incision is made along with division of the lateral tarsal plate but not at the lateral canthus. This was developed to overcome the complications of traditional lateral cantholysis.A retrospective chart review was performed for all patients who had received the modified transconjunctival incision. Patient demographics, injury characteristics, and surgical outcomes were evaluated.The baseline demographics of 30 patients in this study was typical of orbital fractures in the Korean population. A take-back operation was required in one case of preseptal hematoma. The mean follow-up period was 6 months, and no long-term functional complications were identified. Of the 30 total patients, 29 showed excellent aesthetic outcome. One patient did present with postoperative notch deformity but did not feel the need for a revision operation.The transconjunctival approach with a lateral paracanthal incision is an alternative approach to the orbital wall. The decoupling of the lower eyelid through the lateral portion of the tarsal plate provides excellent exposure of the orbital floor and provides a reliable and consistent landmark by which the anatomy of the eyelid can be restored. The aesthetic and functional outcomes are excellent.Therapeutic, IV.
View details for DOI 10.1097/PRS.0000000000000639
View details for PubMedID 25347636
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Reply: The Quality of Systematic Reviews in Hand Surgery: An Analysis Using AMSTAR
PLASTIC AND RECONSTRUCTIVE SURGERY
2014; 134 (3): 483E-484E
View details for DOI 10.1097/PRS.0000000000000470
View details for Web of Science ID 000349460300018
View details for PubMedID 25158729
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Quality of life and patient satisfaction after microsurgical abdominal flap versus staged expander/implant breast reconstruction: a critical study of unilateral immediate breast reconstruction using patient-reported outcomes instrument BREAST-Q
BREAST CANCER RESEARCH AND TREATMENT
2014; 146 (1): 117-126
Abstract
Staged expander-implant breast reconstruction (EIBR) and microsurgical abdominal flap breast reconstruction (MAFBR) are the most common modes of breast reconstruction (BR) in the United States. Whether the mode of breast reconstruction has an impact on patient quality of life (QoL) and satisfaction remains a question. A retrospective study was conducted identifying a population of 119 patients who underwent unilateral immediate BR. Only patients who were eligible for either EIBR or MAFBR based on preoperative characteristics were included in the study. The following parameters were retrieved: demographics, mode of reconstruction, cancer, recovery, QoL, and patient satisfaction. The latter two parameters were determined using the BREAST-Q BR module questionnaire. Two-way analysis of variance with mode of reconstruction and occurrence of complication as independent variables was used to determine the effect on patient satisfaction and QoL. The association between mode of reconstruction and patient response with each item of the QoL and satisfaction survey domains was analyzed. The overall response rate was 62.2 %. Non-respondents and respondents did not significantly differ in demographics, surgery type, cancer staging, adjuvant therapy, and complication rate. Age and BMI were significantly higher in MAFBR, while level of education was higher in EIBR. MAFBR had higher scores in psychosocial and sexual wellbeing, satisfaction with outcome, breast, information, and plastic surgeon when compared with patients who underwent EIBR. For patients eligible for both MAFBR and EIBR, MAFBR is associated with higher levels of satisfaction and QoL. Comprehensive pre-operative information of pros and cons of both modes of BR is crucial for patients to make a well-informed decision, thus, resulting in higher levels of satisfaction.
View details for DOI 10.1007/s10549-014-2981-z
View details for Web of Science ID 000338219300012
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Outcome analysis of expander/implant versus microsurgical abdominal flap breast reconstruction: a critical study of 254 cases.
Annals of surgical oncology
2014; 21 (6): 2074-2082
Abstract
Expander-implant breast reconstruction (EIBR) and microsurgical abdominal flap breast reconstruction (MAFBR) are currently the two most frequent breast reconstruction techniques performed in the United States. The aim of this study was to compare outcomes between EIBR and MAFBR in order to help future breast cancer patients to be more knowledgeable and better informed in choosing their optimal reconstruction option.Medical records of 795 patients who underwent breast reconstruction at Stanford Hospital from 2007 to 2011 were reviewed. We found 254 patients to be candidates for both MAFBR and EIBR preoperatively and included them in the study. Patients demographics, postoperative clinic visits, length of hospital stay, postoperative complications, and follow-up time were compared. Logistic regression analysis was used to determine risk factors for major complications.MAFBR patients had 8.7 clinic visits postoperatively, while 14.6 visits were needed for EIBR patients. Length of hospital stay was 4.8 ± 1.32 days for MAFBR and 2.1 ± 0.9 days for EIBR. Complication occurred in 21.3 % of MAFBR versus 37.4 % for EIBR patients. Follow-up duration was 24.7 ± 17.2 months for EIBR and 30.1 ± 18.5 months for MAFBR. On multivariate analysis, EIBR and a body mass index of ≥30 kg/m(2) were the only significant predictors of major complication.For patients eligible for both options, MAFBR has a lower incidence of major complications and fewer postoperative visits, but it has a longer initial hospital stay compared to EIBR. Patients should be informed of not only short-term but also long-term possible risks and benefits in order to make an informed decision.
View details for DOI 10.1245/s10434-014-3521-0
View details for PubMedID 24558063
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Changing attitudes toward hand allotransplantation among North American hand surgeons.
Annals of plastic surgery
2014; 72: S56-60
Abstract
Although more than 70 hand transplants have been performed worldwide, the appropriate clinical indications for this operation are still being determined. Cost and patient exposure to the challenges of lifelong immunosuppression for what is a quality of life-improving (but not life-saving) operation are the focus of the ongoing discussion. A study performed in 2007 showed that surgeons' opinions on the issue varied widely. Recently, more information has been made available regarding long-term patient outcomes, and significant improvements in immunotherapy protocols have been reported. In light of this, we sought to examine changing attitudes regarding hand allotransplantation and its indications by surveying hand surgeons.An email-based survey was sent to members of the American Society for Surgery of the Hand. Demographic information and practice profiles were identified, followed by their risk assessment of hand allotransplants and endorsement of performing the operation in different clinical scenarios. Additional questions focused on the appropriate indications for hand allotransplantation, as well as the procedure's associated ethical and financial implications.A total of 385 surgeons responded to the survey (14% response rate). The majority (82%) considered hand transplantation to be a high-risk operation (as opposed to 27% in hand replantation), with 78% citing lifelong immunosuppression as the primary factor impacting their overall risk assessment. The most commonly accepted indication for hand vascularized composite allotransplantation was loss of bilateral hands (80% in favor). Dominant hand loss (with an intact contralateral hand) was a far less frequently accepted indication (36% in favor). Patient adherence to immunosuppressive regimens (51%) and expectations of functional/aesthetic outcome (38%) were the most frequently chosen top psychosocial issues that must be addressed by the surgical/medical teams involved in the operation.Our study's results demonstrate increasing overall support for hand allotransplantation and increasing acceptance of today's immunosuppressive regimens compared to prior literature. Bilateral hand loss remains the primary agreed-upon indication for transplantation. Despite increasing acceptance in the surgical community, the dangers of chronic immunosuppression, cost and patient adherence continue to be the primary concerns hindering its broader acceptance.
View details for DOI 10.1097/SAP.0000000000000147
View details for PubMedID 24740026
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Outcomes of breast reconstruction in breast cancer patients with a history of mantle radiation for hodgkin lymphoma.
Annals of plastic surgery
2014; 72: S46-50
Abstract
Although mantle radiation (ie, extended field radiation) represented the standard of care in the past for Hodgkin disease, contemporary treatment of lymphoma consists of a multimodal approach with chemotherapy. Patients who were exposed to mantle radiation have a higher risk of breast cancer and are more susceptible to postoperative complications after breast reconstruction due to radiation. In this study, we present postoperative outcomes in patients with a history of mantle radiation who underwent mastectomy and breast reconstruction.All patients at Stanford University Medical Center between January 2006 and December 2012 with a history of Hodgkin lymphoma treated with mantle radiation who received breast reconstruction were identified. A retrospective chart review was conducted analyzing patient demographics, history of Hodgkin treatment, type of reconstruction, follow-up, and complications. Complications were further classified into medical complications, donor-site complications, and recipient-site complications.Sixteen patients with a history of Hodgkin disease and mantle radiation received breast reconstruction. The average age of the patients at their mastectomy was 46 (33-60) years, with the average age at the time of their mantle radiation of 20.5 (10-33) years with an average interval of radiation to breast cancer treatment of 24.8 (16-38) years. There were five unilateral and 11 bilateral reconstructions. All patients had immediate reconstruction with tissue expanders (14 patients) or autologous tissue (one muscle-sparing transverse rectus abdominis myocutaneous and one transverse upper gracilis flap). Eleven (69%) patients had postoperative complications. In the patients who had tissue expander reconstruction, there was an overall complication rate of 64%, which included capsular contracture (n = 5, 56%), mastectomy flap necrosis (n = 5, 56%), cellulitis (n = 4, 44%), seroma (n = 3, 33%), hematoma (n = 1, 11%), and chronic pain (n = 1, 11%). Three (two unilateral and one bilateral) tissue expander infections required removal of the expander and delayed reconstruction with a latissimus dorsi flap, whereas one patient with chronic pain and capsular contracture required a muscle-sparing transverse rectus abdominis myocutaneous for a unilateral implant failure.Although the risk of complications associated with preoperative radiation is well documented, physicians and patients should be cognizant of the increased risk of complications after mantle radiation as it represents a unique modality of radiation exposure.
View details for DOI 10.1097/SAP.0000000000000167
View details for PubMedID 24740024
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Changing attitudes toward hand allotransplantation among north american hand surgeons.
Annals of plastic surgery
2014; 72: S56-60
Abstract
Although more than 70 hand transplants have been performed worldwide, the appropriate clinical indications for this operation are still being determined. Cost and patient exposure to the challenges of lifelong immunosuppression for what is a quality of life-improving (but not life-saving) operation are the focus of the ongoing discussion. A study performed in 2007 showed that surgeons' opinions on the issue varied widely. Recently, more information has been made available regarding long-term patient outcomes, and significant improvements in immunotherapy protocols have been reported. In light of this, we sought to examine changing attitudes regarding hand allotransplantation and its indications by surveying hand surgeons.An email-based survey was sent to members of the American Society for Surgery of the Hand. Demographic information and practice profiles were identified, followed by their risk assessment of hand allotransplants and endorsement of performing the operation in different clinical scenarios. Additional questions focused on the appropriate indications for hand allotransplantation, as well as the procedure's associated ethical and financial implications.A total of 385 surgeons responded to the survey (14% response rate). The majority (82%) considered hand transplantation to be a high-risk operation (as opposed to 27% in hand replantation), with 78% citing lifelong immunosuppression as the primary factor impacting their overall risk assessment. The most commonly accepted indication for hand vascularized composite allotransplantation was loss of bilateral hands (80% in favor). Dominant hand loss (with an intact contralateral hand) was a far less frequently accepted indication (36% in favor). Patient adherence to immunosuppressive regimens (51%) and expectations of functional/aesthetic outcome (38%) were the most frequently chosen top psychosocial issues that must be addressed by the surgical/medical teams involved in the operation.Our study's results demonstrate increasing overall support for hand allotransplantation and increasing acceptance of today's immunosuppressive regimens compared to prior literature. Bilateral hand loss remains the primary agreed-upon indication for transplantation. Despite increasing acceptance in the surgical community, the dangers of chronic immunosuppression, cost and patient adherence continue to be the primary concerns hindering its broader acceptance.
View details for DOI 10.1097/SAP.0000000000000147
View details for PubMedID 24740026
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The Stanford Microsurgery and Resident Training (SMaRT) Scale: Validation of an On-Line Global Rating Scale for Technical Assessment.
Annals of plastic surgery
2014; 72: S84-8
View details for DOI 10.1097/SAP.0000000000000139
View details for PubMedID 24691332
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An Economical Training Model to Teach and Practice Deep Inferior Epigastric Artery Perforator Dissection
ANNALS OF PLASTIC SURGERY
2014; 72: S66-S70
Abstract
Modern surgical training has placed a larger focus on procedural competency base training for surgical specialties. Although various simulators are in existence to teach laparoscopic skills, plastic surgery has a paucity of surgical training models.We developed a low-cost teaching model for the steps and techniques required in the deep inferior epigastric perforator flap and assessed the utility of this model with the resident surgeons using presurvey and postsurvey.A total of 13 residents participated in the surgical skill exercise. The residents felt this exercise increased their proficiency in the steps and techniques required for a deep inferior epigastric perforator flap harvest [4 (0.4)].Overall, residents felt this exercise should be included in the postgraduate years 1 and 2 educational curriculum.
View details for DOI 10.1097/SAP.0000000000000176
View details for Web of Science ID 000334929300016
View details for PubMedID 24740027
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Management of Mastectomy Skin Flap Necrosis in Autologous Breast Reconstruction
ANNALS OF PLASTIC SURGERY
2014; 72: S31-S34
Abstract
Mastectomy skin flap necrosis is a significant problem in the autologous breast reconstruction. The necrosis may create unsightly scarring, produce contour irregularities, and deform the breast mound. This may lead to a poor reconstruction and patient satisfaction. Most importantly, the development and treatment of mastectomy skin flap necrosis can delay further oncologic treatment.We performed a retrospective chart review of all patients undergoing autologous breast reconstruction in the past 5 years to examine our incidence and treatment of mastectomy skin flap necrosis. We then used these data to create a management algorithm for mastectomy skin flap necrosis. The goals of this algorithm were as follows: (1) to not delay further oncologic treatment, (2) to expedite the healing time while minimizing patient risk, and (3) to create an aesthetically pleasing breast reconstruction.A retrospective chart review from 2008 to 2013 was performed of all autologous breast reconstruction at our institution. We then analyzed our data and patient outcomes and developed a treatment algorithm.We identified 204 patients who underwent autologous free flap breast reconstruction that was performed by the senior author (G.K.L.). Our incidence of mastectomy skin necrosis was 30%. There was no delay in adjuvant oncologic treatment for any of our patients. The development of mastectomy skin necrosis was significant for patients with diabetes (P=0.03), current tobacco use (P=0.04), and body mass index (P=0.01). The time for wound healing was prolonged in patients with a high body mass index (P=0.04). Regression analysis of wound size showed full-thickness wounds greater than 6 cm benefited from operative closure.Our incidence of mastectomy skin necrosis was 30%. Despite our high incidence mastectomy skin necrosis, we had no delays in adjuvant oncologic treatment. Retrospective data analysis allowed us to then develop a management algorithm for mastectomy skin necrosis. We feel it is advantageous to the patient and the reconstructive outcome to heal the breast wounds in the acute phase (within 3 weeks); and with regression analysis, we found full-thickness wounds greater than 6 cm benefit from operative intervention. Finally, patients requiring adjuvant oncologic treatment should be healed as quickly as possible so they may continue on with their oncologic care.
View details for DOI 10.1097/SAP.0000000000000174
View details for PubMedID 24667879
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The Stanford Microsurgery and Resident Training (SMaRT) Scale: validation of an on-line global rating scale for technical assessment.
Annals of plastic surgery
2014; 72: S84-8
Abstract
We previously reported results of our on-line microsurgery training program, showing that residents who had access to our website significantly improved their cognitive and technical skills. In this study, we report an objective means for expert evaluators to reliably rate trainees' technical skills under the microscope, with the use of our novel global rating scale."Microsurgery Essentials" (http://smartmicrosurgery.com) is our on-line training curriculum. Residents were randomly divided into 2 groups: 1 group reviewed this online resource and the other did not. Pre- and post-tests consisted of videotaped microsurgical sessions in which the trainee performed "microsurgery" on 3 different models: latex glove, penrose drain, and the dorsal vessel of a chicken foot. The SMaRT (Stanford Microsurgery and Resident Training) scale, consisting of 9 categories graded on a 5-point Likert scale, was used to assess the trainees. Results were analyzed with ANOVA and Student t test, with P less than 0.05 indicating statistical significance.Seventeen residents participated in the study. The SMaRT scale adequately differentiated the performance of more experienced senior residents (PGY-4 to PGY-6, total average score = 3.43) from less experienced junior residents (PGY-1 to PGY-3, total average score = 2.10, P < 0.0001). Residents who viewed themselves as being confident received a higher score on the SMaRT scale (average score 3.5), compared to residents who were not as confident (average score 2.1) (P < 0.001). There were no significant differences in scoring among all 3 evaluators (P > 0.05). Additionally, junior residents who had access to our website showed a significant increase in their graded technical performance by 0.7 points when compared to residents who did not have access to the website who showed an improvement of only 0.2 points (P = 0.01).Our SMaRT scale is valid and reliable in assessing the microsurgical skills of residents and other trainees. Current trainees are more likely to use self-directed on-line education because of its easy accessibility and interactive format. Our global rating scale can help ensure residents are achieving appropriate technical milestones.
View details for DOI 10.1097/SAP.0000000000000139
View details for PubMedID 24691332
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Modification of the Tube-in-Tube Pedicled Anterolateral Thigh Flap for Total Phalloplasty: The Mushroom Flap.
Annals of plastic surgery
2014; 72: S22-6
Abstract
Malformation or absence of the penis can lead to physical and psychological problems for male patients. Reconstruction of the phallus should optimally be completed in a single procedure, be aesthetically pleasing, retain erogenous and tactile sensation, enable micturition in the standing position, and allow for penetrative sexual intercourse. The tube-in-tube flap was described nearly 30 years ago and forms both a urethra and an outer penile shaft with a single flap. Here we present our modification of the original tube-in-tube design with the pedicled anterolateral thigh (ALT) flap and an extension for the neoglans, which we have termed the "mushroom flap" because of its shape and design.The flap is based on the ALT flap; however, the area that will become the neoglans is shaped with a semicircular extension, resembling the head of a mushroom. When the flap is tubularized, the neoglans has the proper anatomic landmarks such as the corona and more closely approximates a circumcised penis. When used in conjunction with the tube-in-tube design, the neophallus, neoglans, and neourethra can all be constructed in a single stage with a single flap.We have performed total phalloplasties in three patients using the pedicled ALT flap, and the mushroom flap design evolved as we sought to improve the aesthetics of the neoglans. In comparing the aesthetic results among our patients as well as those published in the literature, the mushroom flap design seems to provide the most natural and aesthetically pleasing appearance.The pedicled ALT flap can be used to reconstruct an entire penis, as well as a urethra, without the need for microsurgery. By modifying the original tube-in-tube design to include a semicircular extension (a.k.a. the "mushroom flap"), we feel that we have been able to achieve a more natural-appearing neoglans.
View details for DOI 10.1097/SAP.0000000000000072
View details for PubMedID 24740021
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Outcomes of breast reconstruction in breast cancer patients with a history of mantle radiation for Hodgkin lymphoma.
Annals of plastic surgery
2014; 72: S46-50
Abstract
Although mantle radiation (ie, extended field radiation) represented the standard of care in the past for Hodgkin disease, contemporary treatment of lymphoma consists of a multimodal approach with chemotherapy. Patients who were exposed to mantle radiation have a higher risk of breast cancer and are more susceptible to postoperative complications after breast reconstruction due to radiation. In this study, we present postoperative outcomes in patients with a history of mantle radiation who underwent mastectomy and breast reconstruction.All patients at Stanford University Medical Center between January 2006 and December 2012 with a history of Hodgkin lymphoma treated with mantle radiation who received breast reconstruction were identified. A retrospective chart review was conducted analyzing patient demographics, history of Hodgkin treatment, type of reconstruction, follow-up, and complications. Complications were further classified into medical complications, donor-site complications, and recipient-site complications.Sixteen patients with a history of Hodgkin disease and mantle radiation received breast reconstruction. The average age of the patients at their mastectomy was 46 (33-60) years, with the average age at the time of their mantle radiation of 20.5 (10-33) years with an average interval of radiation to breast cancer treatment of 24.8 (16-38) years. There were five unilateral and 11 bilateral reconstructions. All patients had immediate reconstruction with tissue expanders (14 patients) or autologous tissue (one muscle-sparing transverse rectus abdominis myocutaneous and one transverse upper gracilis flap). Eleven (69%) patients had postoperative complications. In the patients who had tissue expander reconstruction, there was an overall complication rate of 64%, which included capsular contracture (n = 5, 56%), mastectomy flap necrosis (n = 5, 56%), cellulitis (n = 4, 44%), seroma (n = 3, 33%), hematoma (n = 1, 11%), and chronic pain (n = 1, 11%). Three (two unilateral and one bilateral) tissue expander infections required removal of the expander and delayed reconstruction with a latissimus dorsi flap, whereas one patient with chronic pain and capsular contracture required a muscle-sparing transverse rectus abdominis myocutaneous for a unilateral implant failure.Although the risk of complications associated with preoperative radiation is well documented, physicians and patients should be cognizant of the increased risk of complications after mantle radiation as it represents a unique modality of radiation exposure.
View details for DOI 10.1097/SAP.0000000000000167
View details for PubMedID 24740024
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Visualizing Dermal Permeation of Sodium Channel Modulators by Mass Spectrometric Imaging
JOURNAL OF THE AMERICAN CHEMICAL SOCIETY
2014; 136 (17): 6401-6405
Abstract
Determining permeability of a given compound through human skin is a principal challenge owing to the highly complex nature of dermal tissue. We describe the application of an ambient mass spectrometry imaging method for visualizing skin penetration of sodium channel modulators, including novel synthetic analogs of natural neurotoxic alkaloids, topically applied ex vivo to human skin. Our simple and label-free approach enables successful mapping of the transverse and lateral diffusion of small molecules having different physicochemical properties without the need for extensive sample preparation.
View details for DOI 10.1021/ja501635u
View details for Web of Science ID 000335369200044
View details for PubMedID 24708172
View details for PubMedCentralID PMC4017602
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Tube-in-a-tube anterolateral thigh flap for reconstruction of a complex esophageal and anterior neck defect.
Annals of plastic surgery
2014; 72 (1): 64-66
Abstract
ABSTRACT: Restoration of a functional digestive track along with acceptable external neck coverage traditionally requires 2 separate flaps. We present a case of a 65-year-old man with a large cervical and esophageal defect treated successfully with a single anterolateral thigh (ALT) free flap. This patient had been treated with primary chemoradiation for laryngeal cancer, and subsequently, developed a severe esophageal stricture. He had undergone prior multiple attempts at reconstruction with a pectoralis major, radial forearm, and deltopectoral flaps, skin grafts, and gastric pull-up, which had all failed. We used an ALT free flap that was designed in a "tube-in-a-tube" fashion to simultaneously reconstruct the cervical esophagus while resurfacing the anterior neck. The patient successfully restarted a liquid diet on the 19th postoperative day. Tube-in-a-tube ALT flap design is a reliable and efficient way to concurrently restore esophageal continuity and provide anterior neck coverage in a single-stage procedure.
View details for DOI 10.1097/SAP.0b013e3182605400
View details for PubMedID 23241776
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Aesthetic Surgery Training during Residency in the United States: A Comparison of the Integrated, Combined, and Independent Training Models.
Plastic surgery international
2014; 2014: 281923-?
Abstract
Background. Three educational models for plastic surgery training exist in the United States, the integrated, combined, and independent model. The present study is a comparative analysis of aesthetic surgery training, to assess whether one model is particularly suitable to provide for high-quality training in aesthetic surgery. Methods. An 18-item online survey was developed to assess residents' perceptions regarding the quality of training in aesthetic surgery in the US. The survey had three distinct sections: demographic information, current state of aesthetic surgery training, and residents' perception regarding the quality of aesthetic surgery training. Results. A total of 86 senior plastic surgery residents completed the survey. Twenty-three, 24, and 39 residents were in integrated, combined, and independent residency programs, respectively. No statistically significant differences were seen with respect to number of aesthetic surgery procedures performed, additional training received in minimal-invasive cosmetic procedures, median level of confidence with index cosmetic surgery procedures, or perceived quality of aesthetic surgery training. Facial aesthetic procedures were felt to be the most challenging procedures. Exposure to minimally invasive aesthetic procedures was limited. Conclusion. While the educational experience in aesthetic surgery appears to be similar, weaknesses still exist with respect to training in minimally invasive/nonsurgical aesthetic procedures.
View details for DOI 10.1155/2014/281923
View details for PubMedID 25225615
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Chronic cutaneous chest wall fistula and gallstone empyema due to retained gallstones.
BMJ case reports
2014; 2014
Abstract
We report a case of a 72-year-old man who presented with a persistent pleural effusion and painful abscess in the right lower chest wall 6 months following a laparoscopic cholecystectomy. The patient subsequently developed a chronic cutaneous chest wall fistula requiring a large resection and complex closure. The complication was likely secondary to intraoperative spillage of gallstones. While previous reports describe gallstone spillage in the abdominal cavity as benign, this case illustrates that stones left in the abdominal cavity can potentially lead to significant morbidity. Therefore, stones should be diligently removed from the abdominal cavity when spillage occurs. In addition, it is important that operative notes reflect the occurrence of stone spillage so stones may be suspected when a patient presents with an abdominal or thoracic infection following a cholecystectomy.
View details for DOI 10.1136/bcr-2013-010159
View details for PubMedID 25123567
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Enabling Autologous Human Liver Regeneration With Differentiated Adipocyte Stem Cells
CELL TRANSPLANTATION
2014; 23 (12): 1573-1584
Abstract
We developed a novel method for differentiating adipocyte-derived stem cells (ASCs) into hepatocyte-like cells (iHeps). ASCs are cultured as spherical cellular aggregates, and are then induced by culture in chemically defined media for a short time period to differentiate into spherical-culture iHeps (SCi-Heps). SCi-Heps have many of the in vitro functional properties of mature hepatocytes, and they can stably reconstitute functioning human liver in vivo in a murine model system, and implantation studies demonstrate that SCi-Heps have a very low malignant potential. All human liver regenerative procedures, including ultrasound-guided direct liver implantation, are scalable and appropriate for human clinical use. These methods can be used to achieve the major promise of regenerative medicine; it may now be possible to regenerate human liver using autologous stem cells obtained from a readily accessible tissue.
View details for DOI 10.3727/096368913X673432
View details for PubMedID 24148223
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Essential Hand Surgery Procedures for Mastery by Graduating Plastic Surgery Residents: A Survey of Program Directors
PLASTIC AND RECONSTRUCTIVE SURGERY
2013; 132 (6): 977E-984E
Abstract
This study was designed to establish the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. This framework can then be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach technical skills in hand surgery.Ten expert hand surgeons were surveyed regarding the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. The top 10 procedures from this survey were then used to survey all 89 Accreditation Council for Graduate Medical Education-approved plastic surgery program directors.There was a 69 percent response rate to the program director survey (n = 61). The top nine hand surgery procedures included open carpal tunnel release, open A1 pulley release, digital nerve repair with microscope, closed reduction and percutaneous pinning of metacarpal fracture, excision of dorsal or volar ganglion, zone II flexor tendon repair with multistrand technique, incision and drainage of the flexor tendon sheath for flexor tenosynovitis, flexor tendon sheath steroid injection, and open cubital tunnel release.Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method for accomplishing this task. There has been no consensus regarding which hand surgery procedures should be mastered by graduating plastic surgery residents. The authors have identified nine procedures that are overwhelmingly supported by plastic surgery program directors. These nine procedures can be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach and document technical skills in hand surgery.
View details for DOI 10.1097/01.prs.0b013e3182a8066b
View details for Web of Science ID 000330465800009
View details for PubMedID 24281644
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Commentary to "current microsurgery training programs in India".
Annals of plastic surgery
2013; 71 (5): 624-625
View details for DOI 10.1097/SAP.0b013e318283d1b8
View details for PubMedID 23728244
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Lag-Time to Publication in Plastic Surgery Potential Impact on the Timely Practice of Evidence-Based Medicine
18th Annual Meeting of the American-Society-for-Reconstructive-Microsurgery
LIPPINCOTT WILLIAMS & WILKINS. 2013: 410–14
View details for DOI 10.1097/SAP.0b013e31824bd75c
View details for Web of Science ID 000330453500021
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Nipple Reconstruction: Risk Factors and Complications after 189 Procedures.
European journal of plastic surgery
2013; 36 (10): 633-638
Abstract
A multitude of different approaches have been proposed for achieving optimal aesthetic results after nipple reconstruction. In contrast, however, only a few studies focus on the morbidity associated with this procedure, particularly after implant-based breast reconstruction.Using a cross-sectional study design all patients who underwent implant-based breast reconstruction with subsequent nipple reconstruction between 2000 and 2010 at Stanford University Medical Center were identified. The aim of the study was to analyze the impact of the following parameters on the occurrence of postoperative complications: age, final implant volume, time interval from placement of final implant to nipple reconstruction, and history of radiotherapy.A total of 139 patients with a mean age of 47.5 years (range, 29 to 75 years) underwent 189 nipple reconstructions. The overall complication rate was 13.2 percent (N = 25 nipple reconstructions). No association was observed between age (p = 0.43) or implant volume (p = 0.47) and the occurrence of complications. A trend towards higher complication rates in patients in whom the time interval between final implant placement and nipple reconstruction was greater than 8.5 months was seen (p = 0.07). Radiotherapy was the only parameter that was associated with a statistically significant increase in postoperative complication rate (51.7 percent vs. 6.25 percent; p < 0.00001).While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy, the presence of an irradiated field converts it to a high-risk one with a significant increase in postoperative complication rate. Patients with a history of radiotherapy should be informed about their risk profile and as a result may choose autologous reconstruction instead.IV.
View details for PubMedID 24072956
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Nipple reconstruction after implant-based breast reconstruction: A "matched-pair" outcome analysis focusing on the effects of radiotherapy.
Journal of plastic, reconstructive & aesthetic surgery : JPRAS
2013; 66 (9): 1202-1205
Abstract
BACKGROUND: The major focus of research when addressing nipple reconstruction has been on developing new techniques to provide for long-lasting nipple projection. Rarely, has the outcome of nipple reconstruction as it relates to postoperative morbidity, particularly after implant-based breast reconstruction, been analyzed. METHODS: A "matched-pair" study was designed to specifically answer the question whether a history of radiotherapy predisposes to a higher complication rate after nipple reconstruction in patients after implant-based breast reconstruction. Only patients with a history of unilateral radiotherapy who underwent bilateral mastectomy and implant-based breast reconstruction followed by bilateral nipple reconstruction were included in the study. RESULTS: A total of 17 patients (i.e. 34 nipple reconstructions) were identified who met inclusion criteria. The mean age of the study population was 43.5 years (range, 23-69). Complications were seen after a total of 8 nipple reconstructions (23.5 percent). Of these, 7 complications were seen on the irradiated side (41.2 percent) (p = 0.03). CONCLUSION: While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy the presence of an irradiated field converts it to a procedure with a significant increase in postoperative complication rate.
View details for DOI 10.1016/j.bjps.2013.04.052
View details for PubMedID 23664573
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Breast reconstruction national trends and healthcare implications.
breast journal
2013; 19 (5): 463-469
Abstract
Breast reconstruction improves quality-of-life of breast cancer patients. Different reconstructive options exist, yet commentary in the plastic surgery literature suggests that financial constraints are limiting access to autologous reconstruction (AR). This study follows national trends in breast reconstruction and identifies factors associated with reconstructive choices. Data were obtained from the Nationwide Inpatient Sample from 1998 to 2008. Patients were categorized as having either implant or ARs. Bivariate and multivariate regression analysis identified variables associated with receiving implants versus AR. Physician fee schedules were analyzed using national average Medicare physician reimbursement rates. From 1998 to 2008, 324,134 breast reconstructions were performed. Reconstructions increased 4% per year. The proportion of implant reconstructions increased 11% per year, whereasARs decreased 5% per year (p < 0.05). Our model showed that the odds of having implant-based versus AR were significantly associated with age, disease severity, payer type, hospital teaching status, and year of surgery. Year of surgery was the strongest predictor of implant reconstruction; patients receiving breast reconstructive surgery in 2009 were three times more likely to have implant breast reconstructive surgery compared with similar patients in 2002. Medicare reimbursement steadily declined for AR over a similar time frame. From 1998 to 2008, autologous breast reconstruction has significantly declined, parallel to a decrease in physician reimbursement. Our data found no significant change in patient characteristics supporting the lack of choice of AR. Further research is warranted to better understand this shift to implant reconstruction and to ensure future access of these complex reconstructive procedures.
View details for DOI 10.1111/tbj.12148
View details for PubMedID 23758582
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Surgical Management of Silicone Mastitis: Case Series and Review of the Literature
AESTHETIC PLASTIC SURGERY
2013; 37 (4): 738-745
Abstract
Free silicone injection for breast augmentation, which became widespread in the 1960s and continues illicitly to this day, has well-known adverse effects. In this retrospective chart review of 14 patients treated for silicone mastitis from 1990 to 2002, we present our experience with the surgical management of patients with silicone mastitis.All the patients were women, ranging in age from 49 to 76 years old (mean age = 58.8). Patients presented to us a mean of 29.9 years after their free silicone breast injection. Treatment modalities were analyzed, and, specifically, methods of breast reconstruction involving autologous tissue transfers, implants, or a combination were evaluated.The majority of patients (12 of 14) required mastectomies for extensive silicone-infiltrated tissues. The remaining two patients had focal areas of disease and were successfully treated with excision and local breast parenchyma flaps. Autologous reconstruction was performed with a total of 20 flaps, including 12 free transverse rectus abdominis myocutaneous flaps, 4 free superior gluteal artery perforator (SGAP) flaps, and 4 pedicled latissimus dorsi (LD) flaps. Two patients had bilateral implant-based breast reconstruction.A variety of reconstructive options are available for patients presenting with silicone mastitis. Once an appropriate breast cancer workup has been performed, the surgical goal is to excise as much of the silicone-infiltrated tissues as possible before reconstruction. To our knowledge, this is the first reported series that incorporates the use of SGAP and LD flaps as a means of autologous tissue reconstruction for silicone-infiltrated breasts.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
View details for DOI 10.1007/s00266-013-0170-9
View details for Web of Science ID 000322005400016
View details for PubMedID 23812611
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Intra-abdominal pedicled rectus abdominis muscle flap for treatment of high-output enterocutaneous fistulae: Case reports and review of literature
JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY
2013; 66 (8): 1145-1148
Abstract
Despite advances in nutritional supplementation, sepsis management, percutaneous drainage and surgical technique, enterocutaneous fistulae remain a considerable source of morbidity and mortality. Use of adjunctive modalities including negative pressure wound therapy and fibrin glue have been shown to improve the rapidity of fistula closure; however, the overall rate of closure remains poor. The challenge of managing chronic, high-output proximal enterocutaneous fistulae can be successfully achieved with appropriate medical management and intra-abdominal placement of pedicled rectus abdominis muscle flaps. We report two cases of recalcitrant high output enterocutaneous fistulae that were treated successfully with pedicled intra-abdominal rectus muscle flaps. Indications for pedicled intra-abdominal rectus muscle flaps include persistent patency despite a reasonable trial of non-operative intervention, failure of traditional operative interventions (serosal patch, Graham patch), and persistent electrolyte and nutritional abnormalities in the setting of a high-output fistula.
View details for DOI 10.1016/j.bjps.2012.12.008
View details for Web of Science ID 000321441300026
View details for PubMedID 23317765
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Single-Institution Financial Analysis of Biologic Versus Synthetic Mesh Hernia Repair: A Retrospective Analysis of Patients Readmitted for Hernia Repair.
Annals of plastic surgery
2013: -?
Abstract
The advent and proliferation of commercially available biologic mesh material has expanded the repertoire of hernia repair materials available to the surgeon. Given the higher initial cost of these mesh materials relative to synthetic materials such as polypropylene, there has been debate regarding the purported benefit of the use of biologic mesh. This study is a single-institution review of complex hernia repairs using both biologic and synthetic mesh materials. The patients included in the analyses were admitted to the institution at least twice for management of hernia; this permitted specific evaluation of a given diagnosis, hernia, in the same patient, but at different points in time. In a subset of patients, hernia repair was performed upon the second admission with conversion from biologic or synthetic mesh, which had been placed at the initial repair. The objective of this study was to evaluate the financial implications of mesh choice. Specific parameters reviewed included type of mesh used, total costs of hospitalization, direct cost associated with the hernia repair, total collections, and percentage of collections relative to total charges. Through such analysis, our aim was to determine whether there were any variances in revenue and costs associated with the application of either mesh material or the associated clinical scenarios.
View details for PubMedID 23851372
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Development of an Affordable System for Personalized Video-Documented Surgical Skill Analysis for Surgical Residency Training
ANNALS OF PLASTIC SURGERY
2013; 70 (4): 442-446
Abstract
Surgical competency requires the development of decision-making and technical skills. Despite lectures, literature, and written and oral examinations, both skill sets are difficult to systematically teach and analyze. With the advent of head-mounted video cameras, we seek to incorporate a surgical video database into our surgical training curriculum. We hope to not only change the way and rate at which surgical trainees develop their surgical skills but to also introduce a novel tool for surgical skill assessment.
View details for DOI 10.1097/SAP.0b013e31827e513c
View details for Web of Science ID 000316603400016
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Essential Hand Surgery Procedures for Mastery by Graduating Orthopedic Surgery Residents: A Survey of Program Directors
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2013; 38A (4): 760-765
Abstract
To establish the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. This framework can then be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.A select group of 10 expert hand surgeons was surveyed regarding the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. The top 10 procedures from this survey were then used to survey all 155 American Council of Graduate Medical Education-approved orthopedic surgery program directors regarding the essential procedures that should be mastered by graduating orthopedic surgery residents.We had a 39% response rate to the program director survey. The top 8 hand surgery procedures as determined by the orthopedic surgery program directors included open carpal tunnel release, open A1 pulley release, open reduction internal fixation of distal radius fracture, flexor tendon sheath steroid injection, excision of dorsal or volar ganglion, closed reduction and percutaneous pinning of metacarpal fracture, open cubital tunnel release, and incision and drainage of flexor tendon sheath for flexor tenosynovitis.Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method to accomplish this task. However, there has been no consensus regarding which hand surgery procedures should be mastered by graduating orthopedic surgery residents. We have identified 8 procedures that were overwhelmingly supported by orthopedic surgery program directors. These 8 procedures can be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.This study addresses the future of orthopedic surgery education as it pertains to hand surgery.
View details for DOI 10.1016/j.jhsa.2012.12.035
View details for Web of Science ID 000317246100019
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Histologic Analysis of Fetal Bovine Derived Acellular Dermal Matrix in Tissue Expander Breast Reconstruction
ANNALS OF PLASTIC SURGERY
2013; 70 (4): 447-453
Abstract
BACKGROUND: This study seeks to determine human host response to fetal bovine acellular dermal matrix (ADM) in staged implant-based breast reconstruction. METHODS: A prospective study was performed for patients undergoing immediate breast reconstruction with tissue expander placement and SurgiMend acellular fetal bovine dermis. At the time of exchange for permanent implant, we obtained tissue specimens of SurgiMend and native capsule. Histological and immunohistochemical assays were performed to characterize the extent of ADM incorporation/degradation, host cell infiltration, neovascularization, inflammation, and host replacement of acellular fetal bovine collagen. RESULTS: Seventeen capsules from 12 patients were included in our study. The average "implantation" time of SurgiMend was 7.8 months (range, 2-23 months). Histological analysis of the biopsy of tissue revealed rare infiltration of host inflammatory cells, even at 23 months. One patient had an infection requiring removal of the tissue expander at 2 months. Contracture, inflammatory changes, edema, and polymorphonuclear leukocyte infiltration were rare in the ADM. An acellular capsule was seen in many cases, at the interface of SurgiMend with the tissue expander. CONCLUSIONS: SurgiMend demonstrated a very infrequent inflammatory response. An antibody specific to bovine collagen allowed for direct identification of bovine collagen separate from human collagen. Cellular infiltration and neovascularization of SurgiMend correlated with the quality of the mastectomy skin flap rather than the duration of implantation. Future studies are needed to further characterize the molecular mechanisms underlying tissue incorporation of this product.
View details for DOI 10.1097/SAP.0b013e31827e55af
View details for Web of Science ID 000316603400017
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Microsurgical Head and Neck Reconstruction After Oncologic Ablation A Study Analyzing Health-Related Quality of Life
ANNALS OF PLASTIC SURGERY
2013; 70 (4): 462-469
Abstract
BACKGROUND: Evaluation of quality of life (QOL) measures is increasingly being valued as an essential parameter to determine treatment results after head and neck reconstruction. The present study was designed to evaluate the effect of microsurgical reconstruction on patient-reported QOL. METHODS: Patients undergoing microsurgical reconstruction after radical oncosurgical ablation of head and neck malignancies from March 2007 to March 2010 were included in the study. To assess health-related QOL, the following questionnaires were sent to patients who met inclusion criteria: European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30 [Version 3.0]) and Head and Neck Cancer Quality of Life Questionnaire (QLQ-H and N35). RESULTS: A total of 60 patients underwent microsurgical reconstruction of postablative head and neck defects during the study period. Twenty-one patients were successfully contacted, all of which completed the surveys. Satisfactory global QOL scores were achieved. Advanced age correlated with greater impairment for the ability to taste and smell (P = 0.05). Radiotherapy seemed to be associated with "sticky saliva"; although this was not statistically significant (P = 0.06). Recurrent disease at the time of surgical ablation and microsurgical reconstruction did not seem to have any appreciable impact on QOL. Finally, patients who developed postoperative complications had lower levels of "cognitive functioning" (P = 0.04), problems with "insomnia" (P = 0.04) and "social contact" (P = 0.03), and more commonly "felt ill" (P = 0.03). CONCLUSIONS: Improved global QOL scores were observed after microsurgical reconstruction of various head and neck defects when compared to reported pretreatment scores. Of the parameters analyzed, it seems that postoperative complications have the most profound effect on items assessed with the EORTC QLQ-C30 and H and N35 surveys. Our findings provide further scientific evidence that patients with head and neck malignancy benefit from surgical intervention with respect to postoperative QOL.
View details for DOI 10.1097/SAP.0b013e31827737a5
View details for Web of Science ID 000316603400020
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The Matrix Rib Plating System Improving Aesthetic Outcomes in Microvascular Breast Reconstruction
ANNALS OF PLASTIC SURGERY
2013; 70 (4): 384-388
Abstract
INTRODUCTION: During microvascular breast reconstruction, exposure of internal mammary vessels (IMVs) is facilitated by the removal of a portion of the rib resulting in occasional chest contour deformity (CCD). The use of rib plating may reduce CCD and reduce postoperative pain. METHODS: All patients underwent microvascular breast reconstruction using IMVs. In the retrospective arm, photographs were assessed by a blinded reviewer for CCDs. In the prospective cohort, patients were randomized to rib plating with the Synthes Matrix Rib Plating System or no rib plating. Postoperatively, patients were assessed for CCD and pain. RESULTS: In the retrospective arm, 11 of 98 (11.2%) patients representing 12 of 130 (9.2%) breast reconstructions had a noticeable contour deformity. The average body mass index (BMI) of patients with CCDs was 26.6 kg/m. In the prospective arm, there was 16% (3 of 19) rate of visible and palpable CCDs among controls, compared to 0% rate of palpable and visible contour deformity in the rib plating group. Pain was decreased in the rib plating group on all postoperative days. The pain reduction was statistically significant at rest by postoperative day 30. CONCLUSION: The majority of patients (9 of 11) with compromised aesthetic outcomes had a BMI less than 30 kg/m, suggesting a paucity of overlying soft tissue contributed to visibility of these bony defects. Rib plating prevented chest contour deformity, reduced postoperative pain, and added limited additional morbidity. We believe that rib plating is a safe, useful adjunct to microvascular breast reconstruction using IMVs, as it may improve aesthetic outcomes and reduce postoperative pain.
View details for DOI 10.1097/SAP.0b013e3182853d86
View details for Web of Science ID 000316603400002
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Transverse Tensor Fascia Lata Myocutaneous Flap for Microvascular Breast Reconstruction Case Report and Review of the Literature
ANNALS OF PLASTIC SURGERY
2013; 70 (4): 438-441
Abstract
The transverse tensor fascia lata (TTFL) flap is an important alternative flap for autologous breast reconstruction. It is a horizontal variant of the tensor fascia lata myocutaneous flap and contains fat from the prominence of the upper lateral thigh (saddle bag). We present the surgical management of a woman with trochanteric lipodystrophy, who underwent staged bilateral mastectomy and autologous breast reconstruction with TTFL flaps. We discuss technical points in TTFL flap design and harvest. Breast reconstruction was successful and the thigh donor sites had excellent aesthetic contour. There were no complications at either recipient or donor sites. The TTFL flap is an important alternative flap for autologous breast reconstruction when other options are less optimal, and has a secondary benefit of thigh donor site closure with lateral thigh lift techniques. The TTFL flap should be presented as an option for autologous breast reconstruction in women with prominent trochanteric lipodystrophy of the upper lateral thighs.
View details for DOI 10.1097/SAP.0b013e31828a0c80
View details for Web of Science ID 000316603400015
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Teaching Core Competencies of Reconstructive Microsurgery With the Use of Standardized Patients
ANNALS OF PLASTIC SURGERY
2013; 70 (4): 476-481
Abstract
The Accreditation Council of Graduate Medical Education has defined 6 core competencies that residents must master before completing their training. Objective structured clinical examinations (OSCEs) using standardized patients are effective educational tools to assess and teach core competencies. We developed an OSCE specific for microsurgical head and neck reconstruction. Fifteen plastic surgery residents participated in the OSCE simulating a typical new patient consultation, which involved a patient with oral cancer. Residents were scored in all 6 core competencies by the standardized patients and faculty experts. Analysis of participant performance showed that although residents performed well overall, many lacked proficiency in systems-based practice. Junior residents were also more likely to omit critical elements of the physical examination compared to senior residents. We have modified our educational curriculum to specifically address these deficiencies. Our study demonstrates that the OSCE is an effective assessment tool for teaching and assessing all core competencies in microsurgery.
View details for DOI 10.1097/SAP.0b013e3182853f2c
View details for Web of Science ID 000316603400022
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The Quality of Systematic Reviews in Hand Surgery: An Analysis Using AMSTAR
PLASTIC AND RECONSTRUCTIVE SURGERY
2013; 131 (4): 831-837
Abstract
Systematic reviews constitute the top of the "level-of-evidence pyramid." Despite their strengths, they have been found to be of varying quality, thus raising concerns about their validity and role in influencing clinical practice. In the present study, a quality analysis of systematic reviews with a focus on hand surgery was performed.A PubMed search was performed to identify all systematic reviews published up to and including December of 2011 in eight surgical journals. Two authors independently reviewed the literature and extracted data from included reviews. Discrepancies were resolved by consensus. Quality assessment was performed using AMSTAR.The initial search retrieved 687 articles. After screening titles and abstracts, 635 articles were excluded. Full-text review of the remaining 52 articles resulted in further exclusion of 10 articles, leaving 42 systematic reviews for final analysis. A significant increase in the number of published systematic reviews over time was noted (p = 0.04), with the majority of systematic reviews being published in The Journal of Hand Surgery (n = 19) and Plastic and Reconstructive Surgery (n = 12). Although a significant improvement in the quality of systematic reviews was noted over time (p = 0.01), a median AMSTAR score of 7 indicated the bulk of reviews to be of fair to good quality.The trend to publish more systematic reviews in hand surgery is paralleled by an increase in the quality of systematic reviews. Nonetheless, increased efforts are indicated to further improve the quality of systematic reviews in hand surgery.
View details for DOI 10.1097/PRS.0b013e3182818d24
View details for Web of Science ID 000317282800062
View details for PubMedID 23542254
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Essential hand surgery procedures for mastery by graduating orthopedic surgery residents: a survey of program directors.
journal of hand surgery
2013; 38 (4): 760-765
Abstract
To establish the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. This framework can then be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.A select group of 10 expert hand surgeons was surveyed regarding the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. The top 10 procedures from this survey were then used to survey all 155 American Council of Graduate Medical Education-approved orthopedic surgery program directors regarding the essential procedures that should be mastered by graduating orthopedic surgery residents.We had a 39% response rate to the program director survey. The top 8 hand surgery procedures as determined by the orthopedic surgery program directors included open carpal tunnel release, open A1 pulley release, open reduction internal fixation of distal radius fracture, flexor tendon sheath steroid injection, excision of dorsal or volar ganglion, closed reduction and percutaneous pinning of metacarpal fracture, open cubital tunnel release, and incision and drainage of flexor tendon sheath for flexor tenosynovitis.Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method to accomplish this task. However, there has been no consensus regarding which hand surgery procedures should be mastered by graduating orthopedic surgery residents. We have identified 8 procedures that were overwhelmingly supported by orthopedic surgery program directors. These 8 procedures can be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.This study addresses the future of orthopedic surgery education as it pertains to hand surgery.
View details for DOI 10.1016/j.jhsa.2012.12.035
View details for PubMedID 23433941
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Histologic Analysis of Fetal Bovine Derived Acellular Dermal Matrix in Tissue Expander Breast Reconstruction.
Annals of plastic surgery
2013
Abstract
BACKGROUND: This study seeks to determine human host response to fetal bovine acellular dermal matrix (ADM) in staged implant-based breast reconstruction. METHODS: A prospective study was performed for patients undergoing immediate breast reconstruction with tissue expander placement and SurgiMend acellular fetal bovine dermis. At the time of exchange for permanent implant, we obtained tissue specimens of SurgiMend and native capsule. Histological and immunohistochemical assays were performed to characterize the extent of ADM incorporation/degradation, host cell infiltration, neovascularization, inflammation, and host replacement of acellular fetal bovine collagen. RESULTS: Seventeen capsules from 12 patients were included in our study. The average "implantation" time of SurgiMend was 7.8 months (range, 2-23 months). Histological analysis of the biopsy of tissue revealed rare infiltration of host inflammatory cells, even at 23 months. One patient had an infection requiring removal of the tissue expander at 2 months. Contracture, inflammatory changes, edema, and polymorphonuclear leukocyte infiltration were rare in the ADM. An acellular capsule was seen in many cases, at the interface of SurgiMend with the tissue expander. CONCLUSIONS: SurgiMend demonstrated a very infrequent inflammatory response. An antibody specific to bovine collagen allowed for direct identification of bovine collagen separate from human collagen. Cellular infiltration and neovascularization of SurgiMend correlated with the quality of the mastectomy skin flap rather than the duration of implantation. Future studies are needed to further characterize the molecular mechanisms underlying tissue incorporation of this product.
View details for DOI 10.1097/SAP.0b013e31827e55af
View details for PubMedID 23486129
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Development of an Affordable System for Personalized Video-Documented Surgical Skill Analysis for Surgical Residency Training.
Annals of plastic surgery
2013
Abstract
Surgical competency requires the development of decision-making and technical skills. Despite lectures, literature, and written and oral examinations, both skill sets are difficult to systematically teach and analyze. With the advent of head-mounted video cameras, we seek to incorporate a surgical video database into our surgical training curriculum. We hope to not only change the way and rate at which surgical trainees develop their surgical skills but to also introduce a novel tool for surgical skill assessment.
View details for DOI 10.1097/SAP.0b013e31827e513c
View details for PubMedID 23486125
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The Matrix Rib Plating System: Improving Aesthetic Outcomes in Microvascular Breast Reconstruction.
Annals of plastic surgery
2013
Abstract
INTRODUCTION: During microvascular breast reconstruction, exposure of internal mammary vessels (IMVs) is facilitated by the removal of a portion of the rib resulting in occasional chest contour deformity (CCD). The use of rib plating may reduce CCD and reduce postoperative pain. METHODS: All patients underwent microvascular breast reconstruction using IMVs. In the retrospective arm, photographs were assessed by a blinded reviewer for CCDs. In the prospective cohort, patients were randomized to rib plating with the Synthes Matrix Rib Plating System or no rib plating. Postoperatively, patients were assessed for CCD and pain. RESULTS: In the retrospective arm, 11 of 98 (11.2%) patients representing 12 of 130 (9.2%) breast reconstructions had a noticeable contour deformity. The average body mass index (BMI) of patients with CCDs was 26.6 kg/m. In the prospective arm, there was 16% (3 of 19) rate of visible and palpable CCDs among controls, compared to 0% rate of palpable and visible contour deformity in the rib plating group. Pain was decreased in the rib plating group on all postoperative days. The pain reduction was statistically significant at rest by postoperative day 30. CONCLUSION: The majority of patients (9 of 11) with compromised aesthetic outcomes had a BMI less than 30 kg/m, suggesting a paucity of overlying soft tissue contributed to visibility of these bony defects. Rib plating prevented chest contour deformity, reduced postoperative pain, and added limited additional morbidity. We believe that rib plating is a safe, useful adjunct to microvascular breast reconstruction using IMVs, as it may improve aesthetic outcomes and reduce postoperative pain.
View details for DOI 10.1097/SAP.0b013e3182853d86
View details for PubMedID 23486136
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Microsurgical Head and Neck Reconstruction After Oncologic Ablation: A Study Analyzing Health-Related Quality of Life.
Annals of plastic surgery
2013
Abstract
BACKGROUND: Evaluation of quality of life (QOL) measures is increasingly being valued as an essential parameter to determine treatment results after head and neck reconstruction. The present study was designed to evaluate the effect of microsurgical reconstruction on patient-reported QOL. METHODS: Patients undergoing microsurgical reconstruction after radical oncosurgical ablation of head and neck malignancies from March 2007 to March 2010 were included in the study. To assess health-related QOL, the following questionnaires were sent to patients who met inclusion criteria: European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30 [Version 3.0]) and Head and Neck Cancer Quality of Life Questionnaire (QLQ-H and N35). RESULTS: A total of 60 patients underwent microsurgical reconstruction of postablative head and neck defects during the study period. Twenty-one patients were successfully contacted, all of which completed the surveys. Satisfactory global QOL scores were achieved. Advanced age correlated with greater impairment for the ability to taste and smell (P = 0.05). Radiotherapy seemed to be associated with "sticky saliva"; although this was not statistically significant (P = 0.06). Recurrent disease at the time of surgical ablation and microsurgical reconstruction did not seem to have any appreciable impact on QOL. Finally, patients who developed postoperative complications had lower levels of "cognitive functioning" (P = 0.04), problems with "insomnia" (P = 0.04) and "social contact" (P = 0.03), and more commonly "felt ill" (P = 0.03). CONCLUSIONS: Improved global QOL scores were observed after microsurgical reconstruction of various head and neck defects when compared to reported pretreatment scores. Of the parameters analyzed, it seems that postoperative complications have the most profound effect on items assessed with the EORTC QLQ-C30 and H and N35 surveys. Our findings provide further scientific evidence that patients with head and neck malignancy benefit from surgical intervention with respect to postoperative QOL.
View details for DOI 10.1097/SAP.0b013e31827737a5
View details for PubMedID 23486123
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Transverse Tensor Fascia Lata Myocutaneous Flap for Microvascular Breast Reconstruction: Case Report and Review of the Literature.
Annals of plastic surgery
2013
Abstract
The transverse tensor fascia lata (TTFL) flap is an important alternative flap for autologous breast reconstruction. It is a horizontal variant of the tensor fascia lata myocutaneous flap and contains fat from the prominence of the upper lateral thigh (saddle bag). We present the surgical management of a woman with trochanteric lipodystrophy, who underwent staged bilateral mastectomy and autologous breast reconstruction with TTFL flaps. We discuss technical points in TTFL flap design and harvest. Breast reconstruction was successful and the thigh donor sites had excellent aesthetic contour. There were no complications at either recipient or donor sites. The TTFL flap is an important alternative flap for autologous breast reconstruction when other options are less optimal, and has a secondary benefit of thigh donor site closure with lateral thigh lift techniques. The TTFL flap should be presented as an option for autologous breast reconstruction in women with prominent trochanteric lipodystrophy of the upper lateral thighs.
View details for DOI 10.1097/SAP.0b013e31828a0c80
View details for PubMedID 23486142
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Teaching Core Competencies of Reconstructive Microsurgery With the Use of Standardized Patients.
Annals of plastic surgery
2013
Abstract
The Accreditation Council of Graduate Medical Education has defined 6 core competencies that residents must master before completing their training. Objective structured clinical examinations (OSCEs) using standardized patients are effective educational tools to assess and teach core competencies. We developed an OSCE specific for microsurgical head and neck reconstruction. Fifteen plastic surgery residents participated in the OSCE simulating a typical new patient consultation, which involved a patient with oral cancer. Residents were scored in all 6 core competencies by the standardized patients and faculty experts. Analysis of participant performance showed that although residents performed well overall, many lacked proficiency in systems-based practice. Junior residents were also more likely to omit critical elements of the physical examination compared to senior residents. We have modified our educational curriculum to specifically address these deficiencies. Our study demonstrates that the OSCE is an effective assessment tool for teaching and assessing all core competencies in microsurgery.
View details for DOI 10.1097/SAP.0b013e3182853f2c
View details for PubMedID 23486137
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White light spectroscopy for free flap monitoring
MICROSURGERY
2013; 33 (3): 198-202
Abstract
White light spectroscopy non-invasively measures hemoglobin saturation at the capillary level rendering an end-organ measurement of perfusion. We hypothesized this technology could be used after microvascular surgery to allow for early detection of ischemia and thrombosis. The Spectros T-Stat monitoring device, which utilizes white light spectroscopy, was compared with traditional flap monitoring techniques including pencil Doppler and clinical exam. Data were prospectively collected and analyzed. Results from 31 flaps revealed a normal capillary hemoglobin saturation of 40-75% with increase in saturation during the early postoperative period. One flap required return to the operating room 12 hours after microvascular anastomosis. The T-stat system recorded an acute decrease in saturation from ~50% to less than 30% 50 min prior to identification by clinical exam. Prompt treatment resulted in flap salvage. The Spectros T-Stat monitor may be a useful adjunct for free flap monitoring providing continuous, accurate perfusion assessment postoperatively.
View details for DOI 10.1002/micr.22069
View details for Web of Science ID 000316335400005
View details for PubMedID 23280724
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Is routine histological examination of mastectomy scars justified? An analysis of 619 scars
JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY
2013; 66 (2): 182-186
Abstract
The increasing incidence of breast cancer is paralleled by an increasing demand for post-mastectomy breast reconstruction. At the time of breast reconstruction routine submission of mastectomy scars has been considered appropriate clinical practice to ensure that no residual cancer exists. However, this practice has been challenged by some and has become the topic of controversy. In a retrospective analysis we wished to assess whether routine submission of mastectomy scars altered treatment.Utilizing the Stanford Translational Research Integrated Database Environment (STRIDE) all patients who underwent implant-based breast reconstruction with routine histological analysis of mastectomy scars were identified. The following parameters were retrieved and analyzed: age, cancer histology, cancer stage (according to the American Joint Committee on Cancer staging system), receptor status (estrogen receptor [ER], progesterone receptor [PR], Her2neu), time interval between mastectomy and reconstruction, and scar histology.A total of 442 patients with a mean age of 45.9 years (range, 22-73 years) were included in the study. Mastectomy with subsequent reconstruction was performed for in-situ disease and invasive cancer in 83 and 359 patients, respectively. A total of 619 clinically unremarkable mastectomy scars were sent for histological analysis, with the most common finding being unremarkable scar tissue (i.e. collagen fibers). Of note, no specimen revealed the presence of carcinoma.According to published reports routine histological examination of mastectomy scars may detect early local recurrence. However, we were not able to detect this benefit in our patient population. As such, particularly in the current health-care climate the cost-effectiveness of this practice deserves further attention. A more selective use of histological analysis of mastectomy scars in patients with tumors that display poor prognostic indicators may be a more reasonable utilization of resources.
View details for DOI 10.1016/j.bjps.2012.09.013
View details for Web of Science ID 000313620600012
View details for PubMedID 23044349
View details for PubMedCentralID PMC3545080
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The Chicken Foot Dorsal Vessel as a High-Fidelity Microsurgery Practice Model
PLASTIC AND RECONSTRUCTIVE SURGERY
2013; 131 (2): 311E-312E
View details for DOI 10.1097/PRS.0b013e318278d760
View details for Web of Science ID 000314355700041
View details for PubMedID 23358048
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Computed tomography angiography in microsurgery: indications, clinical utility, and pitfalls.
Eplasty
2013; 13
Abstract
Computed tomographic angiography (CTA) can be used to obtain 3-dimensional vascular images and soft-tissue definition. The goal of this study was to evaluate the reliability, usefulness, and pitfalls of CTA in preoperative planning of microvascular reconstructive surgery.A retrospective review of patients who obtained preoperative CTA in preparation for planned microvascular reconstruction was performed over a 5-year period (2001-2005). The influence of CTA on the original operative plan was assessed for each patient, and CTA results were correlated to the operative findings.Computed tomographic angiography was performed on 94 patients in preparation for microvascular reconstruction. In 48 patients (51%), vascular abnormalities were noted on CTA. Intraoperative findings correlated with CTA results in 97% of cases. In 42 patients (45%), abnormal CTA findings influenced the original operative plan, such as the choice of vessels, side of harvest, or nature of the reconstruction (local flap instead of free tissue transfer). Technical difficulties in performing CTA were encountered in 5 patients (5%) in whom interference from external fixation devices was the main cause.This large study of CTA obtained for preoperative planning of reconstructive microsurgery at both donor and recipient sites study demonstrates that CTA is safe and highly accurate. Computed tomographic angiography can alter the surgeon's reconstructive plan when abnormalities are noted preoperatively and consequently improve results by decreasing vascular complication rates. The use of CTA should be considered for cases of microsurgical reconstruction where the vascular anatomy may be questionable.
View details for PubMedID 24023972
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Tissue expander with acellular dermal matrix for breast reconstruction infected by an unusual pathogen: Candida parapsilosis
JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY
2012; 65 (10): E286-E289
Abstract
Infections occur in approximately 2-5% percent of women undergoing breast reconstruction by tissue expansion depending on patient characteristics and timing of reconstruction. Bacteria, specifically Staphylococci, are the most common pathogens. Treatment varies depending on the surgeon and the aggressiveness of the infection. We report a case of unilateral tissue expander infection with Candida parapsilosis in an otherwise healthy female undergoing immediate tissue expander placement after bilateral nipple-sparing mastectomies. The patient was treated with a one-stage irrigation, debridement, and tissue expander exchange as well as a 21-day course of oral antifungal therapy. Her infection resolved and she was able to complete her implant-based reconstruction. C. parapsilosis is usually responsible for infections in critically ill patients found in association with central lines, peritoneal dialysis catheters and prosthetic heart valves. The affinity of C. parapsilosis for foreign material makes it a causative agent worth considering in difficult to treat tissue expander infections.
View details for DOI 10.1016/j.bjps.2012.04.049
View details for Web of Science ID 000308995700003
View details for PubMedID 22633394
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Free transverse rectus abdominis myocutaneous flap reconstruction of a massive lumbosacral defect using superior gluteal artery perforator vessels
MICROSURGERY
2012; 32 (5): 388-392
Abstract
Despite significant advances in reconstructive surgery, the repair of massive lumbosacral defects poses significant challenges. When the extent of soft tissue loss, tumor resection, and/or radiation therapy preclude the use of traditional local options, such as gluteal advancement flaps or pedicled thigh flaps, then distant flaps are required. We report a case of a 64-year-old male who presented with a large sacral Marjolin's ulcer secondary to recurrent pilonidal cysts and ulcerations. The patient underwent wide local composite resection, which resulted in a wound measuring 450 cm(2) with exposed rectum and sacrum. The massive defect was successfully covered with a free transverse rectus abdominis myocutaneous flap, providing a well-vascularized skin paddle and obviating the need for a latissimus flap with skin graft. The free-TRAM flap proved to be a very robust flap in this situation and would be one of our flaps of choice for similar defects.
View details for DOI 10.1002/micr.21981
View details for Web of Science ID 000306178000009
View details for PubMedID 22473859
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Supercharged Free Fibula for Complex Ankle Arthrodesis A Case Report
ANNALS OF PLASTIC SURGERY
2012; 68 (4): 342-345
Abstract
We report the successful use of a supercharged free fibula for tibial reconstruction and ankle arthrodesis. A 28-year-old woman underwent resection of a giant cell tumor of the distal tibia and reconstruction using a methyl methacrylate cement spacer 12 years prior. The spacer eroded into her ankle joint causing significant pain with ambulation. Therefore, she required ankle arthrodesis but lacked distal tibia bone stock. The ipsilateral fibula was harvested for reconstruction and transferred on its distal blood supply into the bony tibial defect. The proximal blood supply of the fibula flap was then anastomosed to the posterior tibial vessels to supercharge the blood supply. An Ilizarov was placed for external fixation. The combination of a supercharged free fibula and stable external fixation for tibial reconstruction led to timely bony union and ambulation, as well as avoiding the potential complications that can occur with other reconstructive options.
View details for DOI 10.1097/SAP.0b013e31824189d0
View details for PubMedID 22421475
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Outcomes of Complex Abdominal Herniorrhaphy Experience With 106 Cases
ANNALS OF PLASTIC SURGERY
2012; 68 (4): 382-388
Abstract
Reconstruction of abdominal wall defects is a challenging problem. Often, the surgeon is presented with a patient having multiple comorbidities, who has already endured numerous unsuccessful operations, leaving skin and fascia that are attenuated and unreliable. Our study investigated preoperative, intraoperative, and postoperative factors and techniques during abdominal wall reconstruction to determine which variables were associated with poor outcomes.Data were collected on all patients who underwent ventral abdominal hernia repair by 3 senior-level surgeons at our institution during an 8-year period. In all cases, placement of either a synthetic or a biologic mesh was used to provide additional reinforcement of the repair.A total of 106 patients were included. Seventy-nine patients (75%) had preoperative comorbid conditions. Sixty-seven patients developed a postoperative complication (63%). Skin necrosis was the most common complication (n = 21, 19.8%). Other complications included seroma (n = 19, 17.9%), cellulitis (n = 19, 17.9%), abscess (n = 14 13.2%), pulmonary embolus/deep vein thrombosis (n = 3, 2.8%), small bowel obstruction (n = 2, 1.9%), and fistula (n = 8, 7.5%). Factors that significantly contributed to postoperative complications (P < 0.05) included obesity, diabetes, hypertension, fistula at the time of the operation, a history of >2 prior hernia repairs, a history of >3 prior abdominal operations, hospital stay for >14 days, defect size > 300 square cm, and the use of human-derived mesh allograft. Factors that significantly increased the likelihood of a hernia recurrence (P < 0.05) included a history of >2 prior hernia repairs, the use of human-derived allograft, using an overlay-only mesh placement, and the presence of a postoperative complication, particularly infection. Hernia recurrences were significantly reduced (P < 0.05) by using a "sandwich" repair with both a mesh overlay and underlay and by using component separation.A history of multiple abdominal operations is a major predictor of complications and recurrences. If needed, component separation should be used to achieve primary tension-free closure, which helps to reduce the likelihood of hernia recurrences. Our data suggest that mesh reinforcement used concomitantly in a "sandwich" repair with component separation release may lead to reduced recurrence rates and may provide the optimal repair in complex hernia defects.
View details for DOI 10.1097/SAP.0b013e31823b68b1
View details for Web of Science ID 000301800600013
View details for PubMedID 22421484
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Use of Fetal Bovine Acellular Dermal Xenograft With Tissue Expansion for Staged Breast Reconstruction
ANNALS OF PLASTIC SURGERY
2012; 68 (4): 338-341
Abstract
Staged breast reconstruction with implants and human acellular cadaveric dermis offers advantages of precise expander positioning, higher initial expander fill volumes, and improved outcomes. This study reports breast reconstruction using fetal bovine acellular dermal matrix (FBADM). The high type III collagen content of FBADM may allow for more rapid tissue incorporation and healing.A total of 49 breast reconstructions in 28 patients (group A) with FBADM were retrospectively compared with 123 reconstructions in 91 patients operated without FBADM (group B).FBADM sizes ranged from 48 to 100 cm2 (mean size: 70.6 cm2). The mean immediate fill volume in group A was 181.2 ± 148.3 mL and 117.7 ± 66.3 mL in group B (P < 0.001). The duration of drainage was significantly shorter in group A (8.51 ± 3.4 days) as compared with controls (11.07 ± 5.1 days), t-test (P = 0.015). There was no significant difference in the overall complication rate (20.8% in group A, 13.0% in group B). Further subgroup analysis of group A patients with complications and without complications, showed that group with complications had significantly longer drain removal time (9.48 vs. 7.97 days), larger initial fill volumes (238.1 vs. 145.3 mL), and a higher BMI (25.8 vs. 22.6 kg/m2) when compared with the complication-free subgroup.The use of FBADM in breast reconstruction offers results comparable with that of human acellular dermal matrix as reported in the literature. However, FBADM significantly reduced wound drainage time in our study when compared with patients without FBADM.
View details for DOI 10.1097/SAP.0b013e31823b68d0
View details for Web of Science ID 000301800600003
View details for PubMedID 22421474
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Is Microsurgical Head and Neck Reconstruction Profitable? Analysis at an Academic Medical Center
ANNALS OF PLASTIC SURGERY
2012; 68 (4): 401-403
Abstract
The complexity of modern head and neck reconstruction is paralleled by consumption of large amounts of resources provided by both treating physicians as well as the institution, that is, hospital. In times of increasing economic constraints, analysis of the financial value of providing these services seems prudent. A retrospective analysis of medical and billing records of patients who underwent immediate microsurgical reconstruction of postablative head and neck defects from 2007 to 2010 at Stanford University Medical Center was performed. Financial data related to the treatment of 60 patients were analyzed. Total reimbursement for plastic surgery services was $319,609, representing a collection rate of 18.4%. Total hospital charges were $31,038,846.10. Actual reimbursement was $9,109,776.55, which represents a collection rate of 29.3%. Analysis of hospital revenue revealed a net profit of $1,512,136.46, which represents a mean net revenue of $25,202.27 per case. Microsurgical reconstruction secures substantial revenue for the institution. Innovative reimbursement models need to be implemented to attract skilled microsurgeons, who represent the backbone of these services.
View details for DOI 10.1097/SAP.0b013e31823d2dec
View details for Web of Science ID 000301800600017
View details for PubMedID 22421488
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Plastic Surgery Residency Graduate Outcomes A 43-Year Experience at a Single Institution and the First "Integrated" Training Program in the United States
ANNALS OF PLASTIC SURGERY
2012; 68 (4): 404-409
Abstract
The Accreditation Council for Graduate Medical Education emphasizes outcome-based residency education. This project is an outcomes study on graduates of the Stanford University Integrated Plastic Surgery Residency.A survey assessing various outcomes, including practice profile, financial, personal, and educational issues, was electronically distributed to all 130 graduates between 1966 and 2009.There was a 65% response rate. Nearly all respondents are currently in practice. Popular fellowships included hand and microsurgery. Most respondents participated in research and held leadership roles. Adequate residency education was noted in areas of patient care, board preparation, and ethical and legal issues. Inadequate residency education was noted in areas of managing a practice, coding, and cost-effective medicine.This is the first long-term outcomes study of plastic surgery graduates. Most are in active, successful practice. We have incorporated educational content related to running a small business, contract negotiating, and marketing to better prepare our residents for future practice.
View details for DOI 10.1097/SAP.0b013e31823b6902
View details for Web of Science ID 000301800600018
View details for PubMedID 22421489
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Vertical Island Trapezius Myocutaneous Flap for Cervical Esophagoplasty Case Report and Review of the Literature
ANNALS OF PLASTIC SURGERY
2012; 68 (4): 362-365
Abstract
Reconstruction of the cervical esophagus can be fraught with a variety of complications, such as fistula formation or stricture. Additional complicating factors may include local tumor recurrence, failed prior reconstruction, partial or total flap necrosis, and compromised tissues in an irradiated field. Once complications occur, the chance of a successful reconstruction in subsequent operations is greatly reduced. We report a case of a patient who had local tumor recurrence despite chemoradiotherapy necessitating cervical esophagectomy. Reconstruction of the esophagus was initially performed with a tubed anterolateral thigh flap, which was complicated by partial flap necrosis and salivary fistula. Since the patient was elderly and already had a pectoralis flap used in a previous operation, we elected to perform a vertical island trapezius myocutaneous flap as a salvage procedure to restore esophageal continuity. Postoperatively, the patient had no evidence of further fistula and was able to tolerate a regular diet.
View details for DOI 10.1097/SAP.0b013e31823b68eb
View details for Web of Science ID 000301800600008
View details for PubMedID 22421479
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"Phantom" Publications Among Plastic Surgery Residency Applicants
ANNALS OF PLASTIC SURGERY
2012; 68 (4): 391-395
Abstract
Previous studies in other medical specialties have shown a significant percentage of publications represented in residency applications are not actually published. A comprehensive evaluation of applicants to plastic surgery residency over an extended period has not been previously reported in the literature. The purpose of our study was to determine the incidence of misrepresented or "phantom" publications in plastic surgery residency applicants and to identify possible predisposing characteristics.We used the Electronic Residency Application Services database to our plastic surgery residency program during a 4-year period from 2006 to 2009. Applicant demographic information and listed citations were extracted. Peer-reviewed journal article citations were verified using robust methods including PubMed, Institute for Scientific Information (ISI) Web of Knowledge, and Google. Unverifiable articles were categorized as phantom publications and then evaluated with respect to applicant demographic information and characteristics.During the 4-year study period, there were 804 applications (average, 201 applicants per year). There was a total of 4725 publications listed; of which, 1975 had been categorized as peer-reviewed journal articles. Two hundred seventy-six (14%) of peer-reviewed publications could not be verified and were categorized as phantom publications. There was an overall significant positive trend in percentage of phantom publications during the 4 application years (P = 0.005). A positive predictive factor for having phantom publications was being a foreign medical graduate (P = 0.02). A negative predictive factor for phantom publications was being a female applicant (P = 0.03). There also appeared to be a positive correlation with the number of publications listed and likelihood of phantom publications.Among plastic surgery residency applicants, we found a significant percentage of unverifiable publications. There are several possible explanations for our findings, which include the fact that plastic surgery is a highly sought-after specialty and applicants may feel the need to appear competitive to residency programs. Publications are an important aspect of the residency selection process and factors into applicant ranking, but our study suggests publications listed in plastic surgery residency applications may not necessarily be an accurate representation of actual published articles. Program directors and faculty are advised to scrutinize listed publications carefully when evaluating applicants.
View details for DOI 10.1097/SAP.0b013e31823d2c4e
View details for Web of Science ID 000301800600015
View details for PubMedID 22421486
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Microsurgery Education in Residency Training Validating an Online Curriculum
Annual Conference of the California-Society-of-Plastic-Surgeons
LIPPINCOTT WILLIAMS & WILKINS. 2012: 410–14
Abstract
Plastic surgery training has traditionally been modeled as an "apprenticeship," where faculty teach surgical skills to residents on live patients. Although this is a well-established process, the demand by the public and healthcare agencies for improved patient care, outcomes, and patient safety has led to the development of adjunct methods of teaching. The goal of this project is to assess the effectiveness of a web-based microsurgical curriculum.We developed an interactive Web site to teach essential microsurgical competencies. Residents were randomly divided into 2 cohorts: one experimental group completed this online resource and the other control group did not. Pre- and postassessments were administered, consisting of a written test and a recorded microsurgery skills session.A total of 17 plastic surgery residents of various training levels participated in the study. Residents who completed the web-based curriculum showed dramatic improvement in their knowledge and skills, with a 17-percentage point increase in their test scores (P = 0.01) compared with controls (P = 0.80). The experimental group was more likely to perform microanastomoses faster with an average of 4.5-minute improvement compared with 1.25-minute change among the control group. Residents performed self-assessments, and those who rated themselves as "very confident" had higher overall test scores (85% test score vs. 59%, P = 0.004), as well as shorter times to complete the microsurgical task (7.5 minutes vs. 13.6 minutes, P = 0.007). Overall, 62% of residents rated the online webpage as extremely valuable. The majority of residents reported the webpage improved their knowledge and markedly improved their microsurgical technique, which was confirmed by faculty experts.Our interactive Web-based curriculum is a novel resource, teaching microsurgery in an organized, competency-based manner, which we believe is the first Web site of this nature. An individualized, self-paced Web site is ideal for plastic surgery trainees of all levels. Overall, the widespread implementation of our proposed curriculum--online self-directed training combined with regular practice sessions--will establish a strong foundation of microsurgery knowledge and skills acquisition for all plastic surgery residents.
View details for DOI 10.1097/SAP.0b013e31823b6a1a
View details for Web of Science ID 000301800600019
View details for PubMedID 22421490
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Should we continue to consider obesity a relative contraindication for autologous microsurgical breast reconstruction?
JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY
2012; 65 (4): 420-425
Abstract
Obesity is not only a causative factor for premature mortality, it has also been demonstrated to be associated with an increased postoperative complication rate. As such, it has traditionally been considered a relative contraindication to autologous breast reconstruction. The purpose of this study was to assess whether this recommendation is justified.A retrospective study was conducted analyzing the effect of obesity on complication rate after microsurgical autologous breast reconstruction using abdominal tissue. Patients undergoing breast reconstruction between November 2006 and February 2011 were included. In contrast to prior studies, only patients meeting criteria to undergo bariatric surgery were included in the study, thus, representing a particularly high-risk subset of patients (Group 1: BMI greater 40 kg/m(2); Group 2: BMI greater 35 kg/m(2) with co-morbidities).A total of 42 breast reconstructions were performed in 28 patients who met inclusion criteria. Surgical complications were seen in a total of 9 patients (p = 1.00). All complications were successfully managed conservatively and did not prolong hospitalization. No differences were seen among study groups with respect to donor-site (p = 0.57) and recipient-site complications (p = 1.00). Of note, no partial or total flap loss was seen in this study.Obesity is associated with a relatively high risk of minor complications postoperatively. However, complications can typically be managed non-operatively and on an outpatient basis with fairly minimal patient morbidity. We believe that obesity should not be considered a relative contraindication to autologous microsurgical breast reconstruction. Patients should, however, be informed preoperatively about their higher risk of postoperative complications.
View details for DOI 10.1016/j.bjps.2011.10.005
View details for Web of Science ID 000301982000012
View details for PubMedID 22024538
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Split, Temporalis Muscle Flap for Repair of Recalcitrant Cerebrospinal Fluid Leaks of the Anterior Cranial Fossa
JOURNAL OF CRANIOFACIAL SURGERY
2012; 23 (2): 539-542
Abstract
Cerebrospinal fluid repair after dural disruption is critical in preventing morbidity and mortality in trauma and cancer patients. Among reconstructive options, coverage with the temporalis muscle has been a staple in many surgeons' armamentarium. However, the donor-site morbidity has been a major drawback in the use of this technique. Here, we present our method of split, temporalis harvest for anterior cranial base reconstruction, which seeks to regain dural integrity, while maintaining aesthetic and functional elements of the donor site. We present 2 patients, demonstrating the ease of harvest, fulfillment of both cosmetic and reconstructive goals, widespread applicability, and versatility of our split, temporalis muscle flap.
View details for DOI 10.1097/SCS.0b013e3182418f18
View details for Web of Science ID 000302171700084
View details for PubMedID 22421850
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Abdominal wall reconstruction with dual layer cross-linked porcine dermal xenograft: The "Pork Sandwich" herniorraphy
JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY
2012; 65 (3): 333-341
Abstract
The repair of large ventral hernias is a challenging problem. This study investigated the use of decellularized, chemically cross-linked porcine dermal xenograft in conjunction with component separation (a.k.a. the "Pork Sandwich" Herniorraphy) in the repair of abdominal wall defects.We prospectively collected data over a 3-year period. Primary or near-total primary fascial closure was our goal in operative repair. A cross-linked porcine dermal xenograft mesh underlay and overlay were used to provide maximal reinforcement of the repair. Outcomes were compared with a case-controlled cohort of 84 patients who underwent ventral hernia repairs with alternative methods at our institution.Nineteen patients were included. Mean age was 55 years old, and mean body mass index (BMI) was 30 kg/m(2). Mean defect size was 321 cm(2). Post-operative complications were observed in ten out of 19 patients. Complications included seroma (n = 2), wound infection (n = 2), abscess (n = 1), skin necrosis (n = 6), and fistula formation (n = 3). Seven patients required re-operation. Statistically significant factors (p < 0.05) that contributed to increased post-operative complications or re-operation rates included smoking, presence of pre-operative enterocutaneous fistulae, extended post-operative hospital stay (>2 weeks), and a defect size greater than 300 cm(2). There were no hernia recurrences in our "Pork Sandwich" group, which contrasted favorably to the retrospective case-control group in which the hernia recurrence rate was 19% (p = 0.038).For the repair of abdominal hernias, primary closure, with component separation as needed, with an underlay and overlay of cross-liked porcine xenograft should be considered to minimize risk of recurrent herniation. Additional long-term prospective comparative studies are needed for further validation of the optimal method and material for repair.
View details for DOI 10.1016/j.bjps.2011.09.044
View details for Web of Science ID 000300524800016
View details for PubMedID 22000333
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Free Flap Scalp Reconstruction in a 91-Year-Old Patient under Local-Regional Anesthesia: Case Report and Review of the Literature
JOURNAL OF RECONSTRUCTIVE MICROSURGERY
2012; 28 (3): 189-193
Abstract
In the elderly population with significant medical comorbidities, the safety of general anesthesia is often in question. In the head and neck, where regional and extradural anesthesia are not options, reconstruction of defects requiring free tissue transfer becomes a particular challenge for patients in whom general anesthesia is contraindicated. We present a case of a scalp reconstruction utilizing a latissimus dorsi free flap in a 91-year-old man performed entirely under local and regional anesthesia. General anesthesia was contraindicated secondary to the patient's multiple medical comorbidities. A paravertebral block was used for the harvest of the latissimus dorsi muscle and skin grafts. The microvascular portion of the procedure and the inset were performed under local anesthesia alone. The patient tolerated the procedure, and the operation was successful. This case is unique in that there are no published reports of head and neck free tissue transfer being performed entirely under local-regional anesthesia. We conclude that despite the medical challenges of performing complex reconstruction in elderly patients, expedient free tissue transfer can offer patients access to successful reconstruction.
View details for DOI 10.1055/s-0031-1301070
View details for Web of Science ID 000302138200007
View details for PubMedID 22274769
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Tarsal ectropion repair and lower blepharoplasty: A case report and review of literature
JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY
2012; 65 (2): 249-251
Abstract
Ectropion is frequently encountered in plastic surgery. A variety of etiologies exist, but tarsal ectropion, defined as complete eversion of the tarsal plate and its overlying conjunctiva, is rarely considered. First described in 1960 by Fox, this variant was initially attributed to pre-septal orbicularis oculi spasm or tarsoligamentous relaxation. However, subsequent investigators determined that the true etiology involved lower lid retractor disinsertion on the tarsal plate. We present a case of chronic right lower lid ectropion in a 66-year-old male. Through understanding of eyelid anatomy, especially that of the lower eyelid retractors, tarsal ectropion was correctly identified in our patient preoperatively. A repair including correction of retractor disinsertion on the tarsus was planned, and given our patient's degree of lower lid delamination and mobilization, we also proceeded with bilateral lower lid blepharoplasty with canthal and lower lid soft tissue support. Ultimately, we were able to achieve an improved aesthetic appearance for our patient, along with resolution of his symptoms.
View details for DOI 10.1016/j.bjps.2011.06.035
View details for Web of Science ID 000299111100022
View details for PubMedID 21764653
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The effect of preoperative radiotherapy on complication rate after microsurgical head and neck reconstruction
JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY
2011; 64 (11): 1454-1459
Abstract
The introduction of radiotherapy (XRT) has resulted in increased survival of patients diagnosed with head and neck malignancies. However, the potentially deleterious impact of radiotherapy on reconstructive efforts continues to be the subject of intense debate. The present study was designed to evaluate the effects of preoperative XRT on complication rates in patients undergoing microsurgical reconstruction of head and neck defects after oncosurgical resection.A retrospective cohort study was conducted of all patients who underwent immediate microsurgical reconstruction of post-ablative defects over a 3-year period. Study subjects were divided into two groups: (1) those who did not receive XRT and (2) those who received preoperative XRT. Clinical variables examined and analysed included age, gender, co-morbid conditions, tobacco history, the presence of recurrent disease and ischaemia time. Outcomes of interest included length of intensive care unit (ICU) and hospital stay and postoperative complications. Complications were further classified as flap-related as well as 'medical'.A total of 60 patients were included in this study (group 1: 26 patients; group 2: 34 patients). Results were similar between the study groups with the exception of a higher rate of flap-related complications in patients undergoing XRT. Overall, 19 patients (31.7%) experienced flap-related complications, with 12% of the patients being in group 1 (N=3) versus 47% of patients being in group 2 (N=16) (p=0.003).Our data suggest that preoperative radiotherapy is associated with a significant increase in postoperative flap-related complications. However, these did not result in a prolonged hospital stay, reflecting the fact that the majority of flap-related complications can be managed on an outpatient basis. Although microsurgical reconstruction is frequently successful, patients with a history of XRT should be informed preoperatively about their increased risk of complications.
View details for DOI 10.1016/j.bjps.2011.06.043
View details for Web of Science ID 000296579400015
View details for PubMedID 21783448
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Micro-Seed Grant Funding for Residents: Fostering Academic Productivity in Plastic Surgery
PLASTIC AND RECONSTRUCTIVE SURGERY
2011; 128 (1): 43E-44E
View details for DOI 10.1097/PRS.0b013e3182174426
View details for Web of Science ID 000292499600021
View details for PubMedID 21701317
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The Use of Standardized Patients in the Plastic Surgery Residency Curriculum: Teaching Core Competencies with Objective Structured Clinical Examinations
78th Annual Meeting of the American-Society-of-Plastic-Surgeons/Meeting on Plastic Surgery
LIPPINCOTT WILLIAMS & WILKINS. 2011: 291–98
Abstract
As of 2006, the Accreditation Council for Graduate Medical Education had defined six "core competencies" of residency education: interpersonal communication skills, medical knowledge, patient care, professionalism, practice-based learning and improvement, and systems-based practice. Objective structured clinical examinations using standardized patients are becoming effective educational tools, and the authors developed a novel use of the examinations in plastic surgery residency education that assesses all six competencies.Six plastic surgery residents, two each from postgraduate years 4, 5, and 6, participated in the plastic surgery-specific objective structured clinical examination that focused on melanoma. The examination included a 30-minute videotaped encounter with a standardized patient actor and a postencounter written exercise. The residents were scored on their performance in all six core competencies by the standardized patients and faculty experts on a three-point scale (1 = novice, 2 = moderately skilled, and 3 = proficient).Resident performance was averaged for each postgraduate year, stratified according to core competency, and scored from a total of 100 percent. Residents overall scored well in interpersonal communications skills (84 percent), patient care (83 percent), professionalism (86 percent), and practice-based learning (84 percent). Scores in medical knowledge showed a positive correlation with level of training (86 percent). All residents scored comparatively lower in systems-based practice (65 percent). The residents reported unanimously that the objective structured clinical examination was realistic and educational.The objective structured clinical examination provided comprehensive and meaningful feedback and identified areas of strengths and weakness for the residents and for the teaching program. The examination is an effective assessment tool for the core competencies and a valuable adjunct to residency training.
View details for DOI 10.1097/PRS.0b013e31821962d2
View details for Web of Science ID 000292499600066
View details for PubMedID 21701346
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Non-viral Delivery of Inductive and Suppressive Genes to Adipose-Derived Stem Cells for Osteogenic Differentiation
PHARMACEUTICAL RESEARCH
2011; 28 (6): 1328-1337
Abstract
To assess the effects of co-delivering osteoinductive DNA and/or small interfering RNA in directing the osteogenic differentiation of human adipose-derived stem cells (hADSCs) using a combinatorial, non-viral gene delivery approach.hADSCs were transfected using combinations of the following genes: BMP2, siGNAS and siNoggin using poly(β-amino esters) or lipid-like molecules. A total of 15 groups were evaluated by varying DNA doses, timing of treatment, and combinations of signals. All groups were cultured in osteogenic medium for up to 37 days, and outcomes were measured using gene expression, biochemical assays, and histology.Biomaterials-mediated gene delivery led to a dose-dependent up-regulation of BMP2 and significant gene silencing of GNAS and Noggin in hADSCs. BMP2 alone slightly up-regulates osteogenic marker expression in hADSCs. In contrast, co-delivery of BMP2 and siGNAS or siNoggin significantly accelerates the hADSC differentiation towards osteogenic differentiation, with marked increase in bone marker expression and mineralization.We report a combinatorial platform for identifying synergistic interactions among multiple genetic signals associated with osteogenic differentiation of hADSCs. Our results suggest that inductive or suppressive genetic switches interact in a complex manner, and highlight the promise of combinatorial approaches towards rapidly identifying optimal signals for promoting desired stem cell differentiation.
View details for DOI 10.1007/s11095-011-0406-9
View details for Web of Science ID 000290804000009
View details for PubMedID 21424160
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THE STERNOCLEIDOMASTOID MYOCUTANEOUS "PATCH ESOPHAGOPLASTY" FOR CERVICAL ESOPHAGEAL STRICTURE
MICROSURGERY
2011; 31 (4): 318-322
Abstract
Esophageal strictures may be caused by many etiologies. Patients suffer from dysphagia and many are tube-feed dependent. Cervical esophageal reconstruction is challenging for the plastic surgeon, and although there are reports utilizing chest wall flaps or even free flaps, the use of a sternocleidomastoid (SCM) myocutaneous flap provides an ideal reconstruction in select patients who require noncircumferential "patch" cervical esophagoplasty. We present two cases of esophageal reconstruction in which we demonstrate our technique for harvesting and insetting the SCM flap, with particular emphasis on design of the skin paddle and elucidation of the vascular anatomy. We believe that the SCM flap is simple, reliable, convenient, and technically easy to perform. There is minimal donor site morbidity with no functional loss. The SCM myocutaneous flap is a viable option for reconstructing partial esophageal defects and obviates the need to perform staged procedures or more extensive operations such as free tissue transfer.
View details for DOI 10.1002/micr.20880
View details for Web of Science ID 000290479000012
View details for PubMedID 21500276
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Adverse Events Following Digital Replantation in the Elderly
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2011; 36A (5): 870-874
Abstract
The decision to proceed with digital replantation in the elderly can be challenging. In addition to success of the replanted part, perioperative morbidity and mortality must be considered. The purpose of this study was to compare adverse events in patients less than 65 years of age compared with those 65 years and older after digital replantation. We hypothesize that there is an increased incidence of mortality and sentinel adverse events in patients aged 65 and older.We obtained data from the Nationwide Inpatient Sample over a 10-year period from 1998 to 2007. Replantation was identified using International Classification of Diseases-9 procedure codes for finger and thumb reattachment (84.21 and 84.22). Adverse events were identified using Patient Safety Indicators (PSI) to identify adverse events occurring during hospitalization. We used the Charlson index to study medical comorbidities and bivariate statistics.During the study period 15,413 finger and thumb replantations were performed in the United States, with 616 performed on patients age 65 and older. The overall in-hospital mortality was 0.04% with no statistical difference when factoring age. For the entire group, the percentage of PSI was 0.6%, the most common being postoperative deep venous thrombosis and pulmonary embolus. Overall, there was no difference in PSI between the 2 groups. The older group had a higher rate of transfusion, 4% versus 8% (p < .05) and were more likely to have a nonroutine disposition (ie, nursing home) (p < .001). We found no correlation between the Charlson index and PSI.This study found no difference in sentinel perioperative complications or mortality when comparing replantation patients under 65 years of age and those age 65 and older. Age alone should not be an absolute contraindication to finger replantation. Instead, the patient's functional demands, type of injury, general state of health, and rehabilitative potential should drive the decision of whether to proceed with replantation.
View details for DOI 10.1016/j.jhsa.2011.01.031
View details for Web of Science ID 000290185700017
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Adverse events following digital replantation in the elderly.
journal of hand surgery
2011; 36 (5): 870-874
Abstract
The decision to proceed with digital replantation in the elderly can be challenging. In addition to success of the replanted part, perioperative morbidity and mortality must be considered. The purpose of this study was to compare adverse events in patients less than 65 years of age compared with those 65 years and older after digital replantation. We hypothesize that there is an increased incidence of mortality and sentinel adverse events in patients aged 65 and older.We obtained data from the Nationwide Inpatient Sample over a 10-year period from 1998 to 2007. Replantation was identified using International Classification of Diseases-9 procedure codes for finger and thumb reattachment (84.21 and 84.22). Adverse events were identified using Patient Safety Indicators (PSI) to identify adverse events occurring during hospitalization. We used the Charlson index to study medical comorbidities and bivariate statistics.During the study period 15,413 finger and thumb replantations were performed in the United States, with 616 performed on patients age 65 and older. The overall in-hospital mortality was 0.04% with no statistical difference when factoring age. For the entire group, the percentage of PSI was 0.6%, the most common being postoperative deep venous thrombosis and pulmonary embolus. Overall, there was no difference in PSI between the 2 groups. The older group had a higher rate of transfusion, 4% versus 8% (p < .05) and were more likely to have a nonroutine disposition (ie, nursing home) (p < .001). We found no correlation between the Charlson index and PSI.This study found no difference in sentinel perioperative complications or mortality when comparing replantation patients under 65 years of age and those age 65 and older. Age alone should not be an absolute contraindication to finger replantation. Instead, the patient's functional demands, type of injury, general state of health, and rehabilitative potential should drive the decision of whether to proceed with replantation.
View details for DOI 10.1016/j.jhsa.2011.01.031
View details for PubMedID 21489718
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Supercharged Jejunum Flap for Total Esophageal Reconstruction: Single-Surgeon 3-Year Experience and Outcomes Analysis
PLASTIC AND RECONSTRUCTIVE SURGERY
2011; 127 (1): 173-180
Abstract
Esophageal reconstruction after total esophagectomy remains a formidable task irrespective of the conduit chosen. Historically, the gastric pull-up and colonic interposition have served as primary choices for such defects. However, where the stomach and colon are unavailable or unsuitable, the jejunum serves as a reliable alternative for the reconstruction of total esophageal defects.The authors performed an outcomes analysis of a single surgeon's surgical technique and experience. Patients who received supercharged pedicled jejunum flaps for reconstruction of total esophageal defects over a 3-year period were included in this study. Data were collected prospectively evaluating operative technique, length of hospital stay, operative time, complications, postoperative diet, and quality-of-life outcomes analysis.Five patients underwent supercharged pedicled jejunal flap surgery during this study period. All flaps had complete viability and no microvascular complications. One patient had a radiographic anastomotic leak detected by barium swallow that was reexplored and closed primarily and reinforced with a pectoralis advancement flap with subsequent resolution. All patients are currently tolerating a regular diet and there are no symptoms of reflux or dumping. No conduit strictures or redundancy has been found to date, and there has been no need for reoperation in the long term.The supercharged jejunum flap is a reliable alternative to the gastric pull-up and colonic interposition for total esophageal reconstruction. In our experience, the key maneuver in this technique is a substernal tunnel for the jejunal conduit and exposure of recipient vessels and the esophageal stump by means of a manubriectomy, clavicle resection, partial first rib resection and, occasionally, a second rib resection.
View details for DOI 10.1097/PRS.0b013e3181f95a36
View details for PubMedID 21200211
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Effectiveness of the Asteame Nipple Guard (TM) in maintaining projection following nipple reconstruction: A prospective randomised controlled trial
42nd Congress of the European-Society-for-Surgical-Research
ELSEVIER SCI LTD. 2010: 1592–96
Abstract
As the final step in breast reconstruction, nipple reconstruction is considered a minor surgical procedure. However, despite the multitude of techniques and postoperative dressings proposed, none have proven to resist the tendency of the reconstructed nipple to gradually flatten over time. A prospective randomized controlled trial was conducted assessing the value of using the Asteame Nipple Guard™ compared to standard gauze dressing in maintaining nipple projection postoperatively. A total of 30 nipple reconstructions in 22 patients were included in the study with randomisation of 15 nipples to each study arm. Nipple projection was measured at various time points postoperatively with calculation of the percent changes in nipple projection. The mean decrease in long-term nipple projection at 6 months in the experimental group was 46.6% vs. 71.8% in the control group (p<0.05). In conclusion, the Nipple Guard™ helps in maintaining nipple projection postoperatively.
View details for DOI 10.1016/j.bjps.2009.10.006
View details for Web of Science ID 000281655500003
View details for PubMedID 19897430
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A CASE OF INTRAOPERATIVE VENOUS CONGESTION OF THE ENTIRE DIEP-FLAP-A NOVEL SALVAGE TECHNIQUE AND REVIEW OF THE LITERATURE
MICROSURGERY
2010; 30 (6): 443-446
Abstract
The deep inferior epigastric perforator (DIEP) flap is gaining popularity for autologous breast reconstruction as it reportedly reduces abdominal donor site morbidity when compared with the transverse rectus abdominis musculocutaneous (TRAM) flap. Disadvantages include greater technical difficulties during flap harvest and a greater incidence of vascular compromise. A well-known and feared complication is venous congestion which requires immediate intervention. We present a novel salvage technique in a case of total flap venous congestion in the setting of absent drainage via the deep inferior epigastric vein (DIEV). Utilizing the superficial venous system via the superficial inferior epigastric vein (SIEV) and using the DIEV as a venous interposition graft resulted in successful salvage of the DIEP flap.
View details for DOI 10.1002/micr.20774
View details for Web of Science ID 000282253300004
View details for PubMedID 20878727
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SUPERCHARGED REVERSE PEDICLE ANTEROLATERAL THIGH FLAP IN RECONSTRUCTION OF A MASSIVE DEFECT: A CASE REPORT
MICROSURGERY
2010; 30 (5): 397-400
Abstract
Secondary reconstruction of lower extremity defects using local tissues is demanding and fraught with potential complications. Reconstructive efforts may be challenged by pre-existing scarring, paucity of recipient vessels, and patient co-morbidities limiting tolerance for prolonged and extensive surgery. We present a case of an 81-year-old male with a recurrent malignant melanoma invading the proximal and middle third of the tibia, who previously underwent reconstruction with the medial gastrocnemius muscle and a skin graft. After wide local re-excision and tibia fixation, a 12 cm x 28 cm reverse anterolateral thigh flap was used for soft tissue coverage. Because of the relatively large size of the flap based upon retrograde flow, we elected to supercharge the flap to augment its blood supply. Supercharging of the flap pedicle was accomplished by anastamosing the lateral circumflex femoral vessels to the anterior tibial vessels. The donor site wasclosed primarily. The flap survived entirely and successfully endured subsequent radiation therapy. Supercharging enhances reliability of the reverse anterolateral thigh flap, and thus, permits harvest of large tissue bulk for coverage of up to proximal two-thirds of the tibia.This is the first report describing successful supercharging of a large reverse anterolateral thigh flap which resulted in entire flap survival.
View details for DOI 10.1002/micr.20761
View details for Web of Science ID 000280085900010
View details for PubMedID 20238382
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COLD ISCHEMIA IN MICROVASCULAR BREAST RECONSTRUCTION
MICROSURGERY
2010; 30 (5): 361-367
Abstract
A major drawback to microvascular free flap breast reconstruction is the length of operation-up to 9 hours or more for bilateral reconstruction. This takes a significant mental and physical toll on the surgical team, producing fatigue that may compromise surgical outcome. To facilitate the operation we have incorporated a period of cold ischemia of the flaps such that members of the surgical team can alternate a brief respite during the operation.We retrospectively reviewed our series of microvascular free flap breast reconstructions performed over a four-year period in which cold ischemia of the flaps were induced.Seventy patients underwent free flap breast reconstruction with 104 flaps. Mean cold ischemia time for all flaps was 2 hours 36 min. Average rest time per surgeon per case was 35 min. Complications included two total flap losses (1.9%), one partial flap loss (1.0%), one anastomotic thrombosis (1.0%), two hematomas (1.9%), three fat necrosis (2.9%), and two delayed healing (1.9%). Statistical analysis revealed that the probability of complications is inversely related to cold ischemia time (P = 0.0163).Cold ischemia facilitates breast reconstruction by allowing the surgical team to alternate breaks during the operation. This helps reduce surgeon fatigue and is well tolerated by the flap. Thus, we believe that the use of cold ischemia is safe and advantageous in microvascular breast reconstruction.
View details for DOI 10.1002/micr.20739
View details for Web of Science ID 000280085900004
View details for PubMedID 20146383
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Flexor Tendon Tissue Engineering: Temporal Distribution of Donor Tenocytes versus Recipient Cells
PLASTIC AND RECONSTRUCTIVE SURGERY
2009; 124 (6): 2019-2026
Abstract
Tissue-engineered tendon material may address tendon shortages in mutilating hand injuries. Tenocytes from rabbit flexor tendon can be successfully seeded onto acellularized tendons that are used as tendon constructs. These constructs in vivo exhibit a population of tenocyte-like cells; however, it is not known to what extent these cells are of donor or recipient origin. Furthermore, the temporal distribution is also not known.Tenocytes from New Zealand male rabbits were cultured and seeded onto acellularized rabbit forepaw flexor tendons (n = 48). These tendon constructs were transplanted into female recipients. Tendons were examined after 3, 6, 12, and 30 weeks using fluorescent in situ hybridization to detect the Y chromosome in the male donor cells. One unseeded, acellularized allograft in each animal was used as a control.The donor male tenocytes populate the epitenon and endotenon of the grafts at greater numbers than the recipient female tenocytes at 3 and 6 weeks. The donor and recipient tenocytes are present jointly in the grafts until 12 weeks. At 30 weeks, nearly all cells are recipient tenocyte-like cells.Donor male cells survive in decreasing numbers over time until 30 weeks. The presence of cells in tissue-engineered tendon grafts has been shown in prior studies to add to the strength of the constructs in vitro. This study shows that recipient cells can migrate into and repopulate the tendon construct. Cell seeding onto tendon material may create stronger constructs that will allow the initiation of motion earlier.
View details for DOI 10.1097/PRS.0b013e3181bcf320
View details for Web of Science ID 000272615600032
View details for PubMedID 19952658
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Transverse Singapore Flap for Reconstruction of a Congenital Rectovaginal Fistula in an 18-Month-Old Infant
ANNALS OF PLASTIC SURGERY
2009; 63 (6): 650-653
Abstract
Many different types of flaps have been used for reconstruction of rectovaginal fistulae. This is the first report of using a transverse Singapore flap for repairing a large 3 cm by 3-cm complex congenital rectovaginal fistula in an 18-month-old infant with VATER syndrome. A right transverse Singapore flap was used to reconstruct both the posterior wall of the vagina and the anterior wall of the rectum while simultaneously joining the 2 structures to the perineum. Despite minor postoperative delayed healing which resolved, the patient has maintained a functionally and cosmetically satisfactory result at 20-month follow-up. For complex rectovaginal fistulae reconstruction in the pediatric patient, the transverse Singapore flap is a reliable and viable option for the reconstructive surgeon.
View details for DOI 10.1097/SAP.0b013e31819ae002
View details for Web of Science ID 000272316400016
View details for PubMedID 19816154
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The Free Gracilis Perforator Flap: Is a Perforator Flap Really Indicated in the Case of the Gracilis Flap?
PLASTIC AND RECONSTRUCTIVE SURGERY
2009; 124 (3): 1008-1009
View details for DOI 10.1097/PRS.0b013e3181b03a79
View details for Web of Science ID 000269485200055
View details for PubMedID 19730342
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A Novel Single-Flap Technique for Total Penile Reconstruction: The Pedicled Anterolateral Thigh Flap
58th Annual Meeting of the California-Society-of-Plastic-Surgeons
LIPPINCOTT WILLIAMS & WILKINS. 2009: 163–66
View details for DOI 10.1097/PRS.0b013e3181ab2593
View details for Web of Science ID 000267895000021
View details for PubMedID 19568056
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Invited discussion: Harvesting of forearm perforator flaps based on intraoperative vascular exploration: Clinical experiences and literature review
MICROSURGERY
2008; 28 (5): 331-332
Abstract
Advancements in microsurgery and a better understanding of vascular anatomy has allowed for expanding indications for perforators flaps in reconstructive surgery. The use of perforator flaps in the forearm has not become widespread, yet the benefit of sparing a major peripheral artery such as the ulnar or radial is certainly worth considering. The authors present their experience with perforator flaps in the forearm.
View details for DOI 10.1002/micr.20498
View details for Web of Science ID 000257818200005
View details for PubMedID 18537175
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The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy
47th Annual Meeting of the American-Society-for-Therapeutic-Radiology-and-Oncology
ELSEVIER SCIENCE INC. 2006: 76–82
Abstract
To quantify the impact of immediate breast reconstruction on postmastectomy radiation therapy (PMRT) planning.A total of 110 patients (112 treatment plans) who had mastectomy with immediate reconstruction followed by radiotherapy were compared with contemporaneous stage-matched patients who had undergone mastectomy without intervening reconstruction. A scoring system was used to assess optimal radiotherapy planning using four parameters: breadth of chest wall coverage, treatment of the ipsilateral internal mammary chain, minimization of lung, and avoidance of heart. An "optimal" plan achieved all objectives or a minor 0.5 point deduction; "moderately" compromised treatment plans had 1.0 or 1.5 point deductions; and "major" compromised plans had > or =2.0 point deductions.Of the 112 PMRT plans scored after reconstruction, 52% had compromises compared with 7% of matched controls (p < 0.0001). Of the compromised plans after reconstruction, 33% were considered to be moderately compromised plans and 19% were major compromised treatment plans. Optimal chest wall coverage, treatment of the ipsilateral internal mammary chain, lung minimization, and heart avoidance was achieved in 79%, 45%, 84%, and 84% of the plans in the group undergoing immediate reconstruction, compared respectively with 100%, 93%, 97%, and 92% of the plans in the control group (p < 0.0001, p < 0.0001, p = 0.0015, and p = 0.1435). In patients with reconstructions, 67% of the "major" compromised radiotherapy plans were left-sided (p < 0.16).Radiation treatment planning after immediate breast reconstruction was compromised in more than half of the patients (52%), with the largest compromises observed in those with left-sided cancers. For patients with locally advanced breast cancer, the potential for compromised PMRT planning should be considered when deciding between immediate and delayed reconstruction.
View details for DOI 10.1016/j.ijrobp.2006.03.040
View details for Web of Science ID 000239931500011
View details for PubMedID 16765534
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The economics of plastic surgery practices: Trends in income, procedure mix, and volume
PLASTIC AND RECONSTRUCTIVE SURGERY
2004; 114 (1): 192-199
Abstract
Anecdotally, plastic surgeons have complained of working harder for the same or less income in recent years. They also complain of falling fees for reconstructive surgery and increasing competition for cosmetic surgery. This study examined these notions using the best available data. To gain a better understanding of the current plastic surgery market, plastic surgeon incomes, fees, volume, and relative mix of cosmetic and reconstructive surgery were analyzed between the years 1992 and 2002. To gain a broader perspective, plastic surgeon income trends were then compared with those of other medical specialties and of nonmedical professions. The data show that in real dollars, plastic surgeon incomes have remained essentially steady in recent years, despite plastic surgeons increasing their surgery load by an average of 41 percent over the past 10 years. The overall income trend is similar to that of members of other medical specialties and other nonmedical professionals. The average practice percentage of cosmetic surgery was calculated and found to have increased from 27 percent in 1992 to 58 percent in 2002. This most likely can be explained by the findings that real dollar fees collected for cosmetic surgery have decreased very slightly, whereas those for reconstructive procedures have experienced sharp declines. This study demonstrates that plastic surgeons have adjusted their practice profiles in recent years. They have increased their case loads and shifted their practices toward cosmetic surgery, most likely with the goal of maintaining their incomes. The strategy appears to have been successful in the short term. However, with increasing competition and falling prices for cosmetic surgery, it may represent a temporary bulwark for plastic surgeon incomes unless other steps are taken.
View details for DOI 10.1097/01.PRS.0000128820.10811.0A
View details for Web of Science ID 000222282100034
View details for PubMedID 15220592
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Magnetic resonance imaging detection of vascular occlusion of a pedicled muscle flap
Surgical Forum of the American-College-of-Surgeons
WILEY-LISS. 1996: 306–12
Abstract
Contrast-enhanced magnetic resonance imaging (MRI) can be a highly sensitive monitor of tissue blood perfusion. This technique has been used to assess blood flow through liver, kidney, and certain tumors, but has not been widely applied to the study of skeletal muscle circulation. In our study, we used a novel scanning software to obtain contrast-enhanced T2*-weighted gradient echo MRI images of pedicled quadriceps muscle flaps in rabbits in order to study images of arterial, venous, and arterio-venous occlusion. We administered an intravenous bolus of gadoteridol contrast agent at the initiation of scanning, which produces a decrease in T2*-signal and improves the sensitivity of measuring blood perfusion. Within 30 seconds of MRI scanning, control flaps with intact pedicles exhibited a rapid decrease in T2*-signal intensity, indicating adequate perfusion of blood through muscle tissue; however, occluded pedicled flaps showed no significant change in signal intensity, indicating lack of blood perfusion. Differences in signal intensities as measured by MRI between occluded and control flaps were statistically significant (P < 0.05). Selective vascular occlusion of either artery alone, or both artery and vein were detected within 15 minutes, whereas selective venous occlusion could be detected after 2 hours. We conclude that MRI has the ability to assess skeletal muscle perfusion, and is capable of noninvasively evaluating a cross-section of tissue in both superficial and buried flaps. MRI, therefore, may have the potential for evaluating perfusion in muscle flaps (including buried flaps), and other disorders of muscle circulation such as compartment syndrome.
View details for Web of Science ID A1996XU71700004
View details for PubMedID 9308714