International efforts in plastic surgery: the Hartford Hospital, Connecticut Children's Medical Center and University of Connecticut experience in Ecuador.

UNLABELLED: Plastic and reconstructive surgery provide a necessary and essential service to public health efforts in resource-poor regions around the world. Disease processes amenable to plastic surgical treatment significantly contribute to worldwide disability, and it is the poor and underserved who are disproportionately affected. METHODS: We conducted a week-long plastic and reconstructive surgical trip to Latacunga, Ecuador to provide reconstructive surgical services for the underserved in this region. RESULTS: Over the course of a week, 97 patients received surgery. Most patients were young (mean age = 21.8 years) and 50.5% were female. Burns and burn scar contractures were the most common diagnoses requiring surgery(21.6%), but cleft lip and palate deformities, scars, nevi, and congenital ear deformities comprised a significant proportion of the case load as well (17.5%, 11.3%, 12.4%, and 10.3%, respectively). There was one postoperative complication requiring reoperation. CONCLUSION: This short-term surgical trip successfully delivered essential reconstructive surgical care to an underserved population in rural Ecuador. Although this is most certainly only a fraction of the true surgical disease burden within this population, our experience provides a testament to the need for essential reconstructive surgical services in developing nations around the world.

Microsurgical reconstruction: a more conservative method of managing large scalp defects?

Scalp reconstruction is a challenging problem requiring attention to the etiology, size, and condition of the defect to formulate an optimal reconstructive plan. Although many "conservative" options have been described even for large wounds, the use of local flaps or split-thickness skin grafts (STSG) may actually result in the need for multiple procedures, prolonged wound care, increased patient discomfort, and an unsatisfactory aesthetic result. We reviewed 37 patients who had received a total of 38 free flaps for scalp defects >or=100 cm(2) secondary to a broad range of etiologies. There were 24 males and 13 females, with a mean age of 47.4 years (range, 7 to 83 years). The mean scalp defect size was 356.2 cm(2) (range, 130 to 675 cm(2)). More than half the patients had undergone prior local flaps or STSG that had failed (n = 20; 54.1%). Latissimus dorsi muscle or myocutaneous flaps were the most commonly used free flaps in our series. Rectus abdominis muscle, scapular, radial forearm, and omental donor sites were also used. There were a total of 10 complications among 10 patients (27%). Two patients (5.4%) had major complications, and 8 patients (21.6%) had minor complications. Four of our complications (40%) were in patients who had received radiation therapy. We achieved definitive closure using free tissue transfer in 95% of patients who had previous attempts at closure using local options. These results demonstrate that free tissue transfer is a safe and highly efficient reconstructive option to manage large scalp defects under a variety of conditions. In large complex scalp wounds, especially in those patients receiving radiation, microsurgical reconstruction should be the preferred method of management.

Telemedicine in plastic surgery: E-consult the attending surgeon.

Telemedicine has evolved into a valuable but underused resource for the delivery of health care to patients at a distance, particularly where patient transport is impractical, expensive, complicated, and/or urgent. Today, over 250,000 telemedicine consults are generated annually, involving various specialties in both military and civilian health delivery systems. The ability to evaluate and triage plastic surgery patients through the use of telemedicine has not been widely explored. We have designed, developed, and tested a "store-and-forward" solution at UMass Memorial Hospital and Beth Israel Deaconess Hospital whereby the plastic surgery residents who responded to a consult request transmitted digital photographs by means of the Internet to the attending physician on call. The customary telephone call between resident and attending physician benefited from the additional photographic data, and patient management resulted in a clear, concise, and unambiguous treatment plan. The initial management suggested by the resident was modified on some occasions, particularly with complex problems. The use of digital images was especially helpful for evaluation of radiographs and complex wounds of the hand and face. The solution proved to be very valuable for both attending physicians and residents in plastic surgery. The photographs provide rich detail and resolution comparable to high-quality prints. The mechanics of obtaining images and the process of sending them electronically was readily mastered. Images reached their destination in only a few minutes over standard telephone lines. No problems were encountered while sending or viewing images on Macintosh or Windows platforms. Determining course of action with a complete clinical history now includes a level of visual detail previously not available. As this application expands into wider use, data integrity and safety will have to be more formally secured and monitored. Our model of telemedicine has broad-reaching ramifications for the improvement of health-care delivery locally, nationally, and internationally.

The clinical and economic impact of a sustained program in global plastic surgery: valuing cleft care in resource-poor settings.

BACKGROUND: The development of surgery in low- and middle-income countries has been limited by a belief that it is too expensive to be sustainable. However, subspecialist surgical care can provide substantial clinical and economic benefits in low-resource settings. The goal of this study is to describe the clinical and economic impact of recurrent short-term plastic surgical trips in low- and middle-income countries. METHODS: The authors conducted a retrospective review of clinic and operative logbooks from Hands Across the World's surgical experience in Ecuador. The authors calculated the disability-adjusted life-years averted to estimate the clinical impact of cleft repair and then calculated the economic impact of surgical intervention for cleft disease. RESULTS: One thousand one hundred forty-two reconstructive surgical cases were performed over 15 years. Surgery was most commonly performed for scar contractures [449 cases (39.3 percent)], of which burn scars comprised a substantial amount [215 cases (18.8 percent)]. There were 40 postoperative complications within 7 days of operation (3.5 percent), and partial wound dehiscence was the most common complication [16 of 40 (40 percent)]. Cleft disorders constituted 277 cases (24.3 percent), and 102 cases were primary cleft lip and/or palate cases. Between 396 and 1042 total disability-adjusted life-years were averted through surgery for these 102 cases of primary cleft repair. This translates to an economic benefit between $4.7 million (human capital approach) and $27.5 million (value of a statistical life approach). CONCLUSIONS: Plastic surgical disease is a significant source of morbidity for patients in resource-limited regions. Dedicated programs that provide essential reconstructive surgery can produce substantial clinical and economic benefits to host countries.