Technical Variables in Lower Extremity Free Flap Reconstruction.

BACKGROUND: Lower extremity free flap failure rates are higher than in other areas of the body. While prior studies assessed the effect of intraoperative technical variables, these generally investigated individual variables and did not examine relationships between the many individual technical decisions made during free tissue reconstruction. Our purpose was to investigate the effect of variation in intraoperative microsurgical techniques on flap outcomes in a diverse cohort of patients requiring lower extremity free flap coverage. METHODS: Consecutive patients undergoing free flap reconstruction of the lower extremity at two level 1 trauma centers from January 2002 to January 2020 were identified using Current Procedural Terminology codes, followed by a review of medical records. Information regarding demographics and comorbidities, indications, intraoperative technical details, and complications was collected. Outcomes of interest included an unplanned return to the operating room, arterial thrombosis, venous thrombosis, partial flap failure, and total flap failure. Bivariate analysis was performed. RESULTS: In total, 410 patients underwent 420 free tissue transfers. The median follow-up time was 17 months (interquartile ranges: 8.0-37). Total flap failure occurred in 4.9% (n = 20), partial flap failure in 5.9% (n = 24), and unplanned reoperation in 9.0% (n = 37), with arterial thrombosis in 3.2% (n = 13) and venous thrombosis in 5.4% (n = 22). Overall complications were significantly associated with recipient artery choice, with arteries other than PT and AT/DP having a higher rate (p = 0.033), and with arterial revisions (p = 0.010). Total flap failure was also associated with revision of the arterial anastomosis (p = 0.035), and partial flap failure was associated with recipient artery choice (p = 0.032). CONCLUSION: Many interoperative options and techniques are available when performing microvascular lower extremity reconstruction that leads to equally high success rates. However, the use of arterial inflow outside of the posterior tibial and anterior tibial arteries leads to a higher overall complication rate and partial flap failure rate. Intraoperative revision of the arterial anastomosis portends poorly for ultimate flap survival.

The Impact of Social Media on Plastic Surgery Residency Applicants.

BACKGROUND: Plastic surgeons have been early adopters of social media, and the efficacy and ethics of this practice have been studied. In addition, plastic and reconstructive surgery (PRS) training programs have begun using social media to connect with the public, including prospective PRS applicants. The ability of social media to attract prospective residency applicants is unknown. This study aims to examine the influence of social media on prospective residency applicants and their perception of a plastic surgery program. METHODS: In the academic years 2018 and 2019, we conducted an anonymous, voluntary survey among applicants applying to both the integrated and independent Harvard PRS residency programs. The survey collected data regarding demographics, social media usage, online information gathering, and PRS programs' social media influence on applicants' perception/rank position of programs. RESULTS: One hundred nine surveys were completed (23%). Ninety-seven percent of respondents reported searching online for information about residency programs. Twenty percent of respondents noted that a residency program's social media platform "influenced their perception of a program or intended rank position of a program" and 72% of those respondents indicated a positive effect on their perception of a program and its rank list position. At least 15% of respondents were concerned that engaging with a program's social media account would attract attention to their own social media accounts. CONCLUSIONS: Applicants routinely rely on online resources to gather information regarding prospective residency programs. Fear of attracting attention to their own personal social media pages may limit applicants' engagement with PRS programs on social media. However, residency programs can still utilize social media to deliver important messages, especially as social media usage continues to grow.

Adherence to the National Comprehensive Cancer Network Criteria of Complete Circumferential Peripheral and Deep Margin Assessment in Treatment of High-Risk Basal and Squamous Cell Carcinoma.

BACKGROUND: The National Comprehensive Cancer Network (NCCN) has established guidelines for the treatment of keratinocyte carcinomas (KCs). Complete circumferential peripheral and deep margin assessment (CCPDMA) is recommended for "high-risk" tumors that cannot be closed primarily. If flap or grafts are needed and CCPDMA was not used, it is recommended that reconstruction be delayed until achieving clear margins. OBJECTIVE: To measure provider utilization rates of the NCCN guidelines for high-risk KCs and assess barriers that are limiting adherence. MATERIALS AND METHODS: A ten-item questionnaire was distributed to NCCN nonmelanoma skin cancer panel members and physicians participating in KC treatment at academic institutions. RESULTS: Response rate was 49% (57/116). Responses were categorized by practice area: Mohs surgery, pathology, and other specialties: General Dermatology, Otolaryngology, Plastic Surgery, Surgical Oncology, Radiation Oncology, and Oral and Maxillofacial Surgery. Mohs surgeons were most likely to use CCPDMA for tumors meeting NCCN criteria with 14/15 using this technique in a majority of their cases, versus 2/6 pathologists and 10/16 specialists from other fields. Reasons cited for not using CCPDMA included deference to pathologists to determine the appropriate method for margin assessment and logistical difficulty. CONCLUSION: Further efforts are needed to increase adherence to NCCN's guidelines regarding CCPDMA in KCs.

In-person, Hybrid, and Virtual Grand Rounds in Plastic Surgery: Impact and Participant Perceptions.

Many plastic surgery residency programs adapted to the COVID-19 pandemic by implementing virtual grand rounds. This study aimed to assess the impact of virtual grand rounds and how attendees perceived virtual grand rounds to inform future programmatic planning. Methods: This was a quality improvement initiative involving a cross-sectional survey and retrospective review of administrative records for the 2017-2018 (in-person) and 2021-2022 (virtual) academic years for two academic plastic surgery training programs in Boston, MA. Respondents were residents, fellows, and faculty within the two multisite plastic surgery residency training programs. Results: There were 39 respondents (51% faculty, 41% residents, and 8% fellows). There was no evidence of different preferences for the format of future grand rounds (P = 0.08), with most preferring hybrid, defined as in person for speakers and others who could attend. Most respondents indicated a more accessible learning environment (86.8%) and lack of in-person interaction (82.1%) as reasons for liking and not liking virtual grand rounds, respectively. Excluding outliers, attendance in 2021-2022 was on average 7.4% points greater than that in 2017-2018 (P < 0.001), or six to seven more individuals at each session. There were significantly more out-of-state speakers in 2021-2022 (84%) as compared to 2017-2018 (28%) (P = 0.0008). Conclusions: Virtual grand rounds improved attendance and the geographic diversity of speakers. Attendees preferred a hybrid format for future grand rounds, citing advantages and disadvantages to both in-person and virtual formats.

Disparities in Telemedicine Literacy and Access in the United States.

BACKGROUND: Because of the expansion of telehealth services through the 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act, the potential of telemedicine in plastic surgery has gained visibility. This study aims to identify populations who may have limited access to telemedicine. METHODS: The authors created a telemedicine literacy index (TLI) using a multivariate regression model and data from the US Census and Pew Research Institute survey. A multivariate regression model was created using backwards elimination, with TLI as the dependent variable and demographics as independent variables. The resulting regression coefficients were applied to data from the 2018 US Census at the county level to create a county-specific technological literacy index (cTLI). Significance was set at P < 0.05. RESULTS: On multivariable analysis, the following factors were found to be significantly associated with telemedicine literacy: age, sex, race, employment status, income level, marital status, educational attainment, and urban or rural classification. Counties in the lowest tertile had significantly lower median annual income levels ($43,613 versus $60,418; P < 0.001) and lower proportion of the population with at least a bachelor's degree (16.7% versus 26%; P < 0.001). Rural areas were approximately three times more likely to be in the lowest cTLI compared with urban areas ( P < 0.001). Additional associations with low cTLI were Black race ( P = 0.045), widowed marital status ( P < 0.001), less than high school education ( P = 0.005), and presence of a disability ( P = 0.01). CONCLUSIONS: These results highlight disadvantaged groups at risk of being underserved with telehealth. Using these findings, key stakeholders may be able to target these communities for interventions to increase telemedicine literacy and access.

Bias in Surgical Residency Evaluations: A Scoping Review.

OBJECTIVE: Given widespread disparities in the surgical workforce and the advent of competency-based training models that rely on objective evaluations of resident performance, this review aims to describe the landscape of bias in the evaluation methods of residents in surgical training programs in the United States. DESIGN: A scoping review was conducted within PubMed, Embase, Web of Science, and ERIC in May 2022, without a date restriction. Studies were screened and reviewed in duplicate by 3 reviewers. Data were described descriptively. SETTING/PARTICIPANTS: English-language studies conducted in the United States that assessed bias in the evaluation of surgical residents were included. RESULTS: The search yielded 1641 studies, of which 53 met inclusion criteria. Of the included studies, 26 (49.1%) were retrospective cohort studies, 25 (47.2%) were cross-sectional studies, and 2 (3.8%) were prospective cohort studies. The majority included general surgery residents (n = 30, 56.6%) and nonstandardized examination modalities (n = 38, 71.7%), such as video-based skills evaluations (n = 5, 13.2%). The most common performance metric evaluated was operative skill (n = 22, 41.5%). Overall, the majority of studies demonstrated bias (n = 38, 73.6%) and most investigated gender bias (n = 46, 86.8%). Most studies reported disadvantages for female trainees regarding standardized examinations (80.0%), self-evaluations (73.7%), and program-level evaluations (71.4%). Four studies (7.6%) assessed racial bias, of which all reported disadvantages for trainees underrepresented in surgery. CONCLUSIONS: Evaluation methods for surgery residents may be prone to bias, particularly with regard to female trainees. Research is warranted regarding other implicit and explicit biases, such as racial bias, as well as for nongeneral surgery subspecialties.

Secondary Surgery after Lower Extremity Free Flap Reconstruction.

BACKGROUND: Microsurgical free tissue transfer may be the only reconstructive option for lower extremity limb salvage. However, the functional and aesthetic results following free tissue transfer after initial salvage may be suboptimal, thus requiring secondary operations to facilitate definitive wound healing and/or refinement. METHODS: A multi-institutional retrospective cohort study was performed including patients who underwent lower extremity free tissue transfer from January of 2002 to December of 2020. The authors' primary outcome variable was the presence of secondary surgery after free tissue transfer for lower extremity reconstruction. Independent variables (eg, wound cause, flap, donor type, recipient, comorbidities) were collected. Secondary surgery was categorized as (1) procedures for definitive wound closure and (2) refinement procedures. Multivariable logistic regression was performed to determine which variables were independently associated with the outcome. RESULTS: A total of 420 free tissue transfers for lower extremity reconstruction were identified. Secondary surgery was performed in over half (57%) of the patients. Presence of diabetes (OR, 2.0; P = 0.01; 95% CI, 1.2 to 3.5) and use of a latissimus dorsi donor (OR, 2.4; P = 0.037; 95% CI, 1.1 to 5.4) were predictors of wound closure procedures. Fasciocutaneous (OR, 3.6; P < 0.001; 95% CI, 1.8 to 7.2) and myocutaneous (OR, 3.0; P = 0.005; 95% CI, 1.5 to 9.9) flaps were predictors of refinement procedures when compared with muscle-only flaps with skin grafts. CONCLUSIONS: The majority of lower extremity free tissue reconstructions required secondary procedures to provide definitive wound closure and/or refinement. Overall, this study provides predictors of secondary surgery that will help formulate patients' expectations of lower extremity limb salvage. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Humicola Trauma-related Invasive Fungal Infection in an Immunocompetent Patient.

The majority of invasive fungal infections arise in immunocompromised patients; however, there exist many clinical interventions and physiologic phenomena in the setting of traumatic injury that induce immunosuppressant states. Enhanced clinical suspicion and early detection of invasive fungal infections has played an increasingly pertinent role in clinical management of patients admitted for traumatic injury, given its substantial morbidity and mortality rates. In this case report, we discuss a case of trauma-related invasive fungal infection by a rare humicola pathogen in a previously immunocompetent patient. We present this case in hopes of instilling a high index of clinical suspicion for trauma-related invasive fungal infections. We also discuss the role of negative pressure wound therapy and aggressive surgical management, including debridement and various levels of amputation to optimize patient outcomes. Clinical management of trauma-related IFI has adopted increasingly aggressive approaches with respect to its formidable morbidity and mortality rates. Multidisciplinary discussions and patient-centered care are essential when making surgical decisions that impact quality of life such as amputation level.

Webinar during COVID-19 Improves Knowledge of Changes to the Plastic Surgery Residency Application Process.

BACKGROUND: The COVID-19 pandemic has significantly impacted residency application process for all specialties, including plastic surgery residency. Almost all plastic surgery residency programs have suspended visiting sub-internship rotations. This study quantifies the impact of a webinar through an analysis of poll questions and a post-webinar survey sent to all registered participants. METHODS: A dedicated webinar was organized and held by the Harvard Plastic Surgery Residency Training Program. All attendees were asked several poll questions during the webinar. The 192 participants were also sent a post-webinar survey. RESULTS: The response rate was 68.2% (n = 131). Respondents were more confident about matching into a plastic surgery residency program at the end of the webinar compared with before the webinar (P < 0.001). Respondents who did not have a plastic surgery residency program at their home institution were less confident at the start of the webinar (P = 0.009). In addition, respondents who had not taken time off for research or for other endeavors during or after medical school were less confident about their chances to match at the start of the webinar (P = 0.034). CONCLUSIONS: An online webinar program increased confidence levels of medical students interested in applying for residency positions in plastic surgery. Residency programs should consider webinars as a method to inform and assist medical students during the upcoming application season.

Intravenous Drug Use-Related Complications of the Hand and Upper Extremity.

BACKGROUND: In the last decade, there has been an increase in intravenous drug use (IVDU) and associated medical problems. Users commonly inject into their upper extremities, which can result in infection and other sequelae in this area. The goal of this study was to compare demographics and treatment for upper extremity infections between intravenous drug users and non-intravenous drug users over the past 10 years at 1 level I emergency department (ED). METHODS: This was a retrospective case-control study. All patients presenting to the ED with an upper extremity infection in 2005, 2010, and 2015 were identified using the ninth revision of the International Statistical Classification of Diseases and Related Health Problems and Current Procedural Terminology codes. Patients with an IVDU-related infection were identified by manually reviewing the medical record and matched with patients with non-IVDU-related infection on demographics. Patient-related factors, infection specifics, and treatment parameters were compared in both groups. RESULTS: The number of IVDU-related upper extremity infection cases presenting to the ED increased 126% over the 10-year period (65 cases in 2005, 109 cases in 2010, and 147 cases in 2015). The location of infection in the IVDU group was more likely to be in a typical injection site (forearm, P < 0.001; wrist, P = 0.002), and IVDU patients had 33% more hospital admissions and stayed in the hospital longer (3 days versus 0.59; P < 0.001). These patients also were more likely to have a computed tomography scan (P < 0.001) and have Methicillin-resistant Staphylococcus aureus (MRSA) or Methicillin-sensitive Staphylococcus aureus (MSSA) (P = 0.009). CONCLUSIONS: Over a 10-year period, the number of IVDU-related upper extremity infections more than doubled, with more severe infections that underwent advanced imaging and intensive treatment.

Distal Radius Fractures: Evaluation of Closed Reduction and Percutaneous Kirschner Wire Pinning.

Objective Closed reduction and percutaneous pinning (CRPP) is losing popularity as a treatment modality for distal radius fractures. However, in select cases, CRPP may have advantages relative to open reduction and internal reduction. We aimed to retrospectively assess the outcomes after CRPP for the treatment of distal radius fractures. Study Design This is a retrospective cohort study. Methods We used billing records to identify all skeletally mature patients with a distal radius fracture who were treated with CRPP by a single surgeon at a level I trauma center in an urban city in the United States. We assessed the medical charts and recorded demographics, trauma and treatment characteristics, radiographic characteristics, and outcomes. Results All patients had a good or excellent range of motion regarding forearm rotation, and almost 80% had good or excellent range of motion regarding flexion or extension of their wrist. One patient had a concern for pin tract infection, and one had subcutaneous migration of a pin, which were both treated by pin removal. Conclusion CRPP is a good option in patients with few and sizeable fracture fragments in patients with a distal radius fracture, and it should be considered as an effective tool to restore radiographic parameters and functional outcomes.

Reconstruction of the Adult and Pediatric Burned Hand.

Thermal injuries of the hand can have a great impact on function. Initial treatment should focus on the prevention of contracture through the use of tissue-sparing techniques and optimized occupational therapy. Surgical intervention should follow the standard reconstructive ladder and can involve several techniques from simple to complex including minimally invasive techniques, such as laser and steroid injection, contracture release and skin grafting, and local tissue rearrangement and regional flaps as well as distant pedicled and free flaps. Reconstructive surgery of the hand, when performed well, can lead to meaningful functional improvement in severe burns.

Comparison of clinical outcomes and patient satisfaction in immediate single-stage versus two-stage implant-based breast reconstruction.

BACKGROUND: The purpose of this study was to assess the outcomes of immediate, single-stage, implant-based reconstruction compared with traditional, two-stage reconstruction (i.e., tissue expander placement followed by exchange to implant). METHODS: A retrospective review of consecutive patients who underwent immediate unilateral or bilateral breast reconstruction over an 8-year period was performed. The primary predictor variable was method of reconstruction (single-stage versus two-stage). Outcome measures were postoperative complication rates, revision rates, and BREAST-Q patient satisfaction scores. Descriptive, bivariate, and multiple regression statistics were computed. RESULTS: The study sample consisted of 346 subjects who underwent reconstruction of 582 breasts (166 single-stage and 416 two-stage reconstructions). Complication rates between the single-stage and two-stage groups were similar for minor infections, major infections, hematoma formation, seroma formation, minor necrosis, and major necrosis (p ≥ 0.20). In a multiple logistic regression model, subjects undergoing single-stage reconstruction were found to be 87 percent more likely to require revision necessitating an additional operation (p = 0.005). In an adjusted regression model, subjects undergoing two-stage reconstruction had higher BREAST-Q scores for satisfaction with medical and office staff (p ≤ 0.02). Subjects undergoing single-stage reconstruction had higher sexual well-being satisfaction scores. CONCLUSIONS: There is no significant difference in complication rates between single-stage versus two-stage implant-based breast reconstructions. Although single-stage reconstruction is associated with higher sexual well-being satisfaction, it is more than 80 percent more likely to require additional operative revisions. Two-stage reconstruction is associated with significantly higher satisfaction with the medical and office staff. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Evolving options for breast reconstruction.

In summary, if the abdomen cannot be used for a donor site, alternative flap selection is based on individual patient anatomy and body habitus, targeting the buttocks and upper thigh. Intraoperative repositioning may be required for ease in flap harvest and donor site closure, adding time to the procedure. Flap dissection is performed in the subfascial plane to avoid injury to the perforator vessels. Deep suspension sutures may be required to maintain the gluteal fold location.

The Boston marathon bombings: the early plastic surgery experience of one Boston hospital.

BACKGROUND: On April 15, 2013, at approximately 2:49 p.m. EDT, two improvised explosive devices detonated near the finish line of the 117th Boston Marathon. Patients were transported from the scene to several trauma centers, including the authors' institution. METHODS: Plastic surgical assessment of patients began in the Emergency Department and then rapidly expanded as the scope of the incident became clear. Daily interdisciplinary meetings involving the acute care surgery, orthopedic surgery, plastic surgery, and nursing services were convened in order to coordinate operating room schedules and treatment plans. An interdisciplinary weekly clinic continued until all patient goals had been reached. RESULTS: Twenty-four patients were treated at Beth Israel Deaconess Medical Center within the first 24 hours of the Boston Marathon bombing. Seven were triaged directly to the operating room from the Emergency Department. The Division of Plastic Surgery was directly involved with the care of 11 patients, all of whom were treated surgically within 24 hours of the bombing. Patients were aged 23 to 50 years old. All 11 patients sustained lower extremity injuries with gross contamination. Four patients also sustained significant upper extremity trauma. Injuries included extremity amputations and fractures, soft-tissue loss, impaction of nails and other debris, burns, ocular injury, and ruptured tympanic membranes. CONCLUSIONS: Twenty-four patients received acute care at Beth Israel Deaconess Medical Center following the Boston Marathon bombing. Institution of dedicated interdisciplinary daily rounds, protected operating room block time, and joint follow-up clinic allowed for efficient early diagnosis and treatment of patients' injuries.