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BACKGROUND: Colorectal cancer is a significant cause of cancer-related death in the United States with abdominoperineal resection (APR) remaining a necessary procedure for many patients. The resultant defects of this radical operation are complex and characterized by significant tissue voids. Pedicled vertical profunda artery perforator flaps (vPAP) can be used to obliterate these defects in patients receiving minimally invasive APR or when the abdominal donor site is unavailable. METHODS: After receiving local institutional review board approval, a single center, retrospective cohort study from January 2020 to December 2021 was performed assessing pedicled vPAP flap reconstruction of APR defects. Age, sex, body mass index, primary diagnosis, comorbidities, concomitant oncologic procedures, radiation, timing, incorporation of gracilis flaps, follow-up, and complications were compared. RESULTS: Ten patients (70% male) with an average age of 56.2 years and BMI of 27.6 were included in the study. Rectal adenocarcinoma (50%) was the most common indication for APR, followed by rectal squamous cell carcinoma (30%), vulvar squamous cell carcinoma (10%), and Crohn disease (10%). Eighty percent of the patients received radiation, and 70% of reconstructions were delayed after the initial resection. The average length of clinical follow-up was 26.1 months. Concerning major complications, 2 patients were required to return to the operating room due to venous congestion (20%), and 2 patients suffered partial flap failure (20%). Minor complications were perineal dehiscence (50%), abscess requiring percutaneous drainage by interventional radiology (30%), and infection requiring antibiotics (20%). Twenty percent of patients developed fistulas requiring surgical excision. There were no instances of donor site dehiscence, and there was no complete flap loss, indicating successful reconstruction in all included cases. CONCLUSIONS: vPAP flaps are a reliable method to reconstruct perineal defects with less donor-site morbidity than previous reconstructive options. vPAP flaps should be considered in the setting of delayed reconstruction, minimally invasive APRs, and when the abdominal donor site is unavailable.
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Colgajo Perforante , Perineo , Procedimientos de Cirugía Plástica , Humanos , Persona de Mediana Edad , Masculino , Femenino , Colgajo Perforante/trasplante , Colgajo Perforante/irrigación sanguínea , Estudios Retrospectivos , Perineo/cirugía , Procedimientos de Cirugía Plástica/métodos , Anciano , Adulto , Proctectomía/métodos , Neoplasias del Recto/cirugíaRESUMEN
ABSTRACT: The authors present a review of the literature regarding pressure injuries (PIs) in neonates and a case of a newborn who developed a PI following a prolonged labor process and fetal malposition. A girl born at 35 weeks' gestation to a 34-year-old gravida 7 para 6 mother with a medical history of untreated gestational diabetes, preeclampsia, and COVID-19 was delivered via cesarean section after failure to progress through labor. The premature infant was found to have a 3.2 × 2.3-cm PI at the nape of the posterior neck. Premature infants have a histologically proven, age-dependent decreased thickness of their stratum corneum, epidermis, and dermis, which places them at increased risk of developing PIs that can be painful and lead to infection. In the present case, the neonate's congenital PI was successfully treated with medical-grade honey for approximately a month.
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Preeclampsia , Úlcera por Presión , Recién Nacido , Embarazo , Humanos , Femenino , Adulto , Cesárea , Úlcera por Presión/diagnóstico , Úlcera por Presión/etiología , Recien Nacido Prematuro , Edad GestacionalRESUMEN
Study Design: A Case Report. Objective: Craniosynostosis is a craniofacial condition defined by premature fusion of at least one cranial suture. Resynostosis or secondary craniosynostosis of a previously patent adjacent suture following primary repair is a relatively common complication. While studies have assessed the rates of secondary craniosynostosis and subsequent reoperation, extremely limited data regarding reoperation techniques is available. Methods: We present a unique case of a pediatric patient with sagittal craniosynostosis who previously underwent a modified pi procedure and later developed resynostosis of the sagittal suture and secondary synostosis of the bicoronal sutures. We subsequently performed total cranial vault reconstruction with virtual surgical planning (VSP). Results: At his 31-month postoperative follow-up, he displayed normal head shape and denied any clinical signs of elevated intracranial pressures with a normal ophthalmological exam. Conclusions: The reoperation was successful with no significant postoperative complications noted. Performing geometric expansion with VSP to manage fusion of a previously open suture following primary treatment of sagittal synostosis should be considered within the armamentarium of operative options.
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BACKGROUND: At a tertiary-care, level 1 pediatric trauma center, we have observed fractures of the distal phalanx involving the physis, with associated nail bed injuries, that are distinct from the classic description of the Seymour fracture. We investigated the time to definitive management and the associated morbidity of these Seymour fracture variants compared with classically described Seymour fractures. We hypothesize that these Seymour variants are similarly problematic in terms of complications and delays to the definitive treatment and thus warrant increased awareness. METHODS: A retrospective chart review was performed of all patients with distal phalanx fractures involving the physis and associated nail bed injuries that were treated with operative intervention at a single pediatric specialty institution over a 9-year period. Radiographs and clinical photographs were reviewed to determine if the patient presented with a classic Seymour fracture or variant. Primary outcomes included time from injury to definitive treatment and complication rate. RESULTS: Of the 66 Seymour fractures identified in the chart review, 36 (55%) were identified as classic Seymour fractures and 30 (45%) were identified as variants. The mean time to operative intervention in the classic and variant groups was 7.3 versus 12.7 days (P=0.216). The complication rates in the classic and variant groups were 11.1% versus 23.3% (P=0.185), with infections accounting for nearly all complications identified. Overall infection rates for the classic and variant cohorts were 8.3% and 20.0% (P=0.169), respectively, with the majority presenting preoperatively (5.6% vs. 13.3%, P=0.274). CONCLUSIONS: We found that patients with classic Seymour fractures or radiographic variants had statistically similar incidence rates, complication rates, and delays in treatment, with a trend towards higher complication rates and delayed time to treatment in patients with variant-type injuries. We propose a minor expansion of the definition of Seymour fractures to include common variants to increase awareness of these problematic injuries, minimize delays in treatment, and decrease complications. LEVEL OF EVIDENCE: Level III; Retrospective Comparative Study.
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Traumatismos de los Dedos , Fracturas Óseas , Humanos , Niño , Estudios Retrospectivos , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/epidemiología , Fracturas Óseas/cirugía , Traumatismos de los Dedos/cirugía , Radiografía , Centros TraumatológicosRESUMEN
BACKGROUND: Procedures performed by plastic surgeons tend to generate lower work relative value units (RVUs) compared to other surgical specialties despite their major contributions to hospital revenue. The authors aimed to compare work RVUs allocated to all free flap and pedicled flap reconstruction procedures based on their associated median operative times and discuss implications of these compensation disparities. METHODS: A retrospective analysis of deidentified patient data from the American College of Surgeons National Surgical Quality Improvement Program was performed, and relevant CPT codes for flap-based reconstruction were identified from 2011 to 2018. RVU data were assessed using the 2020 National Physician Fee Schedule Relative Value File. The work RVU per unit time was calculated using the median operative time for each procedure. RESULTS: A total of 3991 procedures were included in analysis. With increased operative time and surgical complexity, work RVU per minute trended downward. Free-fascial flaps with microvascular anastomosis generated the highest work RVUs per minute among all free flaps (0.114 work RVU/minute). Free-muscle/myocutaneous flap reconstruction generated the least work RVUs per minute (0.0877 work RVU/minute) among all flap reconstruction procedures. CONCLUSIONS: Longer operative procedures for flap-based reconstruction were designated with higher work RVU. Surgeons were reimbursed less per operative unit time for these surgical procedures, however. Specifically, free flaps resulted in reduced compensation in work RVUs per minute compared to pedicled flaps, except in breast reconstruction. More challenging operations have surprisingly resulted in lower compensation, demonstrating the inequalities in reimbursement within and between surgical specialties. Plastic surgeons should be aware of these discrepancies to appropriately advocate for themselves.
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Colgajos Tisulares Libres , Escalas de Valor Relativo , Humanos , Reoperación , Tempo Operativo , Estudios RetrospectivosRESUMEN
Hemifacial microsomia (HFM) is a complex congenital condition with heterogeneous malformations of the facial skeleton that almost always involves mandibular hypoplasia. Here we introduce a unique case in which a patient with HFM had initially successful optimization of facial symmetry using a polyetheretherketone implant for mandibular augmentation. However, multiple factors associated with the intraoperative and postoperative course, including hardware failure and infection, led to diminished mechanical strength of the mandible, ultimately resulting in a mandibular fracture. In this unique case presentation of HFM, we discuss the various factors that contributed to mandibular weakness and increased susceptibility to fracture.
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Numerous innovations within the field of plastic surgery have been developed in Israel over the last few decades. Many of these therapeutic devices and techniques have been established globally with demonstrable efficacy and respectable safety profiles. This article offers an overview of recent Israeli cutting-edge medical therapeutic solutions contributing to the global practice of plastic surgery.
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Soft tissue defects resulting from trauma, vascular disease, burns, and postoncologic resections require reconstructive surgery for appropriate wound coverage and support. Dermal substitutes have been applied to a vast array of reconstructive settings across nearly all anatomical areas with demonstrable success. However, they require meticulous handling and operative technical expertise to optimize management of these soft tissue defects. In this review, we will address three dermal substitutes, their operative techniques, and their surgical applications.
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ABSTRACT: Smile Train, the largest global cleft nonprofit organization, employs a model of establishing partnerships with treatment centers and medical professionals in low- and middle-income countries (LMICs). Having a presence in over 90 countries throughout its history, the organization provides support for cleft lip and palate repair as well as comprehensive cleft care (CCC) for patients with clefts. With the goal of reducing disparities in access to quality surgical, anesthesia, and medical care, Smile Train strengthens partners with training, education, equipment, and patient support grants. Furthermore, safety and quality protocols have been put in place as guidelines for each partner center, and partnerships with other nongovernmental agencies were created to increase safety in the operating rooms. The founder of Smile Train desired to apply technology wherever possible to build sustainability within the treatment centers and surgeons supporting their own community. Smile Train's model, aimed at increased sustainability, is supplemented by technological advancements to assist in the safety and quality of cleft care services provided in LMIC treatment centers. Examples include centralized online data record keeping for every patient, virtual simulations and training, and mobile applications to enhance care. Recently, Smile Train's focus is expanding CCC with nutrition, oral health, speech, and nursing care programs to improve functional and psychosocial outcomes for patients following their procedure. Despite the challenges imposed by the COVID-19 pandemic, Smile Train continues to provide safe, efficacious, and CCC alongside their partners in LMICs further investing tremendous efforts towards the livelihood of children with clefts globally.
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COVID-19 , Labio Leporino , Fisura del Paladar , COVID-19/epidemiología , Niño , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Humanos , Pandemias , HablaAsunto(s)
Craneosinostosis , Hipertensión Intracraneal , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/cirugía , Potenciales Evocados Visuales , Humanos , Hipertensión Intracraneal/diagnóstico , Hipertensión Intracraneal/etiología , Presión Intracraneal/fisiología , Tomografía de Coherencia Óptica/métodosAsunto(s)
Publicaciones Periódicas como Asunto/economía , Publicaciones Periódicas como Asunto/normas , Edición/economía , Edición/normas , Cirujanos/psicología , Cirugía Plástica , Investigación Biomédica/economía , Investigación Biomédica/normas , Conflicto de Intereses/economía , Humanos , Cirujanos/economía , Cirujanos/normas , Cirugía Plástica/economía , Cirugía Plástica/normasRESUMEN
The detrimental effects of the coronavirus disease 2019 (COVID-19) pandemic have profoundly disrupted surgical care at health care facilities worldwide. At our tertiary pediatric hospital, we made substantial adjustments to surgical suite utilization and staff member scheduling to account for reductions in surgical volume, increased demand for staff members in other sectors of the hospital, and the highly infectious properties of the virus. Perioperative leaders took advantage of the pandemic's disruption to clinical activities to design and implement a new procedure-scheduling process to rectify the inefficiencies that had accumulated as the previous system evolved. The implementation of said directives was largely facilitated by establishing communication with all involved parties for their input and feedback throughout the process. Although COVID-19 has had varying effects on procedural operations across pediatric health care facilities, we believe our institutional response to the disruptive forces of COVID-19 is of benefit to pediatric hospitals worldwide.
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COVID-19 , Niño , Hospitales Pediátricos , Humanos , Pandemias , SARS-CoV-2 , Centros de Atención TerciariaRESUMEN
ABSTRACT: The authors provide the case of a 6-year-old male who presented late with multi-suture craniosynostosis and chronically elevated intracranial pressures (ICPs). He was surgically managed with frontal orbital advancement. This particular case illustrates the significant bleeding and unique bony pathology that can occur in patients with high ICP with concomitant venous collateralization. At 1-month follow-up, he demonstrated significant improvement with maintained expansion and no signs of elevated ICP despite delayed intervention. Frontal orbital advancement serves as an effective method for cranial vault expansion and correction of frontal deformities caused by craniosynostosis.
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Craneosinostosis , Niño , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/cirugía , Humanos , Lactante , Presión Intracraneal , Masculino , Procedimientos Neuroquirúrgicos , Cráneo , SuturasRESUMEN
BACKGROUND: Pediatric lymphedema can result in irreversible, debilitating limb swelling, tissue fibrosis, skin ulcers, infection, and impaired limb function in children at an early age. Manual lymphatic drainage (MLD) is a noninvasive technique, which is a part of intensive decongestive therapy to reroute lymphatic flow to healthy channels used to manage lymphedema. Outcomes of this treatment option in children have not been studied. We evaluated the effect of decongestive therapy involving MLD in pediatric patients with complex lymphatic anomalies by measuring treatment progress and functional outcomes via changes in limb circumference, limb functionality, dexterity, skin quality, and pain. METHODS: A single-institution retrospective study on a cohort of 8 pediatric patients with lymphatic anomalies who completed a course of MLD was conducted from 2015 to 2017 to investigate the role MLD plays in their lymphedema reduction. Pain scores were measured on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable. The functional performance was measured by the Canadian Occupational Performance Measurement questionnaire. RESULTS: Among all patients, there were 4 cases affecting the upper extremities, 4 affecting the lower extremities, and 3 affecting the truncal region. Five of 8 patients demonstrated a reduction in lymphedema with an average girth reduction of 8.2% in the lower extremities, 3.0% in the upper extremities, and 7.4% in the truncal regions. In unilateral cases, the difference in limb circumference between the affected and normal extremity decreased by an average of 25.6%. Four patients completed the Canadian Occupational Performance Measurement questionnaire with an average improvement of 30% in daily task performance. Three patients reported complete resolution of pain. CONCLUSIONS: MLD can be used as a reliable noninvasive method for decongestion and analgesia to delay the onset of lymphedema-associated fibrosis and long-term disability in children with complex lymphatic malformations.