Breast Reconstruction Decision Aids Decrease Decisional Conflict and Improve Decisional Satisfaction: A Randomized Controlled Trial.

BACKGROUND: Decision aids are useful adjuncts to clinical consultations for women considering breast reconstruction. This study compared the impact of two online decision aids, the Breast RECONstruction Decision Aid (BRECONDA) and the Alberta Health Services (AHS) decision aid, on decisional conflict, decisional satisfaction, and decisional regret. METHODS: This randomized controlled trial included 60 women considering whether or not to undergo breast reconstruction. Two online decision aids, the AHS and the BRECONDA, were compared using randomized two-arm equal allocation. Participants responded to questionnaires at baseline, after the first and second consultations, and at 6 weeks and 6 months after deciding to, or not to, undergo reconstruction. Change in decisional conflict scores was compared between the BRECONDA and the AHS decision aid. Secondary outcomes included decisional regret and decisional satisfaction. RESULTS: Both groups were similar in demographic, clinical, and behavioral characteristics. Women spent more time consulting the BRECONDA in comparison to women using the AHS decision aid (56.7 ± 53.8 minutes versus 28.4 ± 27.2 minutes; P < 0.05). Decisional conflict decreased (P < 0.05), and decisional satisfaction improved over time in both groups (P < 0.05). However, there were no differences based on the type of decision aid used (P > 0.05). Both decision aids had a similar reduction in decisional regret (P > 0.05). CONCLUSIONS: Decision aids decrease decisional conflict and improve decisional satisfaction among women considering breast reconstruction. Physicians should therefore offer patients access to decision aids as an adjunct to breast reconstruction consultations to help patients make an informed decision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

A Multidisciplinary Hand Clinic Using Physiatrists for the Evaluation of Non-Operative Pathologies.

PURPOSE: The purpose of this study was to describe the impact of using a multidisciplinary hand clinic on (1) hand clinic waitlists for urgent operative pathologies and (2) the volume of urgent operative referrals seen by plastic surgery. METHODS: A retrospective data analysis of all new referrals to the Peter Lougheed Centre hand clinic in Calgary, Alberta, was performed. Data were collected from 6 months before and after the introduction of the multidisciplinary model (ie, between January 2017 and January 2018). Demographics for all new referrals were collected from the clinic database, including wait times, triage type, and volume of referrals triaged to each discipline. RESULTS: Prior to using a multidisciplinary model, 81% (n = 591) of new patient referrals were triaged directly to plastic surgery, 4% (n = 28) to physiotherapy, and 6% (n = 43) to minor surgery (N = 728). However, following the addition of physiatry to the clinic, 62% (n = 451) of new patient referrals were triaged directly to plastic surgery, 24% (n = 173) to physiatry, 2% (n = 17) to physiotherapy, and 4% (n = 31) to minor surgery (N = 730). Overall, the number of urgent operative referrals triaged to plastic surgery proportionally increased by 7%, from 67% to 74%. Mean wait times for urgent referrals to plastic surgery decreased by 1.7 ± 1.0 months (P = .09). CONCLUSION: Applying a multidisciplinary model to a hand clinic can allow non-operative cases to be triaged directly to physiotherapy and physiatry, allowing plastic surgeons to manage a higher volume of urgent and operative referrals. Implementing a multidisciplinary hand clinic can, therefore, decrease waitlist volumes and shorten the time to assessment by a plastic surgeon. TYPE OF STUDY: Level II Prognostic Study.

OBJECTIF: La présente étude vise à décrire les répercussions d'une clinique multidisciplinaire de la main sur 1) la liste d'attente de pathologies devant être opérées d'urgence dans les cliniques de la main; 2) le volume de patients dirigés d'urgence vers la plasturgie. MÉTHODOLOGIE: Des chercheurs ont procédé à l'analyse rétrospective des données de tous les patients dirigés vers la clinique de la main du Peter Lougheed Centre de Calgary, en Alberta. Ils ont recueilli les données entre six mois avant et six mois après l'adoption du modèle multidisciplinaire (entre janvier 2017 et 2018). Ils ont extrait tous les nouveaux patients dirigés vers le centre figurant dans la base de données de la clinique, y compris les temps d'attente, le type de triage et le volume de triage vers chaque discipline. RÉSULTATS: Avant d'utiliser un modèle multidisciplinaire, 81 % (n=591) des nouveaux patients étaient triés directement vers la plasturgie, 4 % (n=28) vers la physiothérapie et 6 % (n=43), vers des interventions chirurgicales mineures (n=728). Cependant, après l'ajout de la physiatrie à la clinique, 62 % (n=451) des nouveaux patients étaient triés directement vers la plasturgie, 24 % (n=173), vers la physiatrie, 2 % (n=17), vers la physiothérapie et 4 % (n=31), vers des interventions chirurgicales mineures (n=730). Dans l'ensemble, la proportion de tris vers une opération d'urgence en plasturgie a augmenté de 7 %, passant de 67 % à 74 %. Les temps d'attente moyens des patients dirigés d'urgence vers la plasturgie ont diminué de 1,7±1,0 mois (p=0,09). CONCLUSION: Le recours à un modèle multidisciplinaire dans une clinique de la main permet de trier directement les cas n'ayant pas à être opérés vers la physiothérapie et la physiatrie. Les plasticiens peuvent ainsi prendre en charge un plus fort volume de patients qui leur ont été dirigés pour une urgence ou une opération. La création d'une clinique multidisciplinaire de la main peut donc réduire le volume de temps d'attente et l'attente avant l'évaluation par un plasticien. TYPE D'ÉTUDE: Étude pronostique de niveau II.

"You Helped Create This, Help Me Now": A Qualitative Analysis of Patients' Concerns about Breast Implants and a Proposed Strategy for Moving Forward.

BACKGROUND: Some women with breast implants express concern about the safety of implants, fearing the possibility of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant-related illness. METHODS: A qualitative analysis was performed to examine the perceived challenges, barriers, and worries experienced by these women. Convenience sampling was used to elicit responses from members of Canadian BIA-ALCL Facebook advocacy groups. Three independent coders read and reread the transcripts, using thematic analysis to identify emerging themes. RESULTS: Sixty-four women answered questions posed by the president of the Canadian Society of Plastic Surgeons regarding concerns about their breast implants. Five themes were identified: informing, listening, acknowledging, clarifying, and moving forward. Patients desire improved communication about possible risks before implantation and as new information becomes available (informing), sincere listening to their concerns (listening), acknowledgement that these disease entities may be real and have psychosocial/physical impact on patients (acknowledging), clarification of implant-related problems and their treatment (clarifying), and improved processes for monitoring and treatment of patients with identified problems (moving forward). Consideration of these themes in the context of the five domains of trust theory (i.e., fidelity, competence, honesty, confidentiality, and global trust) suggests significant breakdown in the doctor-patient relationship for a subset of concerned women. CONCLUSIONS: Concerns related to BIA-ALCL and breast implant-related illnesses have undermined some women's trust in plastic surgeons. Consideration of these five themes and their impact on the five domains of trust can guide strategies for reestablishing patients' trust in the plastic surgery community.

A Single Preoperative Dose of Tranexamic Acid Reduces Perioperative Blood Loss: A Meta-analysis.

OBJECTIVE: To review the efficacy and safety of a single dose of intravenous tranexamic acid (TXA) given preoperatively. SUMMARY BACKGROUND DATA: TXA is a synthetic antifibrinolytic that has been used in various surgical disciplines to reduce blood loss, blood transfusions, ecchymosis, and hematoma formation. However, there is no universal standard on the most effective dose and route of TXA administration, limiting its routine use in many centers. This study evaluates the current evidence for the efficacy and safety of a single preoperative dose of TXA on surgical blood loss in all surgical disciplines. METHODS: With the guidance of a research librarian, in accordance with the Cochrane Handbook Medline, Cochrane Central and Embase were searched in November 2018. Search terms included "Tranexamic Acid" AND "Intravenous," with studies limited to randomized controlled trails in adult humans. Two independent reviewers and an arbitrator assessed articles for inclusion. Criteria included a single preoperative bolus dose of intravenous TXA, surgical patients, and intraoperative blood loss measurement or perioperative blood loss up to 24 hours postsurgery. Quality assessment was done using the Cochrane Collaboration risk-of-bias tool by 2 reviewers. Statistical analysis was carried out using Cochrane Review Manager 5.3. The primary outcome was surgical blood loss. Secondary outcomes included venous thromboembolic complications, transfusion requirements, and dosing. RESULTS: A total of 1906 articles were screened, 57 met inclusion criteria. The majority of included studies were orthopedic (27), followed by obstetric and gynecological (16), oral maxillofacial and otolaryngology (10), cardiac (3), and 1 plastic surgery study focusing on acute burn reconstruction. Across all surgical specialties (n = 5698), the perioperative estimated blood loss was lower in patients receiving TXA, with a standard mean difference of -153.33 mL (95% CI = -187.79 to -118.87). Overall, surgical patients with TXA had a 72% reduced odds of transfusion (odds ratio = 0.28 [95% CI = 0.22-0.36]). The most frequently used dose of TXA was 15 mg/kg. There was no difference in the incidence of venous thromboembolic events between TXA and control groups. CONCLUSIONS: While there is a growing body of evidence to support benefits of perioperative TXA use, this is the first meta-analysis to identify the efficacy and safety of a single preoperative dose of IV TXA. The potential implications for expanding the use of preoperative TXA for elective day surgery procedures is substantial. Preoperative intravenous TXA reduced perioperative blood loss and transfusion requirements in a variety of surgical disciplines without increasing the risk of thromboembolic events. Therefore, it should be considered for prophylactic use in surgery to reduce operative bleeding.

The Whole Glove Tourniquet Technique Revisited With Video Instruction.

This article revisits the whole glove tourniquet technique with video instruction. The whole glove tourniquet is a digital device that can be used to improve patient safety during hand surgery procedures performed under local anesthesia. Major benefits include of using this device are lower risk of the tourniquet being inadvertently left on the finger after completion of the procedure and improved sterile field in patients with heavily soiled extremities. The procedure is simple to use and does not require any specialized equipment, making it ideal for a wide variety of economic environments.

Functional Outcomes of Major Upper Extremity Replantation: A Scoping Review.

BACKGROUND: Traumatic upper limb amputations proximal to the carpus are devastating injuries. Existing literature on outcomes following replantation is limited. Our objective was to perform a scoping review of (1) functional outcomes; (2) return to work data; and (3) secondary surgeries required following proximal to carpus replantation. METHODS: A literature search of MEDLINE, EMBASE, Cochrane, and CINAHL was performed according to PRISMA guidelines. All studies reporting on functional outcomes, return to work, or secondary surgeries following replant of traumatic proximal to carpus amputation were included. RESULTS: Of the 753 articles, 13 studies were included, accounting for 136 major upper extremity replants (0 shoulder, 36 arm, 14 elbow, 86 forearm). Average age was 35 (24 -47) years, with average follow-up of 8 years (2 -18). Chen's Functional Criteria was the most common tool for reporting outcomes (10/13). Level of injury was related to functional outcome, with excellent to good Chen scores for replants distal to elbow, and poor Chen scores for replants at or proximal to elbow. Return to work correlated with level of replantation, with successful return for 65% of forearm, 43% of elbow, and 32% of arm replants. A mean of 2.4 secondary procedures were required. CONCLUSIONS: This study provides insight into major upper extremity replantation, to assist in patient counseling and surgical decision making. Good functional outcomes and successful return to work are directly related to level of injury following major upper extremity replant. Patients should be counseled that more than 1 secondary procedure may be required.

Reconstruction of the Superficial Palmar Arch Using the Subscapular Arterial System.

Hypothenar hammer syndrome is a rare entity warranting urgent exploration of the ulnar artery if signs of critical digital ischemia are present. To the authors' knowledge and based on review of the relevant literature, this case report is the first to describe the harvest of the subscapular arterial system for reconstruction of an extensive arterial defect involving the ulnar artery, superficial palmar arch, and associated branches for a case of hypothenar hammer syndrome. The patient presented with an ischemic and exquisitely painful fourth digit. After undergoing the aforementioned reconstruction, all digits were subsequently well perfused with normal capillary refill, color, warmth, and sensation. A strong ulnar pulse was palpated at the volar wrist crease. Patency of the interposition graft was verified by CT angiography (6 weeks postoperatively) and Doppler ultrasound (4 months postoperatively), showing strong radial and ulnar digital pulses of all digits. CT angiography was repeated at 6 months postoperatively and showed graft occlusion. Despite this, no signs of critical ischemia developed, and clinical symptoms were still much improved from initial presentation, with only residual cold intolerance noted 13 months postoperatively. As an arterial graft donor site, the subscapular system is easily accessible, offers generous length, and provides for multiple branches, making it ideal for the reconstruction of large, complex arterial defects in the hand.

Metacarpal Fracture Fixation in a Minor Surgery Setting Versus Main Operating Room: A Cost-minimization Analysis.

The objective of this study was to compare the costs of performing metacarpal fracture fixation in minor surgery (MS) versus the main operating room (OR) at a tertiary care center in Calgary, Alberta, from the institutional perspective. METHODS: Data were extracted from the Operating Room Information System and the Business Advisory System by a financial analyst. All data were based on actual expenses from the 2016-2017 fiscal year (US$). Direct costs included: staffing, supply, day (outpatient) surgery unit, post-anesthesia care unit (PACU), and anesthesia (anesthesiologist and equipment) costs. Surgeon and hardware costs were deemed neutral and excluded from the analysis. RESULTS: The total cost of metacarpal fixation in MS was $250, compared to $2,226 in the OR, after surgeon and hardware costs were excluded. Staffing costs are a major contributing factor to cost by location ($75 in MS versus $233 in OR), largely attributable to 0.5 nursing staff per room in MS compared to 3 nursing staff per room in the OR. Supply costs (minor tray, $94 versus case cart, $247) are also greater for OR cases. The combined costs for DSU ($465), PACU ($435), and anesthesia ($247) totaled $1,147 and are only incurred for OR cases. CONCLUSIONS: Repair of metacarpal fractures in MS represents a substantial cost-minimization strategy from the institutional perspective. Staffing and supply costs by location and the additional combined costs of DS, PACU, and anesthesia are all contributing factors.

Orbitomaxillofacial Mucormycosis Requiring Complex Multifactorial Management.

Mucormycosis is a rare fungal infection caused by ubiquitous fungi in the order Mucorales. It is the most rapidly progressing fulminant fungal infection that mimics necrotizing soft-tissue infections. Overwhelming fungal sepsis develops quickly and mortality rates approach 70%. Culture negative necrotizing infections and cutaneous necrosis following a vascular pattern should raise suspicion for this rare entity. We describe avoiding mortality in a case of orbitomaxillofacial mucormycosis multifactorially treated with: radical serial debridement, topical amphotericin B irrigation and dressings, parenteral amphotericin B, and hyperbaric oxygen therapy. Tissue biopsy was central to confirming the diagnosis and directing multimodal management that ultimately prevented dissemination to the central nervous system and mortality.

Computed Tomographic Angiography Used for Localization of the Cutaneous Perforators and Selection of Anterolateral Thigh Flap "Bail-Out" Branches.

BACKGROUND: The purpose of this study was to evaluate the territory supplied by the lateral circumflex femoral artery for the consistency of a proximal perforator that could be used as an alternative pedicle for the anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of the perforator used to develop the initial surgical plan. It is hypothesized that a consistent "bail-out" perforator supplying the proximal thigh would facilitate a simpler anterolateral thigh flap harvest, with minimal modification to flap design. METHODS: Computed tomographic images of 9 fresh cadavers were imported using Materialize's Interactive Medical Imaging Control System software to create surface-rendered 3-dimensional reconstructions of 15 lower limbs. Perforators emerging proximally and laterally to a 3-cm radius circle drawn at the midpoint of the anterior superior iliac spine and superolateral patella were considered potential bail-out perforators and evaluated for their number emerging diameter, length, course, and location relative to the anterior superior iliac spine. RESULTS: An average of 2.9 ± 1.8 perforators per limb were identified. Mean pedicle length was 111 ± 20 mm, measured from the origin in the lateral circumflex femoral artery to where the perforators emerged through the deep fascia directly overlying the thigh muscles. Average diameter at origin in the lateral circumflex femoral artery was 2.8 ± 0.8 mm, and that at emergence through the deep fascia was 1.1 ± 0.3 mm. Vessel course was predominantly musculocutaneous (90%). CONCLUSIONS: A significant bail-out perforator routinely supplies the proximal anterolateral thigh and may be used as an alternative vascular pedicle for an anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of a perforator identified within the conventional landmarks (3-cm radius circle at the midpoint of the anterior superior iliac spine and superolateral patella).

Reverse Radial Artery Flap Perforator Anatomy and Clinical Applications.

The pedicled reverse radial forearm flap is a well-known option for the treatment of a variety of soft tissue wounds including dorsal hand wounds. We document the number, emerging diameter, length from origin, course, and location of all perforators of the radial artery in a series of 6 fresh human cadavers after whole body lead oxide and gelatin injection to confirm and comprehensively document the anatomy of the radial artery perforators. This data provide an anatomic basis for a modification to the reversed radial forearm flap used to decrease venous congestion in the postoperative period. Two case reports are presented to provide clinical demonstration of the importance of this modification.