Extracorporeal Pedicles for Free Flap Reconstruction in Diabetic Lower Extremity Wounds.

Diabetic foot ulcers are a severe complication of diabetes, and their management requires a multidisciplinary approach for optimal management. When treating these ulcers, limb salvage remains the ultimate goal. In this article, we present the "hanging" free flap for the reconstruction of chronic lower extremity diabetic ulcers. This two-staged approach involves standard free flap harvest and inset; however, following inset the "hanging" pedicle is covered within a skin graft instead of making extraneous incisions within the undisturbed soft tissues or tunnels that can compress the vessels. After incorporation, a second-stage surgery is performed in 4 to 6 weeks which entails pedicle division, flap inset revision, and end-to-end reconstruction of the recipient vessel. Besides decreasing the number of incisions on diabetic patients, our novel technique utilizing the "hanging" pedicle simplifies flap monitoring and inset and allows reconstruction of recipient vessels to reestablish distal blood flow.

The Challenges of Upper Extremity Intramuscular Hemangioma: A Case Study and Systematic Review.

BACKGROUND: Intramuscular hemangiomas are rare, benign vascular tumors, constituting 0.8 percent of all hemangiomas. Upper extremity intramuscular hemangiomas pose diagnostic and therapeutic challenges because of their rarity, invasive nature, and potential for neurovascular involvement. The authors report a comprehensive systematic review of upper extremity intramuscular hemangioma management and a challenging case report. METHODS: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases were used to identify articles describing upper extremity intramuscular hemangiomas through 2019. Patient demographics, clinical presentation, management, complications, and outcomes were reviewed. Based on operative timing, cases were categorized as either "primary" (excision performed at initial diagnosis) or "secondary" (excision performed after failure of conservative treatment). RESULTS: Eighteen articles encompassing 25 patients were included in the authors' systematic review. Of those, 18 underwent primary excision and seven underwent secondary excision. The majority involved the forearm or antecubital region. Complete excision, evaluated by gross examination or pathology, was reported in all primary cases and 71 percent of secondary cases. Primary excisions demonstrated smaller size of mass (19.4 cm 2 versus 165.3 cm 2 ) and superior reported functional outcomes (100 percent versus 33 percent). Complications were reported in 5 percent of the primary excisions compared to 71 percent of the secondary excisions, where one complication was a fatal hematoma. CONCLUSIONS: The literature concerning upper extremity intramuscular hemangioma is limited to mostly case reports and several case series with the potential risk of bias. With careful dissection and microsurgical technique, wide local excision followed by complete reconstruction can be successfully performed at initial diagnosis for upper extremity intramuscular hemangiomas. At early stages, smaller lesion size significantly reduces the risk of functional impairment and complications.

Evaluation of Chlorhexidine Concentration on the Skin After Preoperative Surgical Site Preparation in Breast Surgery-A Randomized Controlled Trial.

BACKGROUND: Although there is a rationale supporting that preoperative showering with 2% or 4% chlorhexidine gluconate (CHG) would decrease skin bacterial colonization, there is no consensus that this practice reduces the risk of surgical site infection (SSI). OBJECTIVES: Analyze the skin concentration of CHG after preoperative showering associated with the traditional skin preparation with CHG 4% for breast surgery. METHODS: Randomized controlled trial that included 45 patients, all candidates for augmentation mammaplasty, allocated into three groups (A: no preoperative showering; B: one preoperative showering; C: two preoperative showering with CHG 4%) in a 1:1:1 ratio. Skin swabs collection was performed right before the surgical incision. The samples were, then, sent to spectrophotometry in order to determine the skin concentration of CHG at the beginning of surgery. RESULTS: The age ranged from 18 to 61 years, with a mean of 37 years old. Group C had the lowest median concentration (0.057) followed by group B (0.060) and group A (0.072), however, with no statistical significance. The areola was the place with the lowest median concentration level (0.045), followed by the axilla (0.061) and the inframammary fold (IMF) (0.069). Still, when comparing the distribution of the sites, a statistically significant difference was found only between the axilla and the areola (p = 0.022). CONCLUSION: Preoperative showering with CHG 4% did not increase the concentration of this agent on the skin surface right before the surgical incision. 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 .

Cost-effectiveness of Multidisciplinary Care in Plastic Surgery: A Systematic Review.

BACKGROUND: Multidisciplinary care has been previously shown to improve outcomes for patients and providers alike, fostering interprofessional collaboration and communication. Many studies have demonstrated the beneficial health care outcomes of interdisciplinary care. However, there has been minimal focus on the cost-effectiveness of such care, particularly in the realm of plastic surgery. This is the first systematic review to examine cost savings attributable to plastic surgery involvement in multidisciplinary care. METHODS: A comprehensive literature review of articles published on cost outcomes associated with multidisciplinary teams including a plastic surgeon was performed. Included articles reported on cost outcomes directly or indirectly attributable to a collaborative intervention. Explicitly reported cost savings were totaled on a per-patient basis. Each article was also reviewed to determine whether the authors ultimately recommended the team-based intervention described. RESULTS: A total of 604 articles were identified in the initial query, of which 8 met the inclusion criteria. Three studies reported explicit cost savings from multidisciplinary care, with cost savings ranging from $707 to $26,098 per patient, and 5 studies reported changes in secondary factors such as complication rates and length of stay. All studies ultimately recommended multidisciplinary care, regardless of whether cost savings were achieved. CONCLUSIONS: This systematic review of the cost-effectiveness of multidisciplinary plastic surgery care examined both primary cost savings and associated quality outcomes, such as length of stay, complication rate, and resource consumption. Our findings indicate that the inclusion of plastic surgery in team-based care provides both direct and indirect cost savings to all involved parties.

Financial Analysis of Operating a Resident Aesthetic Clinic.

BACKGROUND: Recent changes to the plastic surgery residency training requirements along with a general call for expanded education in cosmetic surgery have encouraged many institutions to incorporate resident aesthetic clinics into their curricula. Although the safety and satisfaction rates of resident aesthetic clinics have been well-studied, their financial viability has not. This study reviews the financial viability of the resident aesthetic clinic at the authors' institution through a cost analysis. METHODS: Billing data were analyzed for all patient visits to the resident aesthetic clinic of the authors' institution during calendar year 2018. Data were extracted, including type and anatomical location of each procedure, charges collected, and supplies used. A financial analysis was performed based on fixed and variable costs and gross revenue. RESULTS: A total of 100 unique patients were seen in the clinic over a 1-year period, resulting in 53 operations. This included 15 face, four breast, and 34 body contouring procedures. In addition, 160 cosmetic injections were performed. The gross revenue was $69,955 and the net revenue was $36,600. CONCLUSIONS: The resident aesthetic clinic at the authors' institution proved to be financially viable. The authors encourage other institutions to more closely examine the financial state of their resident aesthetic clinics as well. Furthermore, the authors hope that this analysis demonstrates to other programs that, with certain practice models, cost should not be a barrier to initiating and maintaining this valuable training tool.

Vascularized Bone Grafts in Spinal Reconstruction: An Overview of Nomenclature and Indications.

Several vascularized bone grafts (VBGs) have been introduced for reconstruction and augmenting fusion of the spine. The expanding use of VBGs in the field of spinoplastic reconstruction, however, has highlighted the need to clarify the nomenclature for bony reconstruction as well as establish the position of VBGs on the bony reconstructive algorithm. In the current literature, the terms "flap" and "graft" are often applied inconsistently when describing vascularized bone transfer. Such inconsistency creates barriers in communication between physicians, confusion in interpreting the existing studies, and difficulty in comparing surgical techniques. VBGs are defined as bone segments transferred on their corresponding muscular attachments without a named major feeding vessel. The bone is directly vascularized by the muscle attachments and unnamed periosteal feeding vessels. VBGs are best positioned as a separate entity in the bony reconstruction algorithm between nonvascularized bone grafts (N-VBGs) and bone flaps. VBGs offer numerous advantages as they supply fully vascularized bone to the recipient site without the microsurgical techniques or pedicle dissection required for raising bone flaps. Multiple VBGs have been introduced in recent years to optimize these benefits for spinoplastic reconstruction.

Operative Pediatric Hand Infections: A Retrospective Review.

BACKGROUND: Infections in the pediatric population are a less well studied topic in hand surgery. Crucial aspects of the management of pediatric hand infections differ from adults, though much of current treatment is generalized from adult care. This study evaluates our clinical experience with regards to the epidemiology, management, and outcomes of pediatric hand infections requiring operative intervention. METHODS: A 7-year retrospective chart review was performed of all pediatric patients who required operative intervention for hand infections at Texas Children's Hospital. Clinical information was collected and analyzed, including demographics, infection characteristics, management, and outcomes. RESULTS: Fifty-seven patients met the inclusion criteria for our study over the 7-year period. Of these, 7% (n=4) had a pre-existing diagnosis of diabetes mellitus, and 5% (n=3) had a recent history of upper extremity infections. The most common infection was a discrete abscess, whereas urgent/emergent conditions represented 25% (n=14) of infections. Radiographic changes consistent with osteomyelitis were present in over one-quarter of patients (n=13, 23%). The median length of hospital stay was 3 days (95% confidence interval: 3.05-5.05) and the most common pathogen was Staphylococcus aureus (n=33, 58%), with slightly more being methicillin sensitive (MSSA) than resistant (MRSA) (n=19, 33% vs. n=14, 25%). The incidence of reoperation was 12.5% (n=7). CONCLUSIONS: Hand infections are a common problem in the pediatric population. Cases tend to be associated with accidental trauma and discrete abscesses colonized by MSSA/MRSA. The vast majority of cases require only one operation and a short course of wound care before discharge. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Health Care Services Utilization by Transgender Patients in a Medicaid Managed Program.

While challenges related to health care utilization among transgender individuals have been discussed, studies examining health services under Medicaid are limited. A retrospective review was performed on all patients who presented with Gender Dysphoria from 2013-2018 to one Medicaid managed program. Utilization rates of distinct services and interventions were analyzed. A total of 192 patients, with 787 encounters, were identified. Mean patient age was 15 years old. Mean number of encounters per patient was 4.1. The average number of distinct specialties seen was 1.4. Behavioral health (BH) services were most commonly utilized (50%). Endocrinology and surgical services were encountered less frequently. Medications were prescribed for 25% of patients; hormonal treatment was prescribed for 6.7%. This study highlights the deficiencies in services this population is receiving under one managed Medicaid program. While behavioral health services are widely employed, underutilization of medical and surgical consultations compromises patient awareness of available interventions.

Multidisciplinary care in surgery: Are team-based interventions cost-effective?

BACKGROUND: Multidisciplinary care has been shown to improve outcomes for patients, and interprofessional collaboration has been demonstrated to be beneficial for providers. In the field of surgery, although a large number of multidisciplinary care teams have been described, no study to date has examined whether or not these team-based interventions are generally cost-effective. This is the first systematic review to examine cost savings attributable to multidisciplinary care across all surgical fields. METHODS: A comprehensive literature review of articles published on cost outcomes associated with multidisciplinary surgical teams was performed. Selected articles reported on cost outcomes directly attributable to a collaborative intervention. Cost savings were totaled on a per-patient basis. Each article was also reviewed to determine whether the authors ultimately recommended the team-based intervention described. RESULTS: A total of 1421 articles were identified in the initial query, of which 43 met inclusion criteria. Thirty-nine studies (91%) reported multidisciplinary care to be cost effective, with an average cost savings among all studies of $5815 per patient. No significant differences in the amount of savings achieved were found between different intervention subtypes. All studies ultimately recommended (40) or gave mixed reviews (3) of multidisciplinary care, regardless of whether cost savings were achieved. CONCLUSION: Multidisciplinary surgical care is beneficial not only in terms of patient and provider outcomes, but also in reference to its cost-effectiveness. Well-designed multidisciplinary teams tend to optimize perioperative care for all involved parties. Efforts to improve surgical care should employ multidisciplinary teams to promote both quality and cost-effective care.

Cost-effectiveness of surgical comanagement: A systematic review.

OBJECTIVE: To determine the impact of surgical comanagement programs on healthcare system costs. BACKGROUND: With increasing emphasis on multidisciplinary care, surgical comanagement programs are increasing in popularity. However, the overall cost-effectiveness of these programs has yet to be evaluated. METHODS: Pubmed, Scopus, and Cochrane were systematically searched for studies that reported on cost outcomes after implementation of a surgical comanagement program. Data points extracted included study design details, cost outcomes, complication rates, duration of hospital stay, hospital volume changes, patient satisfaction, mortality, and overall multidisciplinary care recommendation. RESULTS: A total of 8 studies were included. Five of the 8 studies reported cost savings, with an average savings of $4132 per patient. Three of the 8 studies reported increases in costs, with an average increase of $11,128 per patient. Seven of the 8 studies reported decreases in length-of-stay, with an average decrease of 1.29 days. CONCLUSIONS: Surgical comanagement programs have had mixed results on overall hospital costs, but cost saving interventions do not sacrifice the quality of patient care delivered.

Aesthetic Training in Plastic Surgery Residency.

Training in aesthetic surgery is a core element in a plastic surgery residency program. Nevertheless, in the past, many studies have shown the lack of resident confidence in aesthetic procedures upon graduation. In recent years, a number of efforts have been made to address this concern, including increasing the required residency aesthetic case requirements and the integration of resident aesthetic clinics to increase exposure and independence in this aspect of training. Numerous studies have been conducted to evaluate the efficacy of these resident-run clinics and have substantiated their value as an important educational tool in residency training and validated their safety in patient care. In fact, survey studies have shown that though residents today show a markedly increased confidence in their training when compared with the past, they still feel there is room for improvement in areas such as facial and minimally invasive surgeries, along with procedures that require higher patient volume to refine. In this article, we review the current state of aesthetic surgery training during plastic surgery residency and discuss future directions in the field.

Safety and Regulation of Fat Grafting.

Today, fat grafting has wide applicability across plastic surgery disciplines, including both aesthetic and reconstructive procedures. However, much controversy has surrounded adipose tissue transfer throughout the 20th century, necessitating extensive research to improve the fat grafting process and to better understand its associated complications and benefits. Initial concerns included the technical difficulties of properly handling and processing adipose to ensure adequate outcomes. As these issues were addressed, more modern concerns were raised by the U.S Food and Drug Administration and the general scientific community regarding the oncological potential of adipose tissue and its potential interference with breast cancer screenings. Today, many formalized clinical studies have evidenced the safety of fat grafting, allowing the procedure to gain widespread popularity and opening avenues for future applications.

Access to Multidisciplinary Care for Patients With 22q11.2 Deletion Syndrome: Identifying Breakdowns in the Screening Process.

The 22q11.2 deletion syndrome affects approximately 1 in 4000 live births and involves cardiac defects, immunodeficiency, and endocrine disruption. The complexity of diagnosis and multifaceted care often leads to fragmented management in the short and long term. With the purpose of developing an effective multidisciplinary program, the authors aimed to identify the deficiencies in current screening and referral processes among the teams required in the care for patients with 22q11.2 deletion syndrome. A retrospective chart review was conducted at our institution between 2001 and 2016. Patients with confirmed 22q11.2 deletion diagnoses between the ages of 0 and 28 were included. A list of 15 relevant specialties that should evaluate patients with 22q11.2 deletion syndrome was created according to established guidelines. Patient medical and demographic information were collected and analyzed. A total of 270 patients were included. Mean age at diagnosis was 3.3 years. On average, patients visited 6 of 15 departments (1-14). Only 8.8% of patients visited >10 specialties. The majority were seen by Cardiology, Allergy and Immunology, Genetics, and Speech (57.4-87.8%). A minority were seen by Hematology and Oncology, Sleep Therapy, and Physical Therapy (13.3-16.3%). Only 34.1% encountered plastic surgery. Negative correlation (-0.128; P = 0.035) was demonstrated between patients' age at diagnosis and number of specialty teams encountered. This study highlights the current underutilization of services required to manage patients with 22q11.2 deletion syndrome. While screening guidelines have been established, implementation can be challenging as it requires efficient care coordination between teams. Moving forward, the authors believe that a multidisciplinary clinical approach to streamline patient care is necessary.

Update in Direct-to-Implant Breast Reconstruction.

Implant-based reconstruction (IBR) remains the most commonly utilized breast reconstruction option for post-mastectomy patients. IBR can be approached as either a one-stage reconstruction or a two-stage reconstruction. Facilitated by improvements in surgical technology and advanced techniques, one-stage reconstruction, also known as direct-to-implant (DTI) reconstruction, involves the insertion of an implant at the time of mastectomy. The decision to pursue either a DTI or a two-stage reconstruction is based on several factors, including the patient's overall health, expected risk of postoperative complications, and associated costs to both the patient and hospital.