Reconstruction of oncologic upper extremity defects with fibula free flaps has high union rates and excellent functional outcomes.

BACKGROUND: Limb salvage has better functional outcomes than amputation in the upper extremity. This can however be challenging after bony tumor resections. METHODS: This is a retrospective case series of patients who underwent humerus, ulna, or radius reconstruction with a fibula free flap. Data were collected on demographics, oncologic history, surgical details, and complications. Functional outcome measures included the patient's ability to perform activities of daily living (ADL), presence of pain, and musculoskeletal tumor society (MSTS) score. RESULTS: Over a 25-year period, 38 reconstructions were performed. The flap success rate was 97.5%. Bony union was obtained in 19 of 19 (100%) forearm reconstructions and in 15 of 19 (79%) humerus reconstructions (p = 0.10). All 19 forearm reconstruction patients and 18/19 humerus reconstruction patients were able to perform ADLs with no pain or only occasional pain. The MSTS scores were not significantly different between the humerus and forearm cohorts (27.1 vs. 27.3, p = 0.68). Functional outcomes were significantly better in limbs that achieved union (p < 0.001). Recipient and donor site complications occurred in 10 (26.3%) and 5 (13%) patients, respectively. CONCLUSIONS: Oncologic upper-extremity reconstruction with fibula free flaps has excellent functional outcomes. Bone union is a predictor of superior limb function.

The Standardized Inclusive Numeric Academic Index: An Index to Measure Academic Productivity in Plastic Surgery.

PURPOSE: Academic productivity is a poorly defined metric that is commonly used to determine faculty career advancement. While various indices incorporate scholarly activity, no specific index assimilates the perceived importance of a variety of academic accomplishments a physician may make. Herein, the development and validation of an algorithm to generate an academic productivity score based on surveying physicians nationwide are described. METHODS: From 2016 to 2018, an online cross-sectional survey was distributed to faculty members at an academic institution and plastic surgeons from different academic levels nationwide. Respondents were presented with randomized, binary comparisons of 42 different achievements of an academic physician and asked to choose the more important achievement. Descriptive statistics of demographics and "win rates" of each achievement were reported and an algorithm for academic productivity scoring was designed. To validate the proposed index, 30 curricula vitae of academic surgeons were anonymized and ranked in order of increasing academic achievement by 6 volunteers. Interrater reliability was assessed by Krippendorff α (α ≥ 0.800). RESULTS: Survey respondents completed an average of 116 (SD, 97.6) comparisons each, generating a total of 14,736 ranked comparisons. Of the 42 variables, the highest win rates were attained by being the dean of a medical school (0.90) and editor of a medical journal (0.88). The lowest win rates were attained by industry spokesperson (0.1) and members of the local medical society (0.1). Initial validity evidence found the interrater reliability for the 6 rankers to have a Krippendorff α value of 0.843. The interrater reliability between the average rater ranking and the algorithm-generated ranking had a Krippendorff α value of 0.925. CONCLUSIONS: The present study demonstrates that the standardized inclusive numeric academic index may be used as a valid, comprehensive measure of academic productivity. Future studies should assess its application across different medical specialties.

Plastic Surgery Training and the Problematic Resident: A Survey of Plastic Surgery Program Directors.

INTRODUCTION: Plastic surgery resident education is a significant commitment by both programs and residents. Unfortunately, problematic resident behavior may occur and be difficult to manage. This study was designed to survey plastic surgery program directors to elucidate their experience with problematic resident behavior. METHODS: A electronic survey was prepared using the online platform, qualtrics. The survey was distributed by email to all plastic surgery program directors. Questions were designed to evaluate frequency of problematic behavior and methods to manage the behaviors. A reminder was sent 3 weeks after initial distribution. Responses were collected for an additional 3 weeks. Responses were pooled separately for integrated and independent program directors. RESULTS: Thirty-eight program directors responded including 10 independent and 28 integrated program directors. Integrated and independent program directors estimated prevalence of problematic behavior at 17.5 ± 14.4% and 11.8 ± 7.9%, respectively. Poor clinical skills/judgment and unprofessional behavior were the most commonly reported problematic behaviors by integrated program directors at 21% each. These were also the most commonly reported behaviors by independent program directors at 20.8% and 16.7%, respectively. Fourteen integrated program directors and 5 independent program directors reported having dismissed a resident. Only 5 integrated and 2 independent program directors reported warning signs in hindsight during the resident's initial application. Nine integrated program directors and 4 independent program directors reported at least sometimes reviewing applicant social media accounts. CONCLUSIONS: Prevalence of problematic behavior is estimated between 10% and 20% of plastic surgery residents. Type of problematic behavior are similar between integrated and independent residents. Warning signs on initial application are uncommon. As such, understanding problematic behaviors and methods to manage them are essential.

Is the Vectra 3D Imaging System a Reliable Tool for Predicting Breast Mass?

BACKGROUND: In selecting breast implants for breast reconstruction, current preoperative planning largely relies on 2-dimensional measurements, which are often limited in suboptimal accuracy and objectivity. Although the introduction of 3-dimensional imaging modalities has further improved preoperative planning, they require in-depth analysis of accuracy if they are to be considered as a standardized part of preoperative planning. Thus, the present study analyzes the reliability of the Vectra 3D Imaging System in predicting breast mass and explores potential confounding variables that may limit its accuracy. METHODS: A retrospective review of 202 breasts that received direct-to-implant reconstruction by a single surgeon between February 2015 and February 2019 was conducted. Variables recorded included Vectra predicted mass (VPM; in grams), mastectomy mass (MM; in grams), ptosis grade, and body mass index (BMI). Body mass index was classified as follows: underweight (BMI < 20 kg/m), normal (20 kg/m ≤ BMI < 25 kg/m), overweight (25 kg/m ≤ BMI < 30 kg/m), and obese (BMI ≥ 30 kg/m). Cup size was approximated as follows: A and smaller (MM ≤250 g), B (250 g < MM ≤ 450 g), C (450 g < MM ≤ 600 g), and D and larger (MM ≥ 600 g). Correlation between MM and VPM was evaluated using 2-tailed Pearson correlation coefficients (r), and associated formula was derived from a linear model. Equality of variances was assessed with the Bartlett test. Correlation coefficients calculated for ptosis and BMI categories were then compared with the overall correlation coefficient. Significance was set at α = 0.05, and analyses were conducted in R 3.6.0, version 1.70. RESULTS: There was a strong correlation between MM and VPM (R = 0.90, P < 0.0001). The following equation was derived to predict MM: [MM] = 0.8 × [VPM] + 32 (adjusted r = 0.81). The Bartlett test indicated that VPM varies significantly across cup sizes (P < 0.0001). Comparison of correlation coefficients for ptosis and BMI categories revealed a significantly reduced correlation coefficient for pseudoptosis (0.90 vs 0.75, P = 0.0425). CONCLUSIONS: The present study suggests that the reliability of Vectra in predicting breast mass varies across cup sizes and that there exists a significantly decreased association between VPM and MM among pseudoptotic breasts. These are important considerations when using this technology in surgical planning.

Pedicle De-epithelialization in Reduction Mammoplasty: A Systematic Review of the Literature.

BACKGROUND: Reduction mammoplasty is among the most commonly performed plastic surgery procedures. The reduction pedicle is traditionally de-epithelialized. Many practitioners propose that preservation of the subdermal blood supply results in improved circulation for the nipple-areolar complex. However, this is a time-consuming step of the procedure. Presumed benefits have not been definitively demonstrated. OBJECTIVE: To evaluate current evidence regarding pedicle de-epithelialization in inferior pedicle reduction mammoplasty. METHODS: The MEDLINE database was searched for studies evaluating pedicle de-epithelialization in reduction mammoplasty surgery. Studies reporting outcomes after reduction mammoplasty with pedicle de-epithelialization and deskinning were included. Additionally, reports detailing novel techniques or modification for pedicle de-epithelialization were evaluated and included. RESULTS: One hundred and thirty-eight articles were identified on a systematic review. Thirty-six articles met the study criteria. This includes 23 reporting outcomes after reduction mammoplasty procedures and 13 describing novel techniques for pedicle de-epithelialization. Of the 23 studies reporting outcomes, 6 studies evaluated deskinning of the pedicle. Two of the six studies directly compared deskinning and de-epithelialization. They reported no significant difference in outcomes. The remaining 17 articles described outcomes of inferior pedicle reduction mammoplasty with pedicle de-epithelialization. Studies evaluating deskinning reported ischemic nipple-areolar complex complication rates between 0 and 1.4%. Studies evaluating de-epithelialization reported ischemic nipple-areolar complex complication rates between 0 and 11.1%. CONCLUSIONS: Pedicle de-epithelialization is commonly performed despite limited definitive evidence evaluating its surgical necessity or benefits. Available evidence suggests deskinning may yield acceptable results; however, further investigation is necessary. LEVEL OF EVIDENCE III: 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 .

Variation in Classification of Infection: A Systematic Review of Recent Plastic Surgery Literature.

BACKGROUND: Surgical site infections, also referred to as wound infections, are commonly studied within the plastic surgery literature. The definition of these terms is not standardized in the literature. Individual studies may select criteria to use in identifying infection. This may have important implications upon interpretation of study results. METHODS: Studies evaluating surgical site infection in the plastic surgery literature were identified through search of the MEDLINE database across the five year period ending March 2016. Infection rates were calculated for included studies. Studies were grouped by method of defining infection. Subgroups were compared by calculating percentage of studies reporting greater than 10% infection rates. RESULTS: Three hundred five articles were identified, 77 met study criteria. Thirty-one articles reported criteria for infection and 46 articles did not report criteria for infection. Methods used by studies to define infection were based on treatment received, national/organization definition, characteristics of infection, and International Classification of Diseases, Ninth Revision coding. Studies defining infection by national/organization definition included the greatest percentage reporting infection rates over 10% with 75% of studies. Studies reporting criteria for infection reported infection rates over 10% more often than studies that did not report criteria. 47.5% of studies reporting criteria for infection reported rates over 10% compared with 31.8% of studies which did not. CONCLUSIONS: Criteria used to define infection differs across studies in the plastic surgery literature. Comparison of reported infection rates on the basis of criteria for infection suggests an effect upon infection rate. Many studies do not report criteria used to identify infection and should consider reporting strict criteria for infection.

Deep Inferior Epigastric Perforator Versus Free Transverse Rectus Abdominis Myocutaneous Flap: Complications and Resource Utilization.

INTRODUCTION: Abdominal based breast reconstruction exists in a continuum from pedicled transverse rectus abdominis myocutaneous (TRAM) flap to deep inferior epigastric perforator (DIEP) free flap. DIEP flap has the advantage of complete rectus abdominis sparing during harvest, thus decreasing donor site morbidity. Aim of this study is to determine whether the surgical advantages of the DIEP flap impact postoperative outcomes versus the free TRAM flap (fTRAM). METHODS: We reviewed the Nationwide Inpatient Sample database (2010-2011) for all cases of DIEP and fTRAM breast reconstruction. Inclusion criteria were: female sex and patients undergoing DIEP or fTRAM total breast reconstruction. Male sex was excluded from the analysis. We examined demographic characteristics, hospital setting, insurance information, patient income, comorbidities, postoperative complications (including reoperation, hemorrhage, hematoma, seroma, myocardial infarction, pulmonary embolus, wound infection, and flap loss), length of stay, and total charges (TCs). Bivariate and multivariate analyses were performed to identify independent risk factors of increased length of stay and TCs. RESULTS: Fifteen thousand eight hundred thirty-six cases were identified. Seventy percent were white, 97% were insured, and 83% of patients were treated in an academic teaching hospital setting. No mortalities were recorded. The DIEP cohort was more likely to be obese (P = 0.001). Free TRAM cohort was more likely to suffer pneumonia (P < 0.001; odds ratio [OR], 3.7), wound infection (P = 0.001; OR, 1.7), and wound dehiscence (P < 0.001; OR, 4.3). Type of reconstruction did not appear to affect risk of revision, hemorrhage, hematoma, seroma, or flap loss. Total charges were higher in the DIEP group (P < 0.001). Multivariate analysis demonstrated that fTRAM was an independent risk factor for increased length of stay (P < 0.001; OR, 1.6), and DIEP was an independent risk factor for increased TCs (P < 0.01; OR, 1.5). There was no significant difference in postoperative complications. CONCLUSIONS: The fTRAM cohort was more likely to develop surgical site complications and have an increased length of stay, but TCs were higher for the DIEP group.

Significance of Objective Structured Clinical Examinations to Plastic Surgery Residency Training.

INTRODUCTION: Objective structured clinical examinations (OSCEs) have proven to be a powerful tool. They possess more than a 30-year track record in assessing the competency of medical students, residents, and fellows. Objective structured clinical examinations have been used successfully in a variety of medical specialties, including surgery. They have recently found their way into the subspecialty of plastic surgery. METHODS: This article uses a systematic review of the available literature on OSCEs and their recent use in plastic surgery. It incorporates survey results assessing program directors' views on the use of OSCEs. RESULTS: Approximately 40% of programs surveyed use OSCEs to assess the Accreditation Council for Graduate Medical Education core competencies. We found that 40% use OSCEs to evaluate specific plastic surgery milestones. Objective structured clinical examinations are usually performed annually. They cost anywhere between $100 and more than $1000 per resident. Four milestones giving residents the most difficulties on OSCEs were congenital anomalies, noncancer breast surgery, breast reconstruction, and practice-based learning and improvement. It was determined that challenges with milestones were due to lack of adequate general knowledge and surgical ward patient care, as well as deficits in professionalism and system-based problems. Programs were able to remediate weakness found by OSCEs using a variety of methods. CONCLUSIONS: Objective structured clinical examinations offer a unique tool to objectively assess the proficiency of residents in key areas of the Accreditation Council for Graduate Medical Education core competencies. In addition, they can be used to assess the specific milestones that plastic surgery residents must meet. This allows programs to identify and improve identified areas of weakness.

Open Versus Closed Reduction of Maxillary Fractures: Complications and Resource Utilization.

INTRODUCTION: Maxillary fractures are frequently managed depending on the surgeon's preferences, nature of the injury, presence of associated injuries, and comorbidities. Current literature advocates open reduction with plating versus closed techniques. However, data defining associated costs and complications comparing the 2 approaches remains lacking. METHODS: National Inpatient Sample (2006-2011) was examined for patients undergoing closed or open (76.73-76.74) reduction of maxillary fractures. Treatment-related complications were regarded as re-exploration of surgical site, hemorrhage, hematoma, seroma, wound infection, and dehiscence. RESULTS: Overall, 22,157 patients were identified. There were 18,874 closed and 3283 open procedures. Median age was 35 (interquartile range 27). Median length of stay (LOS) was 4 days. Median total charges were reported as 51486.80 USD. Males comprised 77% of the cohort. 68% of patients were Caucasian. Private payer/HMO accounted for the largest source of health care coverage (43.5%). On risk-adjusted multivariate analysis, there was no difference in surgical approach regarding incidence of postoperative complications. Males (2.73), nonprivate insurer payer (P = 0.002), South region (2.49), and transferred patients (2.55) had higher incidence of complications. Presence of chronic pulmonary disease (2.87) and coagulopathy (6.62) also increased risk of complications. Length of stay was shorter for open reduction (0.68) versus closed. Total charges were also less for open approach (0.37). CONCLUSION: While surgical approach did not affect complications, open approach favorably affected LOS and total charges. Future studies should focus on comorbidities, demographics, and associated injuries in relation to resource utilization for maxillary fractures. In current economic environment, such information might further dictate management options.

The Relationship of Bacterial Biofilms and Capsular Contracture in Breast Implants.

Capsular contracture is a common sequelae of implant-based breast augmentation. Despite its prevalence, the etiology of capsular contracture remains controversial. Numerous studies have identified microbial biofilms on various implantable materials, including breast implants. Furthermore, biofilms have been implicated in subclinical infections associated with other surgical implants. In this review, we discuss microbial biofilms as a potential etiology of capsular contracture. The review also outlines the key diagnostic modalities available to identify the possible infectious agents found in biofilm, as well as available preventative and treatment measures.

Three-Dimensional Surface Analysis for Preoperative Prediction of Breast Volume: A Validation Study.

BACKGROUND: Few studies have examined whether preoperative three-dimensional surface imaging can accurately predict breast volume. Reliably predicting breast volume preoperatively can assist with breast reconstruction planning, patient education, and perioperative risk stratification. METHODS: The authors conducted a review of patients who underwent mastectomy from 2020 to 2021 and included all patients who had preoperative VECTRA XT three-dimensional imaging. VECTRA Analysis Module (VAM) and VECTRA Body Sculptor (VBS) were used for volumetric analysis using standard anatomical breast borders. Breast weights were obtained intraoperatively. Predictive accuracy was defined as VAM estimates ±10% of mastectomy specimen weight or ±100 g of mastectomy weight. RESULTS: The study included 179 patients (266 breasts). There was no significant difference ( P = 0.22) between mean mastectomy weight of 620.8 ± 360.3 g and mean VAM estimate of 609.5 ± 361.9 g. Mean VBS estimate was 498.9 ± 337.6 g, which differed from mean mastectomy weight ( P < 0.001). When defining predictive accuracy as ±100 g, 58.7% of VAM and 44.4% of VBS estimates were accurate. Body mass index, body surface area, and ptosis grade significantly affected VAM and VBS breast volume predictions. CONCLUSIONS: VAM is more accurate at predicting mastectomy weight than VBS, likely because of VAM's analysis of surface topography rather than discrete surface landmarks. Discrepancies between VECTRA estimates and mastectomy weight were likely attributable to differences between surgical mastectomy borders and breast borders used in volumetric analysis. Surgeons should consider the physical characteristics of patients when using three-dimensional imaging. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

Direct to implant breast reconstruction: visualized technique.

Over the past 19 years, direct to implant (DTI) breast reconstruction has been found to decrease medical system cost, improve psychosocial morbidity, and optimize cosmetic outcomes. Acellular dermal matrices (ADMs) have further improved reconstructive outcomes, as the tissue incorporates with new angiogenesis and tissue regeneration. ADMs have been used by the senior author since 2000, and have since become a cornerstone of implant-based reconstruction. The senior author began using contoured perforated ready to use ADM in 2015 and is currently studying the effect of this change on breast reconstruction outcomes. This article details the senior author's technique in performing DTI breast reconstruction and highlights the operative components necessary for success.

Immediate application of vacuum assisted closure dressing over free muscle flaps in the lower extremity does not compromise flap survival and results in decreased flap thickness.

BACKGROUND: Free muscle flaps are a mainstay for reconstruction of distal third leg wounds and for large lower extremity wounds with exposed bone. However a major problem is the significant postoperative flap swelling, which may take months to resolve. We studied the efficacy and safety of immediate application of a vacuum assisted closure (VAC) dressing after a free muscle flap to the lower extremity. METHODS: Over a 19 months period, all consecutive free muscle flaps for lower extremity reconstruction at a Level I trauma center were evaluated prospectively for postoperative flap thickness, complications and flap survival. Immediate application of a VAC dressing was performed in 9 patients, while the flap was left exposed for monitoring in 8 patients. RESULTS: There was no statistically significant difference in flap survival between both cohorts. Mean flap thickness at postoperative day 5 for the VAC group was 6.4±6.4 mm, while flap thickness for the exposed flap group was 29.6±13.5 mm. Flap thickness was significantly decreased at postoperative day 5 for the VAC dressing group. CONCLUSIONS: Immediate application of VAC dressing following free muscle flaps to the lower extremity does not compromise flap survival or outcomes and results in decreased flap thickness and a better aesthetic outcome.

Incidence and risk factors for venous thromboembolism in bilateral breast reduction surgery: An analysis of the National Surgical Quality Improvement Program.

BACKGROUND: The risk of venous thromboembolism (VTE) in patients undergoing bilateral breast reduction surgery remains unknown. This study aimed to determine VTE incidence and risk factors in this patient cohort. METHODS: American College of Surgeons National Surgical Quality Improvement Program (2010-2014) was used to identify women undergoing bilateral breast reduction. Demographic factors, comorbidities, and incidence of postoperative VTE were evaluated. Bivariate and risk-adjusted multivariate logistic regressions were performed to determine factors associated with the development of postoperative VTE. RESULTS: A total of 5371 cases were identified. The mean age was 43.7 years (SD ± 13.9 years). The rate of VTE was 0.22%, with 0.17% rate of pulmonary embolism and 0.07% rate of deep venous thrombosis requiring treatment. Patients who suffered VTE were older (52.4 ± 12.8 vs. 43.7 ± 13.9 years, p < 0.05), had longer length of stay (1.7 ± 2.9 vs. 0.4 ± 2.1 days, p < 0.05), and had higher rates of blood transfusion (8.3% vs. 0.4%, p < 0.01) and reoperation (16.7% vs. 2.0%, p < 0.01). Risk-adjusted multivariate analysis demonstrated that older age (OR 1.05, 95% CI 1.01-1.10), postoperative blood transfusion (OR 12.1, 95% CI 1.3-112.0) and unplanned return to the operating room (OR 6.7, 95% CI 1.3-34.8) were independent risk factors for developing postoperative VTE. CONCLUSION: In bilateral breast reduction surgery, older patients, patients requiring blood transfusion, and patients who have unplanned return to the operating room are at an increased risk of developing postoperative VTE. These factors can be considered for patient risk-stratification and perioperative decision-making regarding VTE prevention.