Use of FLIR ONE Smartphone Thermography in Burn Wound Assessment.

OBJECTIVE: Forward-looking infrared (FLIR) thermography technology uses a handheld camera that measures skin infrared emissivity, captures photographs, and can be analyzed through specialized software. Forward-looking infrared images can be used to analyze and correlate burn wound temperature with burn depth, burn progression, and the number of days needed for healing. FLIR ONE is a miniature, smartphone-compatible thermal imaging camera that has been used to assess inflammation in diabetic foot ulcers, as well as locating perforators in flap surgery. However, FLIR ONE's reliability in burn wound assessment has not been evaluated. This case series investigates the accuracy of FLIR ONE in comparison with the widely used indocyanine green (ICG) angiography in assessing burn wounds. METHODS: Five acute third-degree burn wounds were assessed using ICG angiography and FLIR ONE imaging (infrared thermography) to determine burn extent before surgical intervention. Patients were taken to the operating room within 48 hours of presentation; FLIR ONE images were captured approximately 35 to 45 cm above the wound surface. Margins of unsalvageable tissue as determined by ICG and FLIR ONE were marked and compared. RESULTS: The area of unsalvageable tissue as determined by FLIR ONE closely corresponded to the area determined by ICG. FLIR ONE overestimated unsalvageable tissue margins by approximately 1 to 2 cm. The area estimated by ICG consistently overlapped with more than 90% of the area estimated by FLIR ONE. CONCLUSIONS: There is a strong correlation between FLIR ONE and ICG when assessing salvageable tissue in third-degree burn wounds. FLIR ONE maximizes the convenience and cost-effectiveness of infrared thermography technology but may overestimate unsalvageable tissue area. FLIR ONE is promising as an adjunct to current imaging modalities such as ICG but requires further study for comparison.

Surgical Technique: Spinal Accessory to Infraspinatus Nerve Transfer in Brachial Plexus Birth Injury.

Nerve transfers, nerve grafts, and tendon transfers have been used to restore shoulder active external rotation in patients with brachial plexus birth injuries. Traditionally used nerve surgery techniques are nerve transfer from the spinal accessory nerve to a suprascapular nerve (SSN) or nerve grafting from C5 to the SSN. However, results are often suboptimal. A more distal and more targeted transfer from the spinal accessory nerve directly to the infraspinatus branch of the SSN has previously been described and mid-term outcomes are encouraging. Herein, we describe a modification of this technique with accompanying step-by-step intraoperative photographs.

Robotics in Microsurgery and Supermicrosurgery.

Microsurgery has changed the ability to perform highly precise and technical surgeries through the utilization of high-powered microscopes and specialized instruments to manipulate and repair anatomical structures as small as a few millimeters. Since the first human trials of robotic-assisted microsurgery in 2006, the expansion of microsurgery to supermicrosurgery (luminal diameter less than 1 mm) has enabled successful repair of previously inaccessible structures. Surgical robotic systems can offer two distinct operative advantages: (1) minimal access surgery-by entering body cavities through ports, flap harvest can be redesigned to affect a minimally invasive approach for flaps such as the rectus abdominis muscle, the latissimus flap, and the deep inferior epigastric perforator flap; and (2) precision-by eliminating physiologic tremor, improving ergonomics, increasing accessibility to difficult spaces, and providing motion scaling, precision is significantly enhanced. Robotic-assisted microsurgery is a promising application of robotics for the plastic surgeon and has played an important role in flap harvest, head and neck reconstruction, nerve reconstruction, gender-affirming surgery, and lymphatic reconstruction-all the while minimizing surgical morbidity. This article aims to review the history, technology, and application of microsurgery and supermicrosurgery in plastic surgery.

Vascularized Occipital Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives.

Successful arthrodesis at the craniocervical junction and atlantoaxial joint can be more challenging than in other segments of the cervical spine. Different techniques for spinal fixation in this region have been well described, along with auxiliary methods to improve fusion rates. The occipital vascularized bone graft is a novel technique that can be used to augment bony arthrodesis in the supra-axial cervical spine. It provides the benefits of a vascularized autologous graft, such as accelerated healing, earlier fusion, and increased strength. This technique can be learned with relative ease and may be particularly helpful in cases with high risk of nonunion or pseudoarthrosis in the upper cervical spine.

Fat Processing Techniques.

Autologous fat grafting is an aesthetic and reconstructive procedure in which an individual's own fat is harvested and injected into the soft tissues to correct contour and other abnormalities. Fat graft is considered the ideal soft tissue filler for its biocompatibility, lack of immunogenicity, and availability. The entire procedure of harvesting, processing, and transfer of fat graft affects fat graft take and effectiveness of fat grafting. This article will focus on the most common methods of fat graft processing, including centrifugation, cotton gauze rolling, sedimentation, and filtration/washing. The fragility of the harvested adipocytes makes the technique of fat graft processing of utmost importance, as blood and other unnecessary cellular fragments are removed. Each fat graft processing method has its own merits and shortcomings; however, due to a lack of well-defined prospective studies, there is no evidence to support one processing method as superior to another.

Treating Wounds With an Avascular Component With a Dermal Regenerative Template.

INTRODUCTION: Partially avascular wounds pose a challenge to wound care surgeons. OBJECTIVE: The authors reviewed the literature and institutional results on the use of a dermal regenerative template (DRT) over partially avascular wounds to quantify the ability of the DRT to vascularize over these wounds. MATERIALS AND METHODS: A review of the literature was performed using Ovid MEDLINE, Google Scholar, and Cochrane Library. Patient demographics, comorbidities, wound types, surface area of avascular tissues, and skin graft take were analyzed. A retrospective review of institutional cases was conducted. RESULTS: A total of 32 articles met inclusion criteria. The retrospective review included 26 patients with partially avascular wounds reconstructed with the DRT. Seventeen patients experienced 100% graft take, 6 experienced partial take, and 3 suffered complete loss. The percent and absolute size of avascular surface area in the wound was significantly lower in cases of complete graft take compared with partial take and complete loss (1.9% and 2.7 cm2; 9.3% and 10.0 cm2; 18.0% and 9.3 cm2, respectively, P ⟨ .001). Chronic wound status (P ⟨ .001) was significantly associated with less graft take. CONCLUSIONS: This literature review and retrospective study confirm the DRT is a viable option to provide vascularized coverage over wounds with avascular components. This study suggests the DRT is more reliable in wounds with less than 1.9% avascular tissues and less successful in chronic wounds.

Establishing a Telemedicine Program for Breast Reconstruction.

Telemedicine is an application of modern technology that allows for the remote delivery of healthcare services to diagnose and treat patients. The potential patient benefits of such a program include added convenience, lowered costs, and improved access. From a practical standpoint, establishing a telemedicine program may seem daunting to the plastic surgeon; success requires not only patient and provider adoption, but also integration of new technology. Despite these challenges, breast reconstruction patients are among those who stand to benefit most from telemedicine technology, as this patient population remains vulnerable to limitations to access following an emotion-provoking breast cancer diagnosis. Geographical limitation, especially in rural areas, represents a major barrier to access. To date, the application of telemedicine in caring for breast reconstruction patients has not been described in the literature. In this article, we describe the protocol developed and implemented by our academic plastic surgery group to care for new breast reconstruction candidates and discuss the role of telemedicine in improved access to breast reconstruction care.

Utility of local anesthesia for open carpal tunnel release in patients with psychiatric diagnoses.

PURPOSE: Carpal tunnel release, one of the most commonly performed procedures in Veterans Affairs (VA) medical centers, is often performed under local anesthesia alone. In this patient population, there is an increased prevalence of psychiatric disorders. Our hypothesis is that there is no difference in operating time, request for sedation, or complications in the veteran population with or without a recognized psychiatric history. METHODS: A retrospective cohort study was performed at a VA medical center from January 2013 to January 2017 by the senior surgeon (E.S.L). Patients were divided into two groups: patients with no known psychiatric history (n = =33) and patients with an active psychiatric diagnosis (n = =25), including post-traumatic stress disorder, anxiety disorder, bipolar disorder, depression, substance abuse, or panic disorder. Primary endpoints included operation time, time in operating room, request for sedation, and complication rates. RESULTS: Fifty-nine percent of patients successfully underwent wide-awake hand surgery, while 41% requested sedation. Patients with no known psychiatric history had a 45.5% rate of requesting sedation compared to 36% in those with a psychiatric diagnosis. No patients converted from wide-awake surgery to sedation. There was no statistically significant difference in operation time, time in the operating room, need for sedation, or complication rate between all groups. CONCLUSIONS: Wide-awake hand surgery is an excellent technique that can be safely used in patients with a history of psychiatric illness. Without the need for monitored anesthesia care, the cost for carpal tunnel releases done in military medical centers could decrease dramatically. TYPE OF STUDY: Prognostic. LEVEL OF EVIDENCE: Level II.

Certification and Accreditation in Plastic Surgery Subspecialty Training.

There are multiple subspecialties that residents can pursue after core plastic surgery training, including 5 major fellowship categories: aesthetic, burn, craniofacial, hand, and microsurgery. Hand surgery remains the only plastic surgery subspecialty to date, with a formal accreditation process following fellowship. The purpose of this study was to review the literature regarding the accreditation and match process of plastic surgery fellowship programs, the process of hand surgery certification, and future directions pertaining to certification in other plastic surgery subspecialties.

A Standardized Approach to Deep Inferior Epigastric Perforator Flap Marking.

The deep inferior epigastric perforator (DIEP) flap is the most commonly utilized flap in autologous breast reconstruction. This perforator-based free flap includes the lower abdominal wall adipocutaneous layers while sparing the abdominal musculature. Several studies have looked at preoperative planning for DIEP flap reconstruction using CT angiography; however, no study to date has proposed a standardized approach to DIEP flap markings. We propose a novel technique to standardize DIEP flap marking that leads to greater symmetry and consistency in the donor site.

Indocyanine Green Laser Angiography in the Setting of Tumescence.

Objective: Indocyanine green laser angiography utilizes fluorescent dye to assess tissue perfusion in real time. While various studies have recommended against the concurrent use of indocyanine green angiography with vasoconstrictors, few studies have described the intraoperative effect of tumescent wetting solutions on indocyanine green angiography and its subsequent impact on scan interpretation and clinical decision-making. Methods: A retrospective medical record review was performed for cases in which indocyanine green angiography was utilized to assess an area where epinephrine-based tumescent solution had been used. Results: The authors report 2 cases that utilized epinephrine-based tumescent solution along with intraoperative indocyanine green angiography assessment of the region. The first case was a bilateral reduction mammoplasty, whereas the second case was a nipple-sparing mastectomy with immediate tissue expander reconstruction. In both cases, intraoperative angiography predicted poor tissue perfusion while clinical examination showed good perfusion. Clinical examination was followed in both cases, with no additional tissue being removed. Neither case resulted in tissue necrosis despite angiography results. Conclusions: While indocyanine green angiography is a powerful tool in tissue perfusion assessment, there are some situations in which clinical examination must be used to determine tissue viability.

Breast Massage, Implant Displacement, and Prevention of Capsular Contracture After Breast Augmentation With Implants: A Review of the Literature.

Objective: Capsular contracture, the most common complication following breast augmentation with implants, is a complex inflammatory reaction that ultimately leads to fibrosis at the contact site between the implant and tissue. A number of peri-, pre-, and postoperative techniques have been postulated and implemented by many surgeons to reduce the incidence of capsular contracture. Breast massage and implant displacement technique is a commonly recommended practice that has not been well studied in regard to capsular contracture prevention. The authors present a review of the literature addressing methods and efficacy of massage and implant displacement techniques after breast augmentation. Methods: A literature review was performed using PubMed and the Cochrane Collaboration Library for primary research articles on breast massage or implant displacement after breast augmentation with implants for breast contracture prevention between January 1975 and March 2017. Exclusion criteria were studies that were focused on the treatment rather than prevention of breast contracture, addressed other strategies of preventing contracture as the main focus, or did not report the number of patients studied. Information related to massage technique and capsular contracture outcomes was extracted. Results: The literature search yielded 4 relevant studies, with a total of 587 patients. Outcomes evaluated included massage technique, onset of massage, frequency of massage, and incidence of capsular contracture. Breast massage was introduced between 2 days and 2 weeks postoperatively, performed twice daily, and lasted from 2 to 5 minutes for each breast. Final postoperative follow-up concluded between 6 and 36 months. The average capsular contracture rate was similar, 31% (range, 0-35) in the massage group versus 40% (range, 30-90) in the nonmassage group. Conclusions: While multiple techniques have been proposed and practiced in the prevention of capsular contracture, breast massage and implant displacement techniques remain controversial. While there is a method to measure adequacy of breast massage pressure, it is not widely utilized. The available data do not support breast massage to prevent capsular contracture; more studies with standardized techniques are needed to better assess the efficacy of breast massage in preventing capsular contracture.