Evaluation of modified frailty index for predicting post-operative outcomes after lower-extremity free-flap reconstruction.

BACKGROUND: Risk stratification for complex procedures such as microsurgical reconstruction of the lower extremities is an important part of preoperative planning and counseling. The aim of this study was to determine the effectiveness of the modified five-item frailty index (5-mFI) score, a validated tool for assessing risk in surgical patients, in predicting postoperative complications after lower extremity (LE) free flap reconstruction. METHODS: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was conducted from 2010 to 2020 on patients who underwent LE free-flap reconstruction. 5-mFI scores were calculated and patients were categorized as 5-mFI ≥2 or <2. The primary endpoint was the presence of 30-day overall complications. The secondary endpoints included 30-day readmission, need for reoperation, and need to discharge to a care facility. Comparisons were made using one-way analysis of variances, Pearson's chi-squared test, or Fisher's extract test. Multivariable logistic regression models were performed for sex, age, BMI, smoker status, operative time, and ASA classification. RESULTS: Total of 294 (61.6% males) patients were identified. Univariate analysis showed 5-mFI ≥2 had higher rates of overall complications (p = .043) and hematologic complications (p = .033). In this population, there were also higher rates of reoperation (p = .003) and discharge to care facility (p < .001). Multivariable regression models further substantiated that 5-mFI ≥2 was independently associated with increased overall complications [2.46, CI: 1.10-5.59, p = .031], hematologic complications [2.55, 1.02-6.35, p = .046], reoperation [4.55, 1.54-13.3, p = .006], and discharge to facility [2.86, 1.27-6.45, p = .011]. CONCLUSIONS: There is a strong association of 5-mFI ≥2 with adverse post-operative outcomes in male patients undergoing LE free-flap reconstruction. This can be a valuable adjunct in the counsel of patients for whom lower extremity salvage is feasible.

Literature Review: Robotic-Assisted Harvest of Deep Inferior Epigastric Flap for Breast Reconstruction.

INTRODUCTION: Robotic-assisted surgery is gaining popularity because of reported improvement in aesthetic outcomes while reducing the occurrence of complications compared with conventional surgical methods. Deep inferior epigastric perforator (DIEP) flap harvesting has a long track record as a viable procedure for autologous reconstruction of the breast. In this literature review, we describe the feasibility of using the robotic platform in DIEP flap harvest. METHODS: The Preferred Reporting Items for Systemic Reviews and Meta-Analysis methodology was to guide the literature review. PubMed and Scopus databases were searched from inception to June 6, 2022. The Medical Subject Heading terms and keywords used to conduct this search are as described: "Robotic AND deep inferior epigastric perforator AND Breast reconstruction." RESULTS: Seven publications, detailing a total of 56 robotic-assisted DIEP flap harvest procedures, were selected for review. Four publications used the transabdominal preperitoneal approach, whereas 2 exclusively used a totally extraperitoneal approach, and 1 compared the 2 approaches. The measured outcomes included technical feasibility of flap harvest in cadavers, viable flap harvest in live patients, harvest time and pedicle dissection time, pedicle length, fascial incision length, donor site pain, need for postoperative narcotic, donor site morbidity, and hernia formation. Overall, the reviewed articles demonstrated successful DIEP flap harvesting without the need for conversion to the conventional open procedure. Postoperative complications were minimal. Robotic DIEP flap harvest was shown to be safe and there were no reports of donor-site morbidity in the studies reviewed. The main advantages of the robotic approach include decreased postoperative pain and length of hospital stay, along with improved aesthetic outcomes. The main disadvantages are increased operative time and cost. CONCLUSIONS: Although at its current iteration, the robotic-assisted DIEP flap is feasible, it may not be practical in all settings. Furthermore, the true benefit of the robotic platform is yet to be determined, as more long-term studies are necessary.

Endometriosis in Patients Undergoing Plastic Surgical Procedures: A Case Report and Review of the Literature.

Background: Endometriosis is a common gynecological disorder described as the presence of functional endometrial tissue outside the uterus, which can also be found in extrapelvic locations. Although patients seeking treatment for endometriosis usually present to gynecologists, there are rare cases of endometriosis encountered by plastic surgeons in routine practice, either incidentally or as a concomitant finding. Methods: We present a rare case of a 36-year-old woman with symptoms of panniculitis desiring panniculectomy. During surgery, an abdominal mass was excised and confirmed by pathological analysis to be endometriosis. A comprehensive literature review was conducted using the PubMed search engine of the National Institutes of Health to identify cases of endometriosis in plastic surgery. Following screening of the results, 14 articles were included in this analysis that fit the criteria of our search. Results: Of the 14 articles reviewed, cutaneous endometriosis was the most common subtype found in plastic surgery. None of the studies described findings of endometriosis in routine panniculectomies. Several identified endometriosis discovered during cosmetic abdominoplasties. Conclusions: Endometriosis encountered in plastic surgery is a rare but clinically important occurrence, with the cutaneous subtype representing the majority of cases. Endometriosis should always be on the differential diagnosis when an abdominal mass is found in a patient with a history of abdominal surgery. Abdominal masses found during routine aesthetic or reconstructive surgery should be submitted for tissue analysis to guide possible secondary treatments.

Bilateral Free Deep Inferior Epigastric Artery Perforator Flaps for Reconstruction following Mastectomy in Poland Syndrome Patients.

Background: Poland syndrome is classically described as symbrachydactyly, with hypoplasia of the pectoralis major and other upper thoracic musculoskeletal structures. It is thought to be caused by intrauterine interruption in subclavian arterial flow and often includes breast hypoplasia. Affected vasculature can pose a challenge for reconstruction with free flaps because inflow may not be reliable in this patient population. Methods: We present the rare case of a 28-year-old woman with left-sided Poland syndrome, significant family history of breast cancer, and BRCA1+ mutation who underwent bilateral prophylactic nipple-sparing mastectomies with successful immediate bilateral deep inferior epigastric artery perforator free flap reconstruction. The surgical literature in this clinical scenario is also reviewed. Results: Preoperative computed tomography angiography of the chest successfully demonstrated the patency and quantified the caliber of the internal mammary vessels to support free flap breast reconstruction. Conclusions: Free tissue transfer is a viable option for breast reconstruction in patients with Poland syndrome undergoing mastectomy guided by preoperative computed tomography angiography to characterize the internal mammary vasculature.

Modified Rotationplasty as a Composite Free Flap for Femur and Thigh Reconstruction.

Knee rotationplasty is a suitable reconstructive and limb salvage procedure for infected femur and knee prostheses. It involves external rotation of the lower limb with an intact neurovascular bundle to function as a knee joint. Functionally, it has better outcomes when compared to alternate options like above knee amputation. It results in better cortical reorganization and superior stance mechanics, enabling a more efficient gait and better quality of life. Here we report a 57-yr-old male who underwent modified rotationplasty for an infected knee endoprosthesis as a composite lower leg free flap.

Patient-reported opioid use for tissue expander-based breast reconstruction.

INTRODUCTION: There is limited evidence for appropriate post-operative opioid prescribing in breast reconstruction patients. We sought to describe postoperative outpatient prescription opioid use patterns (quantity and duration) following discharge after immediate breast reconstruction with tissue expanders (TE) and to identify demographic and/or clinical risk factors associated with postoperative outpatient opioid use. METHODS: Patients 18 years and older undergoing immediate TE-based breast reconstruction were given a 28-day postoperative pain medication log book. Descriptive statistics were performed to describe the quantity and duration of opioid use. Preoperative, intraoperative, and postoperative characteristics were examined and tested for their associations with postoperative opioid use. RESULTS: A total of 45 logbooks were completed. On average, patients used opioids for 7.42 days (SD = 6.45) after discharge home and used 15.9 (SD = 18.71) oxycodone 5 mg tablet equivalents (119.3 morphine milligram equivalents, SD = 140.31). The total number of oxycodone 5 mg equivalents consumed prior to discharge was associated with the amount of post-discharge opioid consumption (IRR=1.08, p<0.01). Each additional year of age was associated with a reduction in the days-to-opioid cessation by a factor of 0.97 (p=0.01). Each additional oxycodone 5mg equivalent consumed prior to hospital discharge was associated with an increase in the days-to-cessation after discharge by a factor of 1.04 (p=0.026). CONCLUSIONS: These patient-reported data will provide a benchmark which plastic surgeons can use to minimize narcotic use in patients and will help prevent issues of dependence, misuse, and diversion, while being mindful of adequate pain control. For patients discharging home after a one-night stay for immediate TE breast reconstruction, we recommend a prescription for 10 oxycodone 5 mg tablets, or 15 tablets if they are less than age 49 or have had high inpatient opioid use. Patients should also be counseled that the expected duration of outpatient opioid use is 7-11 days, and that 20 % of patients did not use any opioids following hospital discharge, making nonnarcotic pain regimens a real possibility.

Postoperative monitoring of free flap reconstruction: A comparison of external Doppler ultrasonography and the implantable Doppler probe.

HYPOTHESIS: The time to detection of vascular compromise and the postoperative time to re-exploration are shorter using the implantable Doppler (ID) probe, thereby resulting in earlier surgical re-exploration and a higher flap salvage rate. METHODS: A single-centre experience with 176 consecutive free flap reconstructions in 167 patients from 2000 to 2008 in a university-based teaching hospital by retrospective chart review is presented. RESULTS: There was a significant difference in overall flap survival (ID 98.0%, external Doppler [ED] 89.3%) and total flap loss (ID 2.0%, ED 10.7%) between the two groups (P=0.03). The difference in flap salvage rate was not significant (ID 90.9%, ED 63.6%; P=0.068). The false-positive (ID 0%, ED 3%; P=0.18) and false-negative rates (ID 0.0%, ED 4.5%; P=1.0) were not significantly different. There was also a lower median postoperative time to re-exploration for the ID group, from 48 h to one week after initial surgery (ID 74.5 h, ED 136.8 h; P=0.05). CONCLUSION: The present analysis revealed a potential benefit for the ID probe in the postoperative monitoring of free tissue transfers.

HYPOTHÈSE: Le délai entre la détection d'une atteinte vasculaire et la réexploration postopératoire est plus court à l'aide de la sonde Doppler implantable (DI), ce qui favorise une réexploration chirurgicale plus rapide et un taux plus élevé de sauvegarde des lambeaux. MÉTHODOLOGIE: Les auteurs présentent l'expérience monocentrique de 176 reconstructions consécutives par lambeaux libres chez 167 patients entre 2000 à 2008 dans un hôpital universitaire au moyen d'une analyse de leurs dossiers. RÉSULTATS: Il y avait une différence importante dans la survie globale des lambeaux (DI 98,0 %, Doppler externe [DE] 89,3 %) et perte totale des lambeaux (DI 2,0 %, DE 10,7 %) entre les deux groupes (P=0,03). La différence en matière de taux de sauvegarde des lambeaux n'était pas significative (DI 90,9 %, DE 63,6 %; P=0,068). Les taux de résultats faussement positifs (DI 0 %, DE 3 %; P=0,18) et de résultats faussement négatifs (DI 0,0 %, DE 4,5 %; P=1,0) n'étaient pas sensiblement différents. Le délai postopératoire médian avant la réexploration était également plus court dans le groupe DI, soit de 48 heures à une semaine après l'opération initiale (DI 74,5 h, DE 136,8 h; P=0,05). CONCLUSION: La présente analyse a révélé l'avantage potentiel de la sonde DI lors de la surveillance postopératoire des transferts de tissus libres.