Identifying Factors of Operative Efficiency in Head and Neck Free Flap Reconstruction.

Importance: Head and neck oncological resection and reconstruction is a complex process that requires multidisciplinary collaboration and prolonged operative time. Numerous factors are associated with operative time, including a surgeon's experience, team familiarity, and the use of new technologies. It is paramount to evaluate the contribution of these factors and modalities on operative time to facilitate broad adoption of the most effective modalities and reduce complications associated with prolonged operative time. Objective: To examine the association of head and neck cancer resection and reconstruction interventions with operative time. Design, Setting, and Participants: This large cohort study included all patients who underwent head and neck oncologic resection and free flap-based reconstruction in Calgary (Alberta, Canada) between January 1, 2007, and March 31, 2020. Data were analyzed between November 2021 and May2022. Interventions: The interventions that were implemented in the program were classified into team-based strategies and the introduction of new technology. Team-based strategies included introducing a standardized operative team, treatment centralization in a single institution, and introducing a microsurgery fellowship program. New technologies included use of venous coupler anastomosis and virtual surgical planning. Main Outcomes and Measures: The primary outcome was mean operative time difference before and after the implementation of each modality. Secondary outcomes included returns to the operating room within 30 days, reasons for reoperation, returns to the emergency department or readmissions to hospital within 30 days, and 2-year and 5-year disease-specific survival. Multivariate regression analyses were performed to examine the association of each modality with operative time. Results: A total of 578 patients (179 women [30.9%]; mean [SD] age, 60.8 [12.9] years) undergoing 590 procedures met inclusion criteria. During the study period, operative time progressively decreased and reached a 32% reduction during the final years of the study. A significant reduction was observed in mean operative time following the introduction of each intervention. However, a multivariate analysis revealed that team-based strategies, including the use of a standardized nursing team, treatment centralization, and a fellowship program, were significantly associated with a reduction in operative time. Conclusions: The results of this cohort study suggest that among patients with head and neck cancer, use of team-based strategies was associated with significant decreases in operative time without an increase in complications.

Immobilization of the Wrist After Dorsal Wrist Ganglion Excision: A Systematic Review and Survey of Current Practice.

BACKGROUND: Postoperative care after dorsal wrist ganglion (DWG) excision is highly varied. The effect of immobilization of the wrist on patient outcomes has not yet been examined. METHODS: A systematic review of the literature was performed to determine whether wrist immobilization after DWG surgical excision is beneficial. A survey of hand surgeons in Canada was performed to sample existing practice variations in current immobilization protocols after DWG excision. RESULTS: A systematic review yielded 11 studies that rigidly immobilized the wrist (n = 5 open excision, n = 5 arthroscopic excision, n = 1 open or arthroscopic excision), 10 studies that used dressings to partially limit wrist motion (n = 5 open, n = 5 arthroscopic), 1 study (open) that did either of the above, and 2 studies (arthroscopic) that did not restrict wrist motion postoperatively. This ranged from 48 hours to 2 weeks in open DWG excision and 5 days to 3 weeks in arthroscopic DWG excision. The survey of Canadian hand surgeons had a similarly divided result of those who chose to immobilize the wrist fully (41%), partially (14%), or not at all (55%). Most surgeons surveyed who immobilized the wrist postoperatively did so for 1 to 2 weeks. CONCLUSION: The systematic review and survey of Canadian hand surgeons reveal that hand surgeons are divided regarding the need to immobilize the wrist after DWG excision. In terms of functional outcome, there is no compelling data to suggest 1 strategy is superior. The time frame for immobilization when undertaken was short at 2 weeks or less.The systematic review is registered in the PROSPERO database (PROSPERO 2016:CRD42016050877).

Patient-Reported Outcomes after Fibula Free Flap Harvest: A Pilot Study.

SUMMARY: Patient-reported outcomes regarding donor-site morbidity and quality of life for the fibula free flap in head and neck reconstruction patients have not been studied. The authors reviewed and identified patients who had undergone head and neck reconstruction using a fibula free flap (2011 to 2016). Patients were assessed via physical examination and two patient-reported outcomes questionnaires: the Foot and Ankle Outcome Score (score range, 0 to 100) and the Pain Disability Questionnaire (score range, 0 to 100). Quantitative data were analyzed with appropriate statistical tests. Semistructured interviews exploring donor-site challenges were performed and analyzed using thematic analysis. Seventeen patients agreed to participate. Their mean age was 62 years (range, 41 to 81 years). Mean follow-up was 38 months (range, 12 to 65 years). Mean perceived level of function compared to baseline was 67 percent. Mean scores for the Foot and Ankle Outcome Score subscales were 84.6 (pain), 80.5 (symptoms), 86.7 (activities of daily living), 67.7 (sport), and 65.6 (quality of life). The mean Pain Disability Questionnaire score was 26.3 (mild/moderate perceived disability). Higher perceived level of function was associated with higher Foot and Ankle Outcome Score values (pain, symptoms, and activities of daily living, p < 0.05). Donor limbs had decreased range of motion and manual muscle testing scores compared with their contralateral limbs (p < 0.05). Lack of ankle support and balance, resulting in limitations and aversions to daily and sporting activities, were the most common themes regarding donor-site challenges. In conclusion, patients who have undergone fibula free flap harvest struggle with ankle support and balance and face functional difficulties that have an impact on their quality of life. Multidisciplinary approaches for targeted rehabilitation after fibula free flap harvest should be explored to determine the impact on patients' quality of life.

Evaluating CNVII Recovery after Reconstruction with Vascularized Nerve Grafts: A Retrospective Case Series.

Few studies have evaluated vascularized nerve grafts (VNGs) for facial nerve (CNVII) reconstruction. We sought to evaluate long-term outcomes for CNVII recovery following reconstruction with VNGs. A retrospective review of all patients at a tertiary centre who underwent radical parotidectomy and immediate CNVII reconstruction with VNGs was performed (January 2009-December 2019). Preoperative demographics, perioperative factors (flap type, source of VNGs), and postoperative factors [complications, adjuvant therapy, revisionary procedures, length of follow-up, and CNVII function via the House-Brackmann scale (HB)] were collected. Data were summarized qualitatively. Twelve patients (Mage = 53 ± 18 years) with a mean follow-up of 33 (± 23) months were included. Six patients underwent reconstruction with a radial forearm flap and dorsal sensory branches of the radial nerve. Six patients underwent reconstruction with an anterolateral thigh flap and only deep motor branches of the femoral nerve to the vastus lateralis (n = 4) or combined with the lateral femoral cutaneous nerve (n = 2). Two patients regained nearly normal function (HB = 2). Eight patients regained at least resting symmetry (HB = 3 for n = 7; HB = 4 for n = 1). One patient regained a flicker of movement (HB = 5). One patient did not regain function (HB = 6). Six patients had static revision procedures to improve symmetry. Five patients had disease recurrence; 3 died from their disease. VNGs offer a practical and viable addition to the CNVII reconstruction strategy, and result in good functional recovery with acceptable donor site deficits. The associated adipofascial component of these flaps can also augment the soft tissue defect left after tumor ablation.

Use of an Omental Flow-Through Flap for Recipient Vessels in the Reconstruction of a Lumbar Spine Defect: A Case Report.

CASE: Spine reconstruction after en bloc spondylectomy is challenging and may require multidisciplinary intervention. En bloc spine tumor resection with embolization of local recipient vessels for tumor control limits reconstructive options. Herein, we describe a case where combined efforts from orthopaedic, general, and plastic surgery teams permitted the successful reconstruction of a multilevel lumbar vertebral defect. CONCLUSION: A fibula-free flap within a titanium cage construct anastomosed to the left gastroepiploic vessels via a pedicled omental flow-through flap is a viable and novel method for reconstruction of a multilevel vertebral defect.

The success of salvage procedures for failing digital replants: A retrospective cohort study.

BACKGROUND: The success of salvage procedures for failing digital replants (FR) is poorly documented. We sought to evaluate the success of salvage procedures for FR and factors contributing to successes and failures of replants. METHODS: Adult patients who presented to our center between January 1, 2000 and December 31, 2015, suffered ≥1 digital amputation(s), and underwent digital replantation were included. Preoperative, perioperative, and postoperative details were recorded. Digits were monitored postoperatively via nursing and physician assessments. The presumed reason for failure, details, and outcomes of salvage attempts were recorded for FR. Length of hospital stay and complications were also recorded. RESULTS: Fifty-two patients and 83 digits were included. Fifty-two digits (63%) were compromised (arterial ischemia in 15 digits; venous congestion in 37 digits) and 48 digits had salvage therapy. Twenty-one FR (44%) were salvaged via operative (1 of 2; 50%), nonoperative (19 of 43; 44%), and combined (1 of 3; 33%) therapies. FR patients were more likely than those with successful replants to receive a blood transfusion (52 vs. 23%; p = .009) with more transfused units (3.45 ± 3.30 vs. 0.86 ± 0.95; p = .001). Length of stay was prolonged for FR patients (9 [range: 2-22] vs. 7 [range: 3-19] days; p = .039). Ultimately, 59% (49 of 83) of replants were successful, where 25% (21 of 83) were successfully salvaged. CONCLUSION: Nonoperative and operative salvage therapies improve the rate of replant survival. We suggest close postoperative monitoring of all replants and active salvage interventions for compromised replants in the postoperative period.

The Misconception of Case-Control Studies in the Plastic Surgery Literature: A Literature Audit.

BACKGROUND: Case-control study designs are commonly used. However, many published case-control studies are not true case-controls and are in fact mislabeled. The purpose of this study was to identify all case-control studies published in the top three plastic surgery journals over the past 10 years, assess which were truly case-control studies, clarify the actual design of the articles, and address common misconceptions. METHODS: MEDLINE, Embase, and Web of Science databases were searched for case-control studies in the three highest-impact factor plastic surgery journals (2005 to 2015). Two independent reviewers screened the resulting titles, abstracts, and methods, if applicable, to identify articles labeled as case-control studies. These articles were appraised and classified as true case-control studies or non-case-control studies. RESULTS: The authors found 28 articles labeled as case-control studies. However, only six of these articles (21 percent) were truly case-control designs. Of the 22 incorrectly labeled studies, one (5 percent) was a randomized controlled trial, three (14 percent) were nonrandomized trials, two (9 percent) were prospective comparative cohort designs, 14 (64 percent) were retrospective comparative cohort designs, and two (9 percent) were cross-sectional designs. The mislabeling was worse in recent years, despite increases in evidence-based medicine awareness. CONCLUSIONS: The majority of published case-control studies are not in fact case-control studies. This misunderstanding is worsening with time. Most of these studies are actually comparative cohort designs. However, some studies are truly clinical trials and thus a higher level of evidence than originally proposed.

Compliance with published recommendations for postoperative antibiotic management of children with appendicitis: A chart audit.

BACKGROUND: Recommendations for postoperative antibiotics for appendicitis were published by the American Pediatric Surgical Association (APSA) in 2010. However, implementation of practice recommendations often takes years. We measured compliance of pediatric surgeons (who receive reminders every 6months from the Division Chief) with the APSA recommendations. METHODS: With Research Ethics Board approval, we completed a retrospective review of children who underwent appendectomy since 2010. Compliance with APSA recommendations was analyzed descriptively. Agreement between pediatric surgeons and pathologists was analyzed by kappa. RESULTS: We reviewed 242 charts. Patients were excluded for missing data (n=5) and diagnosis other than appendicitis (n=27), resulting in 210 patients with appendicitis (119 acute, 91 perforated). Agreement of perforation status between surgeons and pathologists was good (κ=0.75; 95% CI: 0.66-0.83). Many patients with nonperforated appendicitis received antibiotics in excess of the APSA recommendations (62/119 (52%)), as did those with uncomplicated perforated appendicitis (52/84 (62%)). CONCLUSIONS: Despite the availability of published recommendations, surgeons continue to prescribe postoperative antibiotics for appendicitis in excess of the recommendations. Overtreatment leads to potential medication errors and increased length-of-stay/medication costs. An intensive implementation program with ongoing education/monitoring may improve compliance with established recommendations to decrease the use of excess postoperative antibiotics and their associated costs/risks.

Messages for men: the efficacy of EPPM-based messages targeting men's physical activity.

OBJECTIVE: The majority of men are insufficiently active. Men's tendencies to participate in risky behaviors and their inactivity likely contribute to their increased risk of morbidity and mortality. Physical activity decreases the risk of developing many chronic diseases and may be an optimal behavior to target in men's health interventions. However, educational resources promoting physical activity for men are lacking. To address this gap, we tested the efficacy of messages based upon the Extended Parallel Process Model (EPPM; Witte, 1992) to increase men's physical activity intentions and behaviors. METHOD: Men who were not meeting physical activity guidelines (n = 611) were randomly assigned to read high or low efficacy physical activity messages paired with high or no health risk information. Participants read four brief messages on four consecutive days. Intentions were assessed at baseline and the first follow-up (Day 5). Manipulation check measures were assessed at Day 5. Behavior was assessed at baseline and the second follow-up (Day 14). RESULTS: Overall, the messages had small sized effects. A completer analysis revealed that although men's intentions to be active increased over the course of the study regardless of the messages they received, only men who received risk information significantly increased their physical activity. Men who received low efficacy and risk information were less likely to meet the physical activity guidelines at Day 14 than men who only received low efficacy information. CONCLUSIONS: From these results, we suggest preliminary recommendations for the development of physical activity messages for men and areas for future EPPM-based research.