Microvascular free tissue transfer for reconstruction of complex lower extremity trauma: Predictors of complications and flap failure.

BACKGROUND: Despite advanced wound care techniques, open fractures in the setting of lower extremity trauma remain a challenging pathology, particularly when free tissue transfer is required for coverage. We aimed to evaluate factors associated with flap failure in this setting using a large, heterogeneous patient population. METHODS: Retrospective review of patients who underwent traumatic lower extremity free flap reconstruction (2002-2019). Demographics wound/vessel injury characteristics, pre and perioperative factors, and flap outcomes were analyzed. RESULTS: One hundred eighty-eight free flaps met inclusion criteria, with 23 partial (12.2%) and 13 total (6.9%) flap failures. Angiography was performed in 87 patients, with arterial injury suffered in 43.1% of those evaluated. Time to flap coverage varied within 3 days (4.5%), 10 days (17.3%), or 30 days of injury (42.7%). In all, 41 (21.8%) subjects suffered from major flap complications, including failure and takebacks. Multivariate regression demonstrated the presence of posterior tibial (PT) artery injury predictive of both flap-failure (Odds ratio [OR] = 11.4, p < .015) and major flap complications (OR = 12.1, p < .012). Immunocompromised status was also predictive of flap failure (OR = 12.6, p < .004) and major complications (OR = 11.6, p < .007), while achieving flap coverage within 30 days was protective against flap complications (OR = 0.413, p < .049). Defect size, infection, and injury location were not associated with failure. CONCLUSIONS: When examining a large, heterogeneous patient cohort, free flap outcomes in the setting of lower extremity open fractures can be influenced by multiple factors. This presence of PT artery injury, flap coverage beyond 30 days of injury, and immunocompromised status appear predictive of flap complications in this context.

Soft-Tissue Reconstruction of Complicated Total Ankle Arthroplasty.

BACKGROUND: Total ankle arthroplasty (TAA) is a popular modality to treat end-stage arthritis or internal ankle derangement. Unfortunately, failure rates remain undesirably high, with severe complications, including prosthesis failure, ankle fusion, and amputation. The importance of a stable soft-tissue envelope for coverage of implant compromise has been previously described, but the predictive factors for successful salvage of complicated TAA remain poorly understood. METHODS: A retrospective review was conducted of patients requiring soft-tissue reconstruction following TAA wound complications. Patient demographics, history, microbiological data, reconstructive approach, and outcomes data were collected. Statistical analysis was used to abstract factors associated with unsuccessful prosthetic salvage. RESULTS: In all, 13 patients met inclusion criteria: 8 (61.5%) achieved prosthetic salvage, and 5 (38.5%) failed. The majority (90.9%) of patients presented with infected joints. Reconstructive techniques included skin grafts, dermal substitutes, locoregional flaps, and free tissue transfer. Successful prosthetic salvage was associated with shorter time intervals between wound diagnosis and index reconstructive surgical intervention (median: 20 days for salvage vs 804 days for failure; P = .014). Additionally, salvage was associated with reduced time from the index orthopaedic/podiatric surgical intervention to the index reconstructive surgery procedure (12 vs 727 days; P = .027). CONCLUSION: The prognosis of complicated TAA requiring soft-tissue reconstruction remains poor, especially in patients who present with infected joints. Several reconstructive techniques, ranging from simple skin grafts to complex free tissue transfers, can be used successfully. Early intervention to achieve soft-tissue coverage is crucial in maximizing salvage rates in the setting of complicated and infected TAA. LEVEL OF EVIDENCE: Level IV.

Are You Thinking About Going Back to School? An Analysis of Plastic Surgery Residents, Alumni, Faculty, and Program Leaders With Advanced Degrees.

BACKGROUND: The number of adults with master's, professional, and doctoral degrees has doubled since 2000. The relevance of advanced degrees in plastic surgery has not been explored. METHODS: Faculty, residents, and recent alumni with advanced degrees from the United States plastic surgery training programs were identified. Degrees were analyzed based on geography, program/hospital rankings, department versus division status, gender, leadership/editorial roles, private versus academic practice, subspecialization training, academic productivity/H-indices, and National Institutes of Health funding. RESULTS: A total of 986 faculties, 1001 residents, and 761 alumni credentials from 95 training programs were reviewed: 9.3% of faculties, 7.1% of residents, and 6.3% of alumni have advanced degrees, majority being men (71%). Residency programs ranked top 10 by Doximity or affiliated with a top 10 medical school/hospital have more faculty/residents/alumni with advanced degrees (P < 0.01). Faculty holding PhDs are less likely fellowship trained (52.5% versus 74.0%, P = 0.034). Master's in Business Administration (MBA) is associated with chair/chief status (30.0% versus 8.57%, P = 0.01) or other major academic title (eg, Dean, Director) (70.0% versus 37.14%, P = 0.01). No significant associations exist between degree type and professor status, research productivity, academic versus private practice, or subspecialization (eg, craniofacial surgery). CONCLUSION: The majority of plastic surgeons with advanced degrees have PhDs, although there is an increasing trend of other research degrees (eg, Master's in Public Health) in current trainees. MBA is associated with chair/chief status or other major academic title. Reasons for obtaining an advanced degree and impact on career deserve further attention.

Risk Factors for Lower Extremity Amputation Following Attempted Free Flap Limb Salvage.

BACKGROUND: Traumatic limb salvage with free flap reconstruction versus primary amputation for lower extremity (LE) injuries remains an oft debated topic. Limb salvage has well-studied benefits and advances in microsurgery have helped reduce the complication rates. A subset of patients eventually requires secondary amputation after a failed attempt at limb salvage. A better understanding of risk factors that predict subsequent amputation after failed free flap reconstruction of LE injuries may improve operative management. PATIENTS AND METHODS: A retrospective study (2002-2019) was conducted on all patients who underwent free flap reconstruction of the LE within 120 days of the original inciting event at a single institution. Patient and operative factors were reviewed including comorbidities, severity of the injury, flap choice, outcomes, and complications. Predictors of subsequent amputation were analyzed. RESULTS: A total of 129 patients requiring free flap reconstructions for LE limb salvage met inclusion criteria. Anterolateral thigh flaps (70.5%) were performed most frequently. Secondary amputation occurred in 10 (7.8%) patients. Preoperative factors associated with eventual amputation include diabetes mellitus (p = 0.044), number of preoperative debridements (p = 0.013), evidence of any arterial injury/pathology (p = 0.008), specifically posterior tibial artery (p = < 0.0001), and degree of three-vessel runoff (p = 0.007). Operative factors associated with subsequent amputation include evidence of recipient artery injury/pathology (p = 0.008). Postoperative factors associated with secondary amputation include total flap failure (p = 0.001), partial flap failure (p = 0.002), minor complications (p = 0.037), and residual osteomyelitis (p = 0.028). CONCLUSION: Many factors contribute to the reconstructive surgical team's decision to proceed with limb salvage or perform primary amputation. Several variables are associated with failed limb salvage resulting in secondary amputation. Further studies are required to better guide management during the limb salvage process.

An Update on Social Media in Academic Plastic Surgery Training Programs: The Rising Trend of Likes, Shares, and Retweets.

BACKGROUND: Increasing in popularity, social media provides powerful marketing and networking tools for private practice plastic surgeons. The authors sought to examine social media utilization by academic plastic surgery training programs. METHODS: Facebook, Instagram, and Twitter were queried for plastic surgery training program, program director, and chief/chair accounts. Training program posts were categorized as educational, operative, social, informational, self-promotional, visiting lecturer, research-related, and other. Factors influencing total number of followers were analyzed including number of accounts followed, frequency, total number, and types of posts as well as duration of account. Other variables included geographic location, 2018 to 2019 Doximity residency ranking, and US News and World Report rankings of affiliated hospital systems and medical schools. Social media accounts were analyzed using Kruskal-Wallis, Wilcoxon rank sum, and regression analysis. RESULTS: Facebook is the most popular social media platform among chiefs/chairs (34, 35.7%), followed by Instagram (20, 21.1%) and Twitter (19, 20.0%). Facebook is used more by program directors (31, 32.6%) followed by Instagram (22, 23.1%) and Twitter (15, 15.7%). The majority of Facebook and Twitter leadership accounts are for personal use (62%-67%), whereas Twitter is used primarily for professional purposes (60%-84%). Training program social media use is rising, with Instagram and Twitter presence growing at exponential rates (R = 0.97 and 0.97, respectively). Of 95 training programs evaluated, 54 (56.8%) have Instagram accounts, 29 (30.5%) have Facebook accounts, and 27 (28.4%) have Twitter accounts. Most training programs using social media have 2 or more accounts (37, 67.3%). West coast programs have more Instagram followers than other geographic regions, significantly more than Southern programs (P = 0.05). Program accounts with more followers are affiliated with top-ranked hospitals (P = 0.0042) or top-ranked Doximity training programs (P = 0.02). CONCLUSIONS: Similar to its adoption by private practice plastic surgery, social media use in academic plastic surgery is growing exponentially. Now, over half of residency programs have Instagram accounts. Program leaders are using Facebook and Instagram primarily for personal use and Twitter for professional use. Programs affiliated with a top-ranked hospital or ranked highly by Doximity have more followers on social media.

Flap Reconstruction for Deep Sternal Wound Infections: Factors Influencing Morbidity and Mortality.

BACKGROUND: Deep sternal wound infections (DSWI) often require flap reconstruction to obliterate dead space and provide healthy soft tissue coverage. A better understanding of risk factors for complications after DSWI flap reconstruction may improve operative management. METHODS: A retrospective study (2007-2018) was conducted of all patients with DSWI after cardiothoracic procedure referred to a single reconstructive surgeon for flap reconstruction. Patient and operative factors were reviewed, including procedure types and outcomes. Predictors of morbidity and mortality rates were analyzed. RESULTS: A total of 119 patients requiring flap reconstruction for DSWI met inclusion criteria. Unilateral (49.6%) or bilateral (40.3%) pectoralis muscle flaps were performed most frequently, followed by vertical rectus abdominis myocutaneous (VRAM) (4.2%), omental (4.2%), and omental/pectoralis flap combination (1.7%). Superficial surgical site infection (SSI) was the predominant postoperative complication (17.6%). Débridement/revisional procedures were required in 19 patients (16%), and flap failure occurred in 5 (4.2%). Overall 30-day mortality was 15.1%. End-stage renal disease (P = .002), congestive heart failure (P = .049), low albumin (P = .004), cardiopulmonary bypass time (P = .0001), need for open chest (P = .020), and high American Society of Anesthesiologists Physical Status Classification (P = .003) were associated with higher mortality. By multivariate analysis, multidrug resistance was predictive of any postoperative complication (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.3-23.2; P = .018), VRAM was predictive of SSI (OR, 9.6; 95% CI, 1.4-66.4; P = .022), and end-stage renal disease (OR, 8.57; 95% CI, 1.06-69.1; P = .044) was predictive of higher mortality. CONCLUSIONS: Pectoralis muscle flaps are the workhorse for complex sternal wound coverage, but complications after flap reconstruction for DSWIs remain high. In particular, end-stage renal disease, VRAM reconstruction, and multidrug-resistant infection may predict a complicated postoperative course in these patients.

The Independent Plastic Surgery Match (2010-2018): Applicant and Program Trends, Predictors of a Successful Match, and Future Directions.

OBJECTIVES: Changes were made to the independent plastic surgery residency in 2009 to 2010 that included full prerequisite training and increased from 2 to 3 years of independent residency. The authors sought to determine subsequent match trends and predictors of a successful match. METHODS: With American Council of Academic Plastic Surgeons approval, the San Francisco Match provided data for the independent match (2010-2018). Trends in the independent plastic surgery were reviewed. Applicant variables were analyzed to determine correlation with a successful match and a match at top-ranked programs using Doximity Residency Navigator. RESULTS: Total independent applicants per cycle decreased 18% while foreign medical school applicants increased from 19.4% to 27%. Available positions decreased from 97 to 66 (32%) and match rate decreased from 82% to 78%. Applicants who matched were from US medical schools, had higher USMLE Step 1 scores, were from University and top General surgery residencies, and averaged more interviews (p < 0.05). By multivariate regression, number of interviews completed (odds ratio [OR] 15.35 95% confidence interval [CI] 7.7-30.6, p < 0.001) and having completed prerequisite training at a university based program in addition to having graduated from an allopathic medical school (OR 1.78 95% CI 1.1-2.97, p = 0.027) were predictive of a successful match. Step 1 score ≥ 240 (OR 3.2, 95% CI 1.0-10.2, p = 0.046), Alpha Omega Alpha membership (OR 2.2, 95% CI 1.1-4.9, p = 0.048), and having completed prerequisite training at the same institution (7.6, 95% CI 2.2-25.7, p < 0.001) were predictive of matching at top-ranked programs. CONCLUSIONS: Since 2010, independent plastic surgery applicant and program participation have decreased. Greater number of interviews, university-based prerequisite training, and allopathic medical school background are variables that correlate with a successful match. Factors predictive of a match at top-ranked Doximity Residency Navigator plastic surgery programs include high Step 1 scores, Alpha Omega Alpha membership, and prerequisite training at the same institution.

Omental Flap Coverage for Management of Thoracic Aortic Graft Infection.

BACKGROUND: Since the first reported use of prosthetic aortic grafts, infection has remained a feared complication. Pedicled omentum is the preferred flap in managing thoracic aortic graft infection (TAGI); however the literature is sparse. The authors present their experience with TAGI managed with pedicled omental flaps. METHODS: A single-institutional review from 2007 to 2018 was performed to analyze postoperative outcomes of omental flap reconstruction, performed by 2 surgeons, after a confirmed diagnosis of TAGI. The primary outcomes of overall complication rate, 30-day mortality, and in-hospital mortality were evaluated with univariate analysis. RESULTS: Twenty patients requiring omental flap reconstruction after TAGI met inclusion criteria. The patient cohort included 14 men and 6 women with a mean age of 60.6 ± 12.9 years and a mean Charlson comorbidity index of 3.3 ± 2.1. Nine patients (45%) received omental flap reconstruction at the time of incipient TAGI surgical management by the cardiothoracic surgery team, whereas 11 patients received delayed reconstruction (mean, 6.22 days [range, 1-27]). The most common complications were graft leak (20%) and pseudoaneurysm (25%), with only 1 patient developing recurrent infection. Overall 30-day mortality was 20%. Chronic obstructive pulmonary disease and delayed omental flap reconstruction were associated with 30-day mortality (P = .04). Four of 11 patients (36.4%) who received delayed omental flap reconstruction died within 30 days, whereas 0 of 9 patients (0%) in the immediate omental coverage group died within 30 days (P = .043). CONCLUSIONS: High mortality rates associated with TAGI exemplify the challenges associated with this disease process and patient population. Pedicled omentum is a safe adjunct with promising results to the management of TAGI while significantly reducing the risk of reinfection.