A Prospective Cohort Study Re-examining Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction.

BACKGROUND: The goal of inpatient monitoring after microsurgical breast reconstruction is to detect vascular compromise before flap loss. Near-infrared tissue oximetry (NITO) is commonly used for this purpose, but recent reports challenge its specificity and utility in current practice. Fifteen years after Keller published his initial study using this technology at our institution, we re-evaluate the role and limitations of this popular monitoring device. METHODS: A 1-year prospective study was performed for patients undergoing microsurgical breast reconstruction and monitored postoperatively using NITO. Alerts were evaluated, and clinical endpoints relating to an unplanned return to the operating room or flap loss were recorded. RESULTS: A total of 118 patients reconstructed with 225 flaps were included within the study. There were no cases of flap loss at the time of discharge. There were 71 alerts relating to a drop in oximetry saturation. Of these, 68 (95.8%) were deemed to be of no significance. In 3 cases (positive predictive value of 4.2%), the alert was significant, and there were concerning clinical signs apparent at that point. A sensor in an inframammary fold position was associated with nearly twice the average number of alerts as compared with areolar or periareolar positions ( P = 0.01). In 4 patients (3.4%), a breast hematoma required operative evacuation, and these cases were detected by nursing clinical examination. CONCLUSIONS: The monitoring of free flaps after breast reconstruction through tissue oximetry shows a poor positive predictive value for flap compromise and requires clinical corroboration of alerts but missed no pedicle-related adverse events. With a high sensitivity for pedicle-related issues, NITO may be helpful postoperatively, but the exact timeframe for use must be weighed at the institutional level.

Obesity and the Abdominal Wall Vasculature: Correlating BMI with Perforator Anatomy.

BACKGROUND: Given the national trends in obesity, reconstructive surgeons are faced with an increasing number of overweight and obese women interested in postmastectomy breast reconstruction. While the link between obesity and adverse postoperative outcomes is well established, few studies have explored the relationship between body mass index (BMI) and the vasculature of the anterior abdominal wall. METHODS: A radiographic review was conducted on female patients who underwent computed tomographic angiography (CTA) of the anterior abdominal wall. CTA studies were evaluated for perforator caliber and quantity. Patients were stratified by BMI. The relationship between BMI and the diameter and number of deep inferior epigastric artery (DIEA) perforators was analyzed using analysis of variance using Minitab software with α of 0.05. RESULTS: There were a total of 916 hemiabdomens included in this study. There was no statistically significant correlation between BMI and DIEA diameter or mean diameter of major (≥ 1 mm) DIEA perforators. There was a statistically significant negative correlation between BMI and the number of major DIEA perforators (p < 0.01). CONCLUSION: Despite the increased demands of excess abdominal adiposity, DIEA perforator caliber was not correlated with BMI on CTA. The number of major DIEA perforators visualized on CTA decreased with increasing body weight may indicate a limitation of CTA for presurgical planning of abdominal free flaps in obese patients.

The Inclusion of Orbicularis Oculi Muscle in the SMAS Flap in Asian Facelift: Anatomical Consideration of Orbicularis Muscle and Zygomaticus Major Muscle.

BACKGROUND: In the malar region, the SMAS flap can be thin and tear easily, making it difficult to securely fix it. And the surgical anatomy of the region may be unclear and confusing. The authors performed an anatomical study on the location of the lateral margin of the orbicularis oculi muscle (OOM) and the origin of the zygomaticus major muscle (ZMM) when using a high-SMAS facelift with finger-assisted spaces dissection technique, which included elevation of the SMAS flap with OOM. METHODS: One hundred twenty-one Asian patients underwent this facelift procedure. Of those, the distances between the posterior margin of tragus and the lateral margin of the OOM and the center of the origin of the ZMM were measured in 20 patients. RESULTS: The mean age of the initial 121 patients was 50.9 years. In all cases, improvement was seen in soft tissue sagging of the midface and lower face. There was no functional impairment of the OOM. In 20 patients of them, the lateral margin of the OOM and the center of the origin of the ZMM were located at mean distances of 50.6 (range 48-53 mm) and 61.0 mm (range 60-65 mm) from the posterior margin of the tragus. CONCLUSIONS: The SMAS flap with the OOM is sufficiently strong enough so that it can maintain the pulling force and also helps to securely fix it. The authors hope that these anatomical findings would be useful when performing it and aid in the understanding of the relationship between the muscles in the malar area. LEVEL OF EVIDENCE IV: 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 .

High superficial musculoaponeurotic system facelift with finger-assisted facial spaces dissection for Asian patients.

BACKGROUND: Few facelift methods are designed specifically for Asian patients. Because of their characteristic thick skin and flat, wide facial geometry, satisfactory facelift results can be difficult to achieve in these patients. OBJECTIVES: The authors evaluated outcomes achieved with a high superficial musculoaponeurotic system (high-SMAS) facelift with finger-assisted facial spaces dissection to rejuvenate the aging Asian face. METHODS: Fifty-three patients underwent this facelift procedure. The indication for surgery was typical sagging of the face associated with aging; the relative contraindications were previous facelift and severe facial atrophy. RESULTS: Mean patient age was 50.7 years. Patients received follow-up for a mean of 19 months. In all cases, improvement was seen in soft-tissue sagging of the midface and lower face. One patient experienced unilateral temporal nerve injury, 3 experienced hematoma, and 2 had wound dehiscence. CONCLUSIONS: Understanding surgical anatomy including facial layers, spaces, and retaining ligaments is crucial for stable application of facelift techniques in Asian patients. Because of the small number of patients evaluated in this study and the limited follow-up period, more research is needed to define suitable facelift methods for these patients.

Retrospective Cohort Analysis on the Use of Hydrolyzed Collagen Powder in Back Reconstruction Following Spinal Instrumentation.

Background: Nearly half a million interbody fusions are estimated to be performed in the US each year, many of which involve complex reconstruction. The ability to limit seroma formation is vital to a seamless postoperative recovery. Methods: A retrospective review was performed for patients undergoing fusion procedures along with flap reconstruction over a period of 20 months. Cohorts reflect a temporal practice shift where use of hydrolyzed collagen powder (HCP) was initiated for hypothesized seroma prevention. Outcomes and associated metrics were used for intergroup comparison. Results: The study included 76 patients, of whom 47 were treated with HCP and 29 were not. Control patients had significantly fewer postoperative seromas than experimental ones (6.9% vs 27.7%; P = .03). The cohorts had no significant differences in time until final drain removal or in number of spinal levels involved (7.8 vs 7.1 days; P = .33, 8.5 vs 8.4 levels; P = .90). Rates of wound dehiscence, hematoma, or infection did not differ significantly between control and experimental patients (3.4% vs 12.8%, P = .17; 0% vs 0%; and 6.9% vs 10.6%, P = .58, respectively). Conclusions: The use of HCP led to a 4-fold increase in postoperative seromas in patients undergoing spinal fusion with flap reconstruction. This was regardless of all analyzed demographic and procedural factors, with the exception of age, whereby control patients were found to be on average slightly younger than experimental counterparts.

Is there a role for a strict incision length criterion for determining conversions during laparoscopic colorectal resection?

PURPOSE: There's no consensus about what defines a conversion for laparoscopic-assisted colorectal resection (LACR). This study's goal was to assess the utility of a strict incision length (IL) definition of conversion (incision > 7 cm) and compare it with results obtained when the surgeon determined (SD) if a LACR had been successfully completed. METHODS: The demographic and perioperative data for 580 elective LACRs were reviewed. The short-term outcomes for each conversion definition were determined and compared. RESULTS: Conversion rates were 22% using the IL definition and 16% via the SD method. Both methods detected significant differences between completed and converted groups regarding the following: incision size, hospital stay, time to flatus, bowel movement, and regular diet as well as rate of wound infection and ileus. The IL method alone detected significant differences in the rate of pulmonary complications and BMI between the completed and converted groups. CONCLUSIONS: The 2 methods yielded similar results for most parameters. The IL method better separated the patients in regard to 2 parameters. This method is objective and easy to apply; however, it may discriminate against obese patients whose extraction incisions are often longer. A conversion definition that considers BMI and IL is needed.

Initial repair of iatrogenic colon perforation using laparoscopic methods.

BACKGROUND: Iatrogenic perforation of the colon during elective colonoscopy is a rare but serious complication. Treatment using laparoscopic methods is a novel approach, only described in the recent literature. We hypothesized that laparoscopic treatment of iatrogenic colon perforation would result in equal therapeutic efficacy, less perioperative morbidity, smaller incisions and decreased length of stay, and an overall better short-term outcome compared to open methods. METHODS: We reviewed our prospectively collected patient database from July 2001 to July 2005 and compared the intraoperative data and postoperative outcomes of patients who underwent laparoscopic primary repair versus those who had open primary repairs of iatrogenically perforated large bowel. RESULTS: The laparoscopic (mean age 70 years; range 20-91 years; 18 percent male) and open (mean age 68 years; range 36-87 years; 43 percent male) groups were similar with regard to age. Overall, patients who underwent laparoscopic (n = 11) versus open (n = 7) repair had comparable operative (OR) times (mean 104 minutes, range 60-150 minutes versus mean 98 minutes, range 40-130 minutes, p = 0.04), shorter length of stay [LOS, (5.1 +/- 1.7 days versus 9.2 +/- 3.1 days, p = 0.01)], fewer complications (two versus five, p = 0.02) and shorter incision length (16 +/- 14.7 mm versus 163 +/- 54.4 mm, p = 0.001). CONCLUSIONS: A laparoscopic approach to iatrogenic colon perforation results in decreased morbidity, decreased length of stay, and a shorter incision length compared to an open method. In those cases where it is feasible and the surgical skills exist, a laparoscopic attempt at colon repair should probably be the initial clinical approach.

Prospective Analysis of Payment per Hour in Head and Neck Reconstruction: Fiscally Feasible or Futile?

BACKGROUND: The authors assess the fiscal viability of complex head and neck reconstructive surgery by evaluating its financial reimbursement in the setting of resources used. METHODS: The authors prospectively assessed provider reimbursement for consecutive patients undergoing head and neck reconstruction. Total care time was determined by adding 15 minutes to the operative time for each postoperative hospital day and each postoperative follow-up appointment within the 90-day global period. Physician reimbursement was divided by total care time hours to determine an hourly rate of reimbursement. A control group of patients undergoing carpal tunnel release was evaluated using the same methods described. RESULTS: A total of 50 patients met the inclusion criteria for study. The payer was Medicaid for nine patients (18 percent), Medicare for 19 patients (38 percent), and commercial for 22 patients (44 percent). The average provider revenue per case was $3241.01 ± $2500.65. For all patients, the mean operative time was 10.6 ± 3.87 hours and the mean number of postoperative hospital days was 15.1 ± 8.06. The mean reimbursement per total care time hour was $254 ± $199.87. Statistical analysis demonstrated difference in reimbursement per total care time hour when grouped by insurance type (p = 0.002) or flap type (p = 0.033). Of the 50 most recent patients to undergo carpal tunnel release, the average revenue per case was $785.27. CONCLUSION: Total care time analysis demonstrates that physician reimbursement is not commensurate with resources used for complex head and neck reconstructive surgery.

Experience with seven cases of massive splenomegaly.

BACKGROUND: Laparoscopic excision of extremely large spleens has been variously reported, but the usual consensus in the literature is that any patient with a spleen anything over 3000 g is simply not a proper candidate for laparoscopy. This report details our experience with 7 patients (out of 95 operated on) with spleens ranging in size up to 4800 g. METHODS: Our operative procedure involved 3 or 4 trocars placed along a virtually semicircular line centered over the splenic hilum. Splenic attachments were excised with the ultrasonic dissector, and the hilum divided with a stapler. Due to the size of the spleens, Pfannenstiel's incisions were utilized for hand-port placement in the extraction of the specimen. RESULTS: Surgery was successful in all 7 cases, and required no conversion to an open procedure. The average splenic weight was 3450 g (range, 3000-4800 g). Mean operative time was 168 minutes (range, 127-250 minutes). CONCLUSION: Because of improved instrumentation (i.e., laparoscopic stapler and ultrasonic dissector) and refinement of technique, spleens very much larger than what was once considered practicable can now be excised laparoscopically with similarly low morbidity as compared with open splenectomy.

Mesh infection in the era of laparoscopy.

BACKGROUND: The incidence of mesh infection during open hernia repair has been reported to be as high as 3%. With the introduction of laparoscopy, the rate of infection is still a matter of debate. METHODS: All 1182 laparoscopic inguinal hernia repairs performed at our institution from September 1991 to June 2002 were retrospectively reviewed to identify both mesh and wound infections. RESULTS: There were two mesh infections (0.17%) during that period, and one wound infection. CONCLUSION: The incidence of mesh infection in laparoscopic repair is considerably lower than in the open procedure. The two main reasons for this are the introduction of mesh through trocars to avoid skin contact, and the mesh is placed far from the trocar incisions, again avoiding contamination. The rate of wound infection is not related to that of mesh infection, and depends mainly on aseptic prepping techniques prior to surgery.