Abdominal donor-site complications following autologous breast reconstruction: A multi-institutional multisurgeon study.

BACKGROUND: The deep inferior epigastric perforator (DIEP) free flap is the gold standard procedure for autologous breast reconstruction. Although breast-related complications have been well described, donor-site complications and contributing patient risk factors are poorly understood. METHODS: We examined a multi-institutional, prospectively maintained database of patients undergoing DIEP free flap breast reconstruction between 2015 and 2020. We evaluated patient demographics, operative details, and abdominal donor-site complications. Logistic regression modeling was used to predict donor-site outcomes based on patient characteristics. RESULTS: A total of 661 patients were identified who underwent DIEP free flap breast reconstruction across multiple institutions. Using logistic regression modeling, we found that body mass index (BMI) was an independent risk factor for umbilical complications (odds ratio [OR] 1.11, confidence interval [CI] 1.04-1.18, p = 0.001), seroma (OR 1.07, CI 1.01-1.13, p = 0.003), wound dehiscence (OR 1.10, CI 1.06-1.15, p = 0.001), and surgical site infection (OR 1.10, CI 1.05-1.15, p = 0.001) following DIEP free flap breast reconstruction. Further, immediate reconstruction decreases the risk of abdominal bulge formation (OR 0.22, CI 0.108-0.429, p = 0.001). Perforator selection was not associated with abdominal morbidity in our study population. CONCLUSIONS: Higher BMI is associated with increased abdominal donor-site complications following DIEP free flap breast reconstruction. Efforts to lower preoperative BMI may help decrease donor-site complications.

Venous Thromboembolism after Deep Inferior Epigastric Perforator Flap Breast Reconstruction: Review of Outcomes After a Postoperative Prophylaxis Protocol.

BACKGROUND: Deep inferior epigastric perforator (DIEP) flap breast reconstruction is among the higher-risk patient groups for venous thromboembolism (VTE) in plastic surgery. Surgeons often opt for a patient-specific approach to postoperative anticoagulation, and the field has yet to come to a consensus on VTE chemoprophylaxis regimens. METHODS: A new chemoprophylaxis protocol was introduced starting March 2019 that involved two weeks of treatment with enoxaparin, regardless of patient risk factors. A retrospective chart review was conducted on all patients who underwent DIEP flap breast reconstruction at our institution between January 2014 and March 2020. Patients were grouped based on whether they enrolled in the new VTE protocol in the postoperative period or not. Patient demographics, prophylaxis type, and outcomes data were recorded, retrospectively. The primary outcome measure was postoperative VTE incidence. RESULTS: Risk of VTE was significantly higher in patients discharged without VTE prophylaxis compared to patients discharged with prophylaxis (3.7% vs. 0%, p = 0.03). Notably, zero patients in the VTE prophylaxis group developed a DVT or PE. Additionally, the risk of a VTE event was 25 times greater in patients with a Caprini score greater than or equal to 6 (p=0.0002). CONCLUSIONS: We demonstrate the successful implementation of a two-week VTE chemoprophylaxis protocol in DIEP flap breast reconstruction patients that significantly reduces the rate of VTE while not affecting the rate of hematoma complications.

Breast Reconstruction Trends in the Setting of Postmastectomy Radiation Therapy: Analysis of Practices among Plastic Surgeons in the United States.

Radiation is an integral part of breast cancer therapy. The ideal type and timing of breast reconstruction with relation to radiation delivery are not well established. The study aimed to identify reconstructive practices among American plastic surgeons in the setting of pre- and postmastectomy radiation. Methods: A cross-sectional survey of members of the American Society of Plastic Surgery was performed. Practice/demographic information and breast reconstruction protocols were queried. Univariate descriptive statistics were calculated, and outcomes were compared across cohorts with χ2 and Fischer exact tests. Results: Overall, 477 plastic surgeons averaging 16.3 years in practice were surveyed. With respect to types of reconstruction, all options were well represented, although nearly 60% preferred autologous reconstruction with prior radiation and 55% preferred tissue expansion followed by implant/autologous reconstruction in the setting of unknown postoperative radiation. There was little consensus on the optimal timing of reconstruction in the setting of possible postoperative radiation. Most respondents wait 4-6 or 7-12 months between the end of radiation and stage 2 implant-based or autologous reconstruction. Common concerns regarding the effect of radiation on reconstructive outcomes included mastectomy flap necrosis, wound dehiscence, capsular contracture, tissue fibrosis, and donor vessel complications. Conclusions: Despite considerable research, there is little consensus on the ideal type and timing of reconstruction in the setting of pre- and postoperative radiation. Understanding how the current body of knowledge is translated into clinical practice by different populations of surgeons allows us to forge a path forward toward more robust, evidence-based guidelines for patient care.

Multidisciplinary Treatment of Persistent Nontuberculous Mycobacterial Spinal Hardware Infection with a Pedicled Superior Gluteal Artery Perforator Flap.

Nontuberculous mycobacterial hardware infections are extremely challenging to treat. Multidisciplinary care involving removal of infected hardware, thorough debridement, and durable soft tissue coverage in conjunction with antibiotic therapy is essential for successful management. This case report presents a patient with chronic mycobacterial spinal hardware infection that underwent successful treatment with aggressive serial debridements and reconstruction with a large pedicled superior gluteal artery perforator flap coverage.

Clinical outcomes of intraoperative dopamine infusion for hypotensive patients during breast reconstruction with deep inferior epigastric perforator (DIEP) flaps.

BACKGROUND: Dopamine has a favorable therapeutic profile but has not been widely used to treat hypotension during microvascular breast reconstruction. The purpose of this study was to evaluate outcomes in patients who received dopamine during breast reconstruction using deep inferior epigastric perforator (DIEP) free flaps and compare them with patients who did not receive dopamine. METHODS: A single-center retrospective review was performed for patients who underwent breast reconstruction with DIEP free flaps between October 2018 and March 2020. Patient demographics, comorbidities, fluid balance, hospital stay, and adverse outcomes were compared between patients who received at least 1 h of dopamine (DA) and patients who did not receive dopamine (ND). Subgroup analyses were performed for bilateral procedures and patients who received dopamine. RESULTS: Twenty-five patients in the DA group and 43 patients in the ND group met the inclusion criteria. There were no flap-related complications. Patients who had dopamine initiated to maintain blood pressures had a higher total volume of intravenous fluid (ND:3.81L vs. DA:5.04L, p = 0.005). However, DA patients exhibited decreased fluid requirements (ND:839 mL/h vs. DA:479 mL/h, p = 0.004) and increased urine output (ND:98.0 mL/h vs. DA:340 mL/h, p = <0.001) once dopamine was initiated. Intraoperative urine output (ND:1.37 L vs. DA:3.48 L, p < 0.001) and rate (ND:1.9 ml/kg/h vs. DA:3.7 ml/kg/h, p < 0.001) were increased in the DA group. The fluid balance of patients undergoing bilateral procedures was closer to neutral for patients who received dopamine (ND:+3.43 L vs. DA:+2.26 L, p = 0.03). CONCLUSION: Dopamine is safe to use in microvascular breast reconstruction. It may be beneficial for hemodynamically labile patients by stabilizing blood pressure and facilitating a neutral fluid balance.

Importance of Incidental Findings in Preoperative Computed Tomography Angiography for Abdominally Based Free Flap Breast Reconstruction: A Multi-Institutional Study.

BACKGROUND: In addition to its intended purpose of perforator mapping, computed tomography angiography can also identify incidental findings that may require further evaluation. In this multi-institutional study, the authors evaluated the frequency of incidental findings and their significance and effects on treatment course and aimed to identify risk factors for detecting such findings. METHODS: A retrospective review of patients who underwent perforator mapping with computed tomography angiography was performed over a 5-year period from three academic institutions. Relevant sociodemographic and clinicopathologic information, computed tomography angiography reports, follow-up visits, and treatment outcomes were reviewed. Univariate and multivariate analyses were performed to assess the relationship between risk factors and incidental findings. RESULTS: From January of 2015 to July of 2020, a total of 656 patients were identified who met inclusion criteria. Overall, 342 incidental findings were found, 76 of which required additional imaging or consultation. Ultimately, 10 patients (1.5 percent) had findings that altered reconstructive management, including five patients (0.8 percent) having severe disease that resulted in the cancellation of their reconstruction. Advanced age and immediate reconstruction timing were independent risk factors for incidental findings. CONCLUSIONS: Incidental findings are commonly identified on preoperative computed tomography angiography for deep inferior epigastric perforator flap breast reconstruction. Suspicious findings should be investigated thoroughly because they can alter the reconstructive course. Understanding of high-risk groups for incidental findings can further advance patient education during initial consultation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Impact of Dermal Matrix Brand in Implant-Based Breast Reconstruction Outcomes.

BACKGROUND: Implant-based reconstruction is the most common procedure for breast reconstruction after mastectomy. Acellular dermal matrix is used to provide additional coverage in subpectoral and prepectoral implant placement. In this study, the authors compared postoperative outcomes between AlloDerm (LifeCell, Branchburg, N.J.) and DermACELL (Stryker, Kalamazoo, Mich.), two acellular dermal matrix brands. METHODS: A retrospective review of implant-based breast reconstruction from 2016 to 2020 was conducted. Patient demographics and comorbidities, implant size and location, acellular dermal matrix choice, and postoperative outcomes were recorded. Primary outcomes assessed were seroma and infection compared between two acellular dermal matrix brands. Independent clinical parameters were assessed with multiple logistic regression models for the primary outcomes. RESULTS: Reconstruction was performed in 150 patients (241 breasts). Eighty-eight patients underwent expander placement with AlloDerm and 62 patients with DermACELL. There were no significant differences in patient characteristics between the two groups. There was a significantly higher incidence of seroma in the AlloDerm group in univariate (AlloDerm 21.7 percent versus DermACELL 8.2 percent, p < 0.005) and multivariate analyses ( p = 0.04; 95 percent CI, 1.02 to 6.07). Acellular dermal matrix use (regardless of type) was not associated with higher rates of infection ( p = 0.99), but body mass index was ( p = 0.004). CONCLUSIONS: Both AlloDerm and DermACELL had similar infection rates regardless of contributing risk factors. AlloDerm was found to be a risk factor for seroma formation in the postoperative period. As such, it is important to be aware of this complication when performing implant-based reconstruction with this brand of acellular dermal matrix. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Invasive brain tissue oxygen and intracranial pressure (ICP) monitoring versus ICP-only monitoring in pediatric severe traumatic brain injury.

OBJECTIVE: Severe traumatic brain injury (TBI) is a leading cause of disability and death in the pediatric population. While intracranial pressure (ICP) monitoring is the gold standard in acute neurocritical care following pediatric severe TBI, brain tissue oxygen tension (PbtO2) monitoring may also help limit secondary brain injury and improve outcomes. The authors hypothesized that pediatric patients with severe TBI and ICP + PbtO2 monitoring and treatment would have better outcomes than those who underwent ICP-only monitoring and treatment. METHODS: Patients ≤ 18 years of age with severe TBI who received ICP ± PbtO2 monitoring at a quaternary children's hospital between 1998 and 2021 were retrospectively reviewed. The relationships between conventional measurements of TBI were evaluated, i.e., ICP, cerebral perfusion pressure (CPP), and PbtO2. Differences were analyzed between patients with ICP + PbtO2 versus ICP-only monitoring on hospital and pediatric intensive care unit (PICU) length of stay (LOS), length of intubation, Pediatric Intensity Level of Therapy scale score, and functional outcome using the Glasgow Outcome Score-Extended (GOS-E) scale at 6 months postinjury. RESULTS: Forty-nine patients, including 19 with ICP + PbtO2 and 30 with ICP only, were analyzed. There was a weak negative association between ICP and PbtO2 (ß = -0.04). Conversely, there was a strong positive correlation between CPP ≥ 40 mm Hg and PbtO2 ≥ 15 and ≥ 20 mm Hg (ß = 0.30 and ß = 0.29, p < 0.001, respectively). An increased number of events of cerebral PbtO2 < 15 mm Hg or < 20 mm Hg were associated with longer hospital (p = 0.01 and p = 0.022, respectively) and PICU (p = 0.015 and p = 0.007, respectively) LOS, increased duration of mechanical ventilation (p = 0.015 when PbtO2 < 15 mm Hg), and an unfavorable 6-month GOS-E score (p = 0.045 and p = 0.022, respectively). An increased number of intracranial hypertension episodes (ICP ≥ 20 mm Hg) were associated with longer hospital (p = 0.007) and PICU (p < 0.001) LOS and longer duration of mechanical ventilation (p < 0.001). Lower minimum hourly and average daily ICP values predicted favorable GOS-E scores (p < 0.001 for both). Patients with ICP + PbtO2 monitoring experienced longer PICU LOS (p = 0.018) compared to patients with ICP-only monitoring, with no significant GOS-E score difference between groups (p = 0.733). CONCLUSIONS: An increased number of cerebral hypoxic episodes and an increased number of intracranial hypertension episodes resulted in longer hospital LOS and longer duration of mechanical ventilator support. An increased number of cerebral hypoxic episodes also correlated with less favorable functional outcomes. In contrast, lower minimum hourly and average daily ICP values, but not the number of intracranial hypertension episodes, were associated with more favorable functional outcomes. There was a weak correlation between ICP and PbtO2, supporting the importance of multimodal invasive neuromonitoring in pediatric severe TBI.

Midline epigastric scars can be associated with higher umbilical complications following DIEP flap harvest.

BACKGROUND: Umbilical complications can be relatively common after breast reconstruction with deep inferior epigastric perforator (DIEP) flaps. The medial umbilical ligaments and the ligamentum teres hepatis can be the sole blood supply to the umbilicus after a DIEP flap harvest. Prior incisions along the epigastric midline may disrupt the ligamentum teres hepatis. In this retrospective study, we assess the influence of previous midline epigastric scars on umbilical complications after DIEP flap harvest. METHODS: All patients who underwent breast reconstruction with DIEP flaps were identified at an academic institution over six years. Relevant sociodemographic and clinicopathologic factors were reviewed in the electronic medical records. Univariate and multivariate analyses were performed to determine the role of clinical variables to predict the chance of umbilical complications. RESULTS: A total of 243 patients met inclusion criteria, with 39 patients (16%) having prior surgery utilizing midline epigastric incisions. Twenty-one patients had umbilical complications. No significant difference in patient characteristics was found between patients with and without prior midline epigastric scars. Patients with a history of previous midline epigastric scars had a higher rate of umbilical complications (20.5% vs. 6.4%, p < 0.01). Bilateral medial row perforator-based DIEP flap harvest was also related to a higher rate of umbilical complications (18.4% vs. 6.2% p < 0.01). CONCLUSION: Previous midline epigastric scars are associated with higher rates of umbilical complications after DIEP flap harvest. Bilateral medial row perforator-based DIEP flap harvest exacerbates the rate of umbilical complications and should be avoided in patients with prior midline epigastric incision whenever possible.

CT angiography prior to DIEP flap breast reconstruction: a randomized controlled trial.

BACKGROUND: CT angiogram (CTA) has become the preferred method for the planning of abdominal-based microsurgical breast reconstruction to gather information about location, number, caliber and trajectory of the abdominal perforators and to decrease overall flap dissection and operating room time. However, the high-level evidence to support its utility has been limited to nonrandomized retrospective and prospective studies. METHODS: Patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction were prospectively randomized to preoperative CTA and no imaging groups. Patient demographics, operative times, selected row and number of perforators for flap harvest, agreement in perforator selection between radiologist and surgeon, and clinical outcomes data were collected. Two-way ANOVA, Fisher's exact and Student's t-tests were used for statistical analysis. RESULTS: Overall, 37 patients with 63 flaps were included in this study. Seventeen patients had CT scan prior to surgery. Mean age was 50.5 ± 9.6 years. Flap dissection time was significantly shorter in the CT group (150.8 ± 17.8 vs 184.7 ± 25.1 min and p< 0.001). Although overall odds ratio (OR) time was also shorter in the CT group, this only reached a statistical significance in bilateral surgeries (575.9 ± 70.1 vs 641.9 ± 79.6 min and p = 0.038). Hemiabdomen side, selected DIEP row, and the number of dissected perforators did not affect the overall dissection time. Complication rates were similar between the two groups. CONCLUSION: This prospective, randomized study demonstrates that preoperative CTA analysis of perforators decreases flap harvest and overall OR time with equivalent postoperative outcomes.

Transcriptional Changes in the Developing Rice Seeds Under Salt Stress Suggest Targets for Manipulating Seed Quality.

Global sea-level rise, the effect of climate change, poses a serious threat to rice production owing to saltwater intrusion and the accompanying increase in salt concentration. The reclaimed lands, comprising 22.1% of rice production in Korea, now face the crisis of global sea-level rise and a continuous increase in salt concentration. Here, we investigated the relationship between the decrease in seed quality and the transcriptional changes that occur in the developing rice seeds under salt stress. Compared to cultivation on normal land, the japonica rice cultivar, Samgwang, grown on reclaimed land showed a greatly increased accumulation of minerals, including sodium, magnesium, potassium, and sulfur, in seeds and a reduced yield, delayed heading, decreased thousand grain weight, and decreased palatability and amylose content. Samgwang showed phenotypical sensitivity to salt stress in the developing seeds. Using RNA-seq technology, we therefore carried out a comparative transcriptome analysis of the developing seeds grown on reclaimed and normal lands. In the biological process category, gene ontology enrichment analysis revealed that the upregulated genes were closely associated with the metabolism of biomolecules, including amino acids, carboxylic acid, lignin, trehalose, polysaccharide, and chitin, and to stress responses. MapMan analysis revealed the involvement of upregulated genes in the biosynthetic pathways of abscisic acid and melatonin and the relationship of trehalose, raffinose, and maltose with osmotic stress. Interestingly, many seed storage protein genes encoding glutelins and prolamins were upregulated in the developing seeds under salt stress, indicating the negative effect of the increase of storage proteins on palatability. Transcription factors upregulated in the developing seeds under salt stress included, in particular, bHLH, MYB, zinc finger, and heat shock factor, which could act as potential targets for the manipulation of seed quality under salt stress. Our study aims to develop a useful reference for elucidating the relationship between seed response mechanisms and decreased seed quality under salt stress, providing potential strategies for the improvement of seed quality under salt stress.

Trajectory of Long-Term Outcome in Severe Pediatric Diffuse Axonal Injury: An Exploratory Study.

Introduction: Pediatric severe traumatic brain injury (TBI) is one of the leading causes of disability and death. One of the classic pathoanatomic brain injury lesions following severe pediatric TBI is diffuse (multifocal) axonal injury (DAI). In this single institution study, our overarching goal was to describe the clinical characteristics and long-term outcome trajectory of severe pediatric TBI patients with DAI. Methods: Pediatric patients (<18 years of age) with severe TBI who had DAI were retrospectively reviewed. We evaluated the effect of age, sex, Glasgow Coma Scale (GCS) score, early fever ≥ 38.5°C during the first day post-injury, the extent of ICP-directed therapy needed with the Pediatric Intensity Level of Therapy (PILOT) score, and MRI within the first week following trauma and analyzed their association with outcome using the Glasgow Outcome Score-Extended (GOS-E) scale at discharge, 6 months, 1, 5, and 10 years following injury. Results: Fifty-six pediatric patients with severe traumatic DAI were analyzed. The majority of the patients were >5 years of age and male. There were 2 mortalities. At discharge, 56% (30/54) of the surviving patients had unfavorable outcome. Sixty five percent (35/54) of surviving children were followed up to 10 years post-injury, and 71% (25/35) of them made a favorable recovery. Early fever and extensive DAI on MRI were associated with worse long-term outcomes. Conclusion: We describe the long-term trajectory outcome of severe pediatric TBI patients with pure DAI. While this was a single institution study with a small sample size, the majority of the children survived. Over one-third of our surviving children were lost to follow-up. Of the surviving children who had follow-up for 10 years after injury, the majority of these children made a favorable recovery.

The Influence of Closing the Abdominal Donor-Site Superficial Fascial System in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: The superficial fascial system is routinely closed to alleviate tension at the abdominal donor site after harvest of the deep inferior epigastric artery perforator flap (DIEP) for breast reconstruction. This is thought to decrease rates of wound dehiscence and improve contour postoperatively. There has been no comparative analysis on closure of the superficial fascial system and its effect on donor-site outcomes. METHODS: The authors retrospectively evaluated outcomes of DIEP flap breast reconstructions performed between 2017 and 2019. After May of 2018, the surgeons collectively agreed to stop closure of the superficial fascial system. All subsequent patients underwent closure of rectus abdominis fascia followed by skin closure. Patient demographic data and abdominal donor-site comorbidities were recorded between the superficial fascial system closure and no-superficial fascial system closure groups. Representative photographs of patients from the two groups were blindly assessed for scar appearance and contour using previously published grading scales. The results were compared. RESULTS: DIEP flap breast reconstruction was performed in 103 consecutive women. Among patients with abdominal donor-site reconstruction, 66 had superficial fascial system closure and 37 did not. There was not a significant difference in fat necrosis or wound dehiscence between the two groups (p = 0.29 and p = 0.39, respectively). Postoperative abdominal scar and contour were evaluated by 10 independent raters and showed no significant difference between the two groups. CONCLUSION: Omission of superficial fascial system closure resulted in no difference in wound dehiscence or fat necrosis rates and aesthetic appearance of the abdominal scar and contour. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Management of refractory Mycobacterium abscessus sternal infection following reoperative cardiac surgery.

Mycobacterium abscessus surgical site infections are rare, but notoriously difficult to treat. Eradication requires aggressive surgical resection, removal of foreign material, prolonged antibiotics, and consideration of delayed reconstruction.

Scoping Review of Therapeutic Strategies for Keloids and Hypertrophic Scars.

BACKGROUND: Keloids are an abnormal proliferation of scars that can involve large areas of tissue beyond the original injury site. Hypertrophic scars are similar clinically, but do not exceed the original scar limits. These scarring abnormalities can cause noxious symptoms such as pain, tenderness, itching, and ulcerations. The aim of this review is to discuss current therapies for both types of abnormal scarring, and to determine if guidelines can be provided for excisional treatment with adjuvant therapies versus non-excisional methods. METHODS: A systematic literature search was performed through the Web of Science database. The search revolved around keywords such as "keloid," "hypertrophic scars," and "treatment." Articles were reviewed and screened for inclusion and exclusion criteria. The review focuses on an analysis and summarization of randomized control trials regarding keloid or hypertrophic scar treatments. RESULTS: The original searches produced 1161 and 1275 articles for keloid and hypertrophic scars, respectively. In total, 316 duplicates were found. After accounting for 2014-2019 publication time, 655 keloid and 893 hypertrophic scar articles were reviewed. This resulted in 15 articles that pertained to treatment and randomized control trials. CONCLUSIONS: Keloids and hypertrophic scars present a clinical challenge. Based on qualitative review of recurrence, neither excision plus adjuvant therapy or nonsurgical treatments can be recommended preferentially at this time. More research is needed to determine if recurrence rate bias exists between the treatment regimens, as excisional treatment plus adjuvant therapy is reserved for refractory scars.

Telehealth: Could It Be an Avenue to Microvascular Breast Reconstruction for Patients with Geographical Barriers?

BACKGROUND: All women undergoing a mastectomy have the right to reconstruction. However, many women do not receive reconstruction and many more are not aware of all the reconstructive options available to them. Travel distance to a center that provides reconstruction and subsequent follow-up may be a contributing factor to this disparity especially among those who seek microsurgical options. Telehealth, which provides patients with remote video consultations and decreases the travel burden, may be a solution to optimize the accessibility of breast reconstruction for these patients. The purpose of this study was to discuss the efficacy and reliability of telehealth to overcome geographic barriers. METHODS: Patients who received breast reconstruction and participated in video telehealth visits between February and May 2020 were included in this study. Patient demographics, comorbidities, and clinical outcomes were collected. Video telehealth encounters were reviewed to determine specific concerns and questions discussed during these encounters. RESULTS: A total of 235 breast reconstruction surgery patient encounters were recorded for 4 plastic surgeons who offer microsurgical breast reconstruction. Eighty-eight patients (37.4%) were seen as telehealth visits, 20 (22.7%) of which were new patient visits. Eight (9.09%) patients were microsurgical breast reconstruction candidates and 25 (28.4%) were following-up after microsurgical breast reconstruction. The majority of telehealth visits included normally healing wounds in the postoperative patient. CONCLUSION: Telehealth provides an avenue for premastectomy consultation, second opinion visits, and postoperative follow-up for patients who have geographical barriers precluding them from reaching plastic surgeons who perform all types of breast reconstruction.

Head of bed elevation in pediatric patients with severe traumatic brain injury.

OBJECTIVE: Head of bed (HOB) elevation to 30° after severe traumatic brain injury (TBI) has become standard positioning across all age groups. This maneuver is thought to minimize the risk of elevated ICP in the hopes of decreasing cerebral blood and fluid volume and increasing cerebral venous outflow with improvement in jugular venous drainage. However, HOB elevation is based on adult population data due to a current paucity of pediatric TBI studies regarding HOB management. In this prospective study of pediatric patients with severe TBI, the authors investigated the role of different head positions on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebral venous outflow through the internal jugular veins (IJVs) on postinjury days 2 and 3 because these time periods are considered the peak risk for intracranial hypertension. METHODS: Patients younger than 18 years with a Glasgow Coma Scale score ≤ 8 after severe TBI were prospectively recruited at a single quaternary pediatric intensive care unit. All patients had an ICP monitor placed, and no other neurosurgical procedure was performed. On the 2nd and 3rd days postinjury, the degree of HOB elevation was varied between 0° (head-flat or horizontal), 10°, 20°, 30°, 40°, and 50° while ICP, CPP, and bilateral IJV blood flows were recorded. RESULTS: Eighteen pediatric patients with severe TBI were analyzed. On each postinjury day, 13 of the 18 patients had at least 1 optimal HOB position (the position that simultaneously demonstrated the lowest ICP and the highest CPP). Six patients on each postinjury day had 30° as the optimal HOB position, with only 2 being the same patient on both postinjury days. On postinjury day 2, 3 patients had more than 1 optimal HOB position, while 5 patients did not have an optimal position. On postinjury day 3, 2 patients had more than 1 optimal HOB position while 5 patients did not have an optimal position. Interestingly, 0° (head-flat or horizontal) was the optimal HOB position in 2 patients on postinjury day 2 and 3 patients on postinjury day 3. The optimal HOB position demonstrated lower right IJV blood flow than a nonoptimal position on both postinjury days 2 (p = 0.0023) and 3 (p = 0.0033). There was no significant difference between optimal and nonoptimal HOB positions in the left IJV blood flow. CONCLUSIONS: In pediatric patients with severe TBI, the authors demonstrated that the optimal HOB position (which decreases ICP and improves CPP) is not always at 30°. Instead, the optimal HOB should be individualized for each pediatric TBI patient on a daily basis.

Indocyanine Green Angiography in Breast Reconstruction: Utility, Limitations, and Search for Standardization.

During reconstructive breast surgery, intraoperative assessment of tissue perfusion has been solely based on subjective clinical judgment. However, in the last decade, intraoperative indocyanine green angiography (ICGA) has become an influential tool to visualize blood flow to the tissue of interest. This angiography technique produces real-time blood flow information to provide an objective assessment of tissue perfusion. METHODS: A comprehensive literature search of articles pertaining to ICGA in breast reconstruction surgery was performed. The overall findings of the articles are outlined here by surgical procedure: skin-sparing and nipple-sparing mastectomy, implant-based reconstruction, and autologous reconstruction. RESULTS: Overall, there were 133 articles reviewed, describing the use of ICGA in breast reconstruction surgery. We found that ICGA can provide valuable information that aids in flap design, anastomotic success, and perfusion assessment. We also included example photographs and videos of ICGA use at our institution. CONCLUSIONS: ICGA can reduce postoperative tissue loss and aid in intraoperative flap design and inset. Despite the benefits of ICGA, its technical use and interpretation have yet to be standardized, limiting its widespread acceptance.

Changes to Venous Flow Coupler Signal during DIEP Flap Inset Can Be Predictive of Poor Clinical Outcomes in Autologous Breast Reconstruction.

BACKGROUND: Venous flow couplers are typically used to monitor free flaps during the postoperative period, with a continuous venous signal available immediately after completion of the anastomosis. Intraoperative loss of the coupler signal is not uncommon and may require adjustments in free flap inset and even flap thickness to get the venous signal to return. The effects of intraoperative coupler signal loss and the role of this technology on flap outcomes have not been evaluated. We hypothesized that the use of intraoperative coupler can be protective of both early and late flap complications by preventing unfavorable flap insets. PATIENTS AND METHODS: All patients who underwent free flap breast reconstruction between January 2018 and June 2019 by single microsurgery team were included. Flap inset and inset changes based on flow coupler signal problems were reviewed in the procedure notes. Patient demographics data and clinical outcomes were analyzed with comprehensive chart review. RESULTS: Forty-four consecutive patients with 69 free flaps were identified. There were no significant differences in patient characteristics or venous coupler size used in venous anastomosis. Although the number of operating room take backs for venous insufficiency was not significantly different between two groups, the free flaps with inset change had significantly higher complications that required later surgical intervention (p = 0.0464). CONCLUSION: Surgeons should be aware that intraoperative coupler signal loss can be associated with poor clinical outcomes postoperatively and these flaps may require more perfusion imaging, flap debulking, or even additional venous anastomosis.

Patient Safety in Microvascular Plastic Surgery.

Patient safety is defined as freedom from accidental or preventable harm produced by medical care. The identification of patient- and procedure-related risk factors enables the surgical team to carry out prophylactic measures to reduce the rate of complications and adverse events.The purpose of this review is to identify the characteristics of patients, practitioners, and microvascular surgical procedures that place patients at risk for preventable harm, and to discuss evidence-based prevention practices that can potentially help to generate a culture of patient safety.