Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia: Analysis of Perioperative Anticoagulation Protocols and Predictors of Flap Failure.

BACKGROUND: No consensus exists regarding the optimal strategy for perioperative thromboprophylaxis in high-risk microsurgical populations. We present our experience with lower extremity free tissue transfer (FTT) in thrombophilic patients and compare outcomes between non-stratified and risk-stratified anticoagulation protocols. METHODS: Between January 2013 and December 2017, 57 patients with documented thrombophilia underwent FTT for non-traumatic, lower extremity reconstruction by a single surgeon. Patients were divided into two cohorts based on the introduction of a novel, risk-stratified algorithm for perioperative anticoagulation in July 2015. Demographic data, chemoprophylaxis profiles, flap outcomes, and complications were retrospectively compared across time periods. RESULTS: Fifty-seven free flaps were performed in hypercoagulable patients treated with non-stratified (n = 27) or risk-stratified (n = 30) thromboprophylaxis. Patients in the risk-stratified cohort received intravenous heparin more often than non-stratified controls (73 vs. 15%, p < 0.001). Lower rates of total (3 vs. 19%, p = 0.06) and partial (10 vs. 37%, p = 0.025) flap loss were observed among risk-stratified patients, paralleling a significant reduction in the prevalence of postoperative thrombotic events (1.2 vs. 12.3%, p = 0.004). While therapeutic versus low-dose heparin infusion was associated with improved flap survival following intraoperative microvascular compromise (86 vs. 25%, p = 0.04), salvage rates in the setting of postoperative thrombosis remained 0%, regardless of protocol. On multivariate analysis, recipient-vessel calcification (odds ratio [OR]: 16.7, p = 0.02) and anastomotic revision (OR, 3.3; p = 0.04) were independently associated with total flap failure. CONCLUSION: Selective therapeutic anticoagulation may improve microsurgical outcomes in high-risk patients with thrombophilia. Our findings highlight the importance of meticulous technique and recipient-vessel selection as critical determinants of flap success in this population.

An Analysis of Plastic Surgeons' Social Media Use and Perceptions.

BACKGROUND: Social media have become ubiquitous in society with an increasing number of active daily users across multiple platforms. Social media use has grown within the field of plastic surgery; many surgeons have created a professional account to gain exposure. OBJECTIVES: This study investigates the patterns of use and perceptions of social media in plastic surgery. METHODS: A 16-item questionnaire was sent electronically to board-certified plastic surgeons to investigate professional social media use and perceptions. A literature review of all studies pertaining to social media and plastic surgery was also undertaken. RESULTS: An online survey was sent to 6136 ASPS members with 454 responses (7.4%). Of the respondents, 61.9% reported having an active professional social media account. Respondents whose practice primarily consisted of aesthetic/cosmetic surgery were the most likely to have an active professional social media account (79.4%). Nonacademic surgeons were most likely to maintain an active professional social media account (71.9%) compared with university-affiliated community surgeons (41.4%) and academic surgeons (29.5%). Nonacademic surgeons were more likely to believe social media is positive for the field (48.9%) compared with the other 2 cohorts (27.6% and 35.1%, respectively). Academic surgeons are more likely to believe social media worsens the image of the field (49.3%) vs the other cohorts (35.4% and 37.2%). CONCLUSIONS: Professional social media use is rising within plastic surgery. However, a dichotomy exists in acceptance. Private practice, younger surgeons are more likely to view social media as an acceptable method of reaching patients.

The P1 Method: Prepectoral Breast Reconstruction to Minimize the Palpable Implant Edge and Upper Pole Rippling.

BACKGROUND: Prepectoral prosthetic-based breast reconstruction has become increasingly popular as an alternative to the partial or total submuscular approach. Potential issues with the prepectoral approach include a noticeable superior implant edge and implant rippling. These concerns are particularly apparent in thin patients. We introduce a novel muscle-sparing technique in which a partial-thickness slip of pectoralis muscle is created in an otherwise prepectoral plane to mask these upper pole defects, mask superior implant rippling, and provide greater implant support (The P1 Method). METHODS: A retrospective review of all patients undergoing modified prepectoral (P1) breast reconstruction at a single institution over 2 years was undertaken. Data pertaining to patient demographics, mastectomy type/weight, reconstruction type, and esthetic and surgical outcomes were collected. Outcomes were analyzed using Fisher exact and Student t tests. RESULTS: Fifty patients (93 breasts) were identified during the study period. Mean final follow-up was 63 weeks (range, 53-85 weeks). Patients undergoing P1 reconstructions achieved improved esthetic results with less implant rippling and complete elimination of animation deformity seen on postoperative clinical images or at final follow-up. CONCLUSIONS: As prepectoral prosthetic-based breast reconstruction becomes more popular, architectural adaptations will be made to improve surgical and patient-centered outcomes. The P1 Method is effective in improving the superomedial contour in thin patients, minimizes upper pole rippling, and provides greater overall implant support.

Outcomes After Combined Radical Resection and Targeted Biologic Therapy for the Management of Recalcitrant Hidradenitis Suppurativa.

BACKGROUND: Trials demonstrating the efficacy of biologic therapy for moderate to severe hidradenitis suppurativa (HS) have inspired new multidisciplinary treatment strategies. We present our experience with combined biologic and surgical therapy for recalcitrant HS. METHODS: Between 2011 and 2014, 21 patients (57 cases) with Hurley Stage III HS underwent radical resection with delayed primary closure alone, or in combination with adjuvant biologic therapy. Demographic data, treatment regimen, outcomes, and complications were retrospectively reviewed for all cases. RESULTS: Eleven patients underwent combined surgical and biologic therapy, whereas radical resection alone was performed in 10 patients. The average soft tissue deficit, before closure, for the combined and surgery-only patients was 56 cm and 48.5 cm, respectively (P = 0.66). Biologic agents including infliximab (n = 8) and ustekinumab (n = 3) were initiated 2 to 3 weeks after closure and were continued for an average of 10.5 months. Recurrence was noted in 19% (4/29) and 38.5% (10/26) of previously treated sites for combined and surgery-only patients (P < 0.01). For the combined cohort, the disease-free interval was approximately 1 year longer on average (P < 0.001); however, this difference was reduced to 4.5 months when considering time to recurrence after cessation of biologic therapy (P = 0.09). New disease developed in 18% (2/11) and 50% (5/10) of combined and surgery-only patients, respectively (P < 001). No adverse events were noted among patients who received biologic therapy. CONCLUSIONS: Lower rates of recurrence and disease progression, as well as a longer disease-free interval may be achieved with the use of adjuvant biologic therapy after radical resection for recalcitrant HS.

Correlating patient-reported outcomes and ambulation success following microsurgical lower extremity reconstruction in comorbid patients.

INTRODUCTION: Microsurgical lower extremity flap reconstruction provides a valuable option for soft tissue reconstruction in comorbid patients. Limb salvage with flap reconstruction can result in limb length preservation. Despite this, few studies have examined the impact of salvage on patient-centered metrics in this cohort of patients. Therefore, we investigated quality of life and patient satisfaction following microsurgical lower extremity reconstruction in this high-risk patient population. Factors that resulted in improved patient-centered outcomes were also identified. METHODS: A retrospective review was conducted of all patients who had lower extremity free flap reconstruction (FFR) following lower extremity wounds. High-risk patients were identified as having multiple comorbidities and chronic wounds. Patients with traumatic wounds were excluded from analysis. Quality of life was evaluated with the Short Form-12 (SF-12) validated survey. Phone interviews were conducted for survey evaluations. RESULTS: From 2005 to 2010, 57 patients had lower extremity flap reconstruction that met the inclusion criteria. Average follow-up was 236.6 weeks (range, 111-461). Comorbidities included diabetes (36%), PVD (24.6%), and ESRD (7%). Limb length preservation and ambulation occurred in 82.5% (47/57). Revisional surgery occurred in 33.3% (19/57). Survey response rate was 63%. Average SF-12 PCS and MCS scores were 44.9 and 59.8 for patients able to achieve ambulation and 27.6 and 61.2 for nonambulatory patients. CONCLUSIONS: Microsurgical flap reconstruction is a valuable reconstructive option in high-risk patients. Quality of life is comparable with a normalized population if limb salvage is successful. Quality of life is decreased significantly when failure to ambulate occurs in this patient cohort.

Systematic review of patient-centered outcomes following lower extremity flap reconstruction in comorbid patients.

BACKGROUND: Lower extremity soft tissue defects pose a challenging problem to patients with comorbidities. Reconstruction with tissue transfer offers an effective alternative to amputation in this population. Although abundant with data on success and complication rates, the literature has not focused on assessing patient-centered outcomes of these reconstructive procedures. METHODS: A systematic review was performed by searching an electronic database for relevant studies. The full text of relevant articles was retrieved and the reference lists of those articles reviewed. Single case reports or articles reporting data on wounds sustained from trauma were excluded. RESULTS: In total, 318 articles were identified. After applying inclusion and exclusion criteria, 50 articles reporting data on 1,079 flaps remained for inclusion in this review. Ambulation outcomes were reported by 35 articles with a weighted mean rate of postoperative ambulation of 77.4%. Postoperative time to ambulation ranged from an average of 9 months to 22 months. Quality of life and patient satisfaction outcomes were infrequently and inconsistently reported in the literature. CONCLUSION: There is a dearth of patient-centered outcomes for lower extremity flap reconstruction currently in the literature. A standardized method to assessing patient-centered outcomes should be employed to better understand the effectiveness of these procedures.Level of Evidence III Therapeutic.

A Plastic-neuro Effort: Vascularized Soft-tissue Coverage for Hostile Wound Bed with Multiple Ventricular Shunt Failures.

Cerebral ventricular shunt placements are the most common neurosurgical procedure performed today, which play a life-long role in the care of patients with hydrocephalus. Complication rates requiring shunt replacement are as high as 25%, and the potential need for multiple revisions throughout a patient's life may result in the formation of scar tissue and compromised wound healing. Without addition of vascularized tissue, patients with scalp scarring and impaired wound healing then enter a cycle of impaired skin closure followed by shunt infection, failure, and revision with little promise of long-term operative or therapeutic success. This plastics-neuro collaboration is the first known report of a free vastus lateralis muscle flap for coverage of a cerebral ventricular shunt, in a patient with congenital hydrocephalus and 17 previous ventricular shunts revisions due to infections and soft tissue exposure from scarring and a hostile wound bed. In the setting of extensive scarring, the free vascularized muscle flap provides soft tissue and vascular supply capable of promoting wound healing, maintaining scalp integrity, and reducing the incidence of shunt infection and the subsequent need for future revision, as supported by the complication-free status of the same patient now 16 months since the date of operation.

Comparison of the Pedicled Latissimus Dorsi Flap with Immediate Fat Transfer versus Abdominally Based Free Tissue Transfer for Breast Reconstruction.

BACKGROUND: Abdominally based free tissue transfer (FTT) and latissimus dorsi and immediate fat transfer (LIFT) procedures are both fully autologous options for breast reconstruction. The former is specialized and requires comfort with microsurgical technique, whereas LIFT combines a common set of techniques familiar to all plastic surgeons. Comparing the two methods for clinical effectiveness and complications for equivalency in outcomes may help elucidate and enhance patient decision-making. METHODS: A retrospective review of a prospectively maintained database between March of 2017 and July of 2018 was performed to compare the LIFTs and FTTs performed by the senior surgeon. Outcomes of interest included postoperative complications, flap success, and follow-up revision and fat-grafting procedures. RESULTS: Sixty-five breasts were reconstructed by FTT; and 31 breasts were reconstructed with LIFT. Demographics were similar (p > 0.05). LIFT had a shorter length of operation time (343 ± 128 minutes versus 49 ± 137 minutes) (p < 0.0001) and a shorter length of stay (1.65 ± 0.85 days versus 3.83 ± 1.65 days) (p < 0.001). FTTs had a shorter time until drain removal (13.3 ± 4.3 days versus 24.0 ± 11.2 days) (p < 0.0001). The number of major (requiring operation) and minor complications were not statistically different (i.e., FTTs, 20.0 percent major and 27.7 percent minor; LIFT, 12.9 percent major and 19.35 percent minor) (p > 0.05). The need for revisions (FTTs, 0.80 ± 0.71; LIFT, 0.87 ± 0.71) and fat grafting (FTTs, 41.54 percent; LIFT, 58.8 percent) was not statistically different (p > 0.05). CONCLUSIONS: Both the LIFT and abdominally based FTT have similar outcomes and complication rates. However, LIFT may be preferred in patients who require shorter operation times. The LIFT may be the fully autologous breast reconstruction of choice for nonmicrosurgeons. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Analysis of Chest Masculinization Surgery Results in Female-to-Male Transgender Patients: Demonstrating High Satisfaction beyond Aesthetic Outcomes Using Advanced Linguistic Analyzer Technology and Social Media.

Satisfaction rates are reported as high after subcutaneous mastectomy for chest masculinization. We examined patient satisfaction based on linguistic analysis of social media posts showing postoperative results and compared them to aesthetic quality ratings from plastic surgeons. METHODS: Fifty publicly available images of subcutaneous mastectomy postoperative results of female-to-male gender transition patients were selected from Instagram. The photograph's corresponding post and comments were then analyzed for sentiment through the IBM Watson tone analyzer, which rated the presence of joy on a continuous scale from 0 to 1. Three plastic surgeons rated aesthetic quality on an ordinal scale of 1 to 10. Results of both analyses were then compared. RESULTS: Joy was rated as a mean value of 0.74 (±0.13) in posts and 0.81 (±0.13) in comments. The mean ratings of results were found to be chest contour 6.1 of 10 (±1.7), scar position 5.3 of 10 (±1.8), scar quality 4.8 of 10 (±1.9), nipple position 5.2 of 10 (±1.9), and nipple quality 5.1 of 10 (±2.0). A positive relationship was found between post joy and nipple quality (r = 0.33, P = 0.0169). There were no other associations detected between level of joy and the ratings of results by plastic surgeons (P > 0.05). CONCLUSIONS: Despite wide variety in surgical appearance, there is a high level of satisfaction and community support. This is in contrast to the low-quality ratings by plastic surgeons. The results demonstrate the strong psychological and functional underpinnings chest masculinization has for patients. However, surgical results can be improved through a variety of techniques such that patients have both excellent surgical results and high satisfaction.

Preparing for Facial Feminization Surgery: Timing.

Facial feminization surgery may be a part of a treatment plan for gender dysphoria. Initial mental health assessment must occur. Referrals for hormonal therapy may then be made if appropriate. No guidelines exist for timing of facial feminization surgery. Generally, recommendations are for individuals to undergo hormonal therapy and live in a gender-congruent role for at least 12 months before surgical intervention. Referral letters meeting World Professional Association of Transgender Health guidelines must be made regarding the treatment course and goals. Informed consent must be obtained; patient should understand how surgical alteration fits into their overall treatment goals.

To Bot or Not? Challenging the Top Social Media Influencers in #PlasticSurgery.

BACKGROUND: The influence of social media on plastic surgery continues to be explored. Prospective patients may seek out surgeons with greater number of followers. Recently, companies selling Twitter bots have been exposed. The authors sought to examine the number of fake users, practice types, and the content of tweets broadcasted by top influencers in plastic surgery. METHODS: Top 100 influencers were identified. The influencers were categorized into academic versus private practice and sorted according to their board-certification status. Among each board-certification status, the top five influencers of each category (American Board of Plastic Surgery, American Academy of Facial Plastic and Reconstructive Surgery, international plastic surgeon, other physician, nonphysician) were determined, and their 300 most recent tweets were analyzed for educational, promotional, or personal content. Fake bots among respective followers were identified by TwitterAudit. RESULTS: Private practice surgeons represented 68 percent of the top tweeters. Academicians were only 8 percent. American board-certified surgeons represented 55 percent of the top tweeters. Compared with American board-certified surgeons, nonphysicians had a higher number of fake bots. Among the 7500 tweets that were analyzed, nonphysicians were more likely to have promotional and less likely to have educational posts when comparing to board-certified American or international plastic surgeons. CONCLUSIONS: Plastic surgeons are quick to adapt to the dynamic and evolving nature of social media. However, academic surgeons are poorly represented among the top influencers. Although top influencers are board-certified plastic surgeons, they continue to occupy only a fraction of the total discourse on plastic surgery.

Expanded Algorithm and Updated Experience with Breast Reconstruction Using a Staged Nipple-Sparing Mastectomy following Mastopexy or Reduction Mammaplasty in the Large or Ptotic Breast.

BACKGROUND: Staged nipple-sparing mastectomy following mastopexy or reduction mammaplasty was first described in 2011 by Spear et al. to expand the indications for nipple-sparing mastectomy to women with large or ptotic breasts. Since that time, the authors have revised their treatment algorithm and technique to enhance oncologic safety and improve wound healing complications. METHODS: An institutional review board-approved retrospective review was undertaken of all patients undergoing staged nipple-sparing mastectomy following mastopexy or reduction mammaplasty at a single institution from July of 2011 through July of 2016. Management followed an updated treatment protocol to improve surgical and oncologic outcomes. RESULTS: Twenty-six patients (50 breasts) were identified who underwent staged nipple-sparing mastectomy. Five breasts (10 percent) required reoperation for a complication such as infection or tissue necrosis. Two devices (4 percent), both in the therapeutic cohort, required explantation because of infection. Skin flap necrosis and nipple-areola complex necrosis were each seen in two breasts (4 percent). Infection was seen in four breasts (8 percent), and wound healing complications were seen in only two breasts (4 percent). CONCLUSIONS: The authors offer their updated treatment algorithm for a staged approach to nipple-sparing mastectomy for patients with macromastia or grade II or III ptosis. Their results build on previously published reports demonstrating the safety and efficacy of this approach for nipple preservation and oncologic management in this patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Public's Preferences on Plastic Surgery Social Media Engagement and Professionalism: Demystifying the Impact of Demographics.

BACKGROUND: Social media discussions are alive among plastic surgeons. This article represents a primer on beginning to understand how the public would seek out plastic surgeons and how demographics shape their preferences. METHODS: An anonymous 31-question survey was crowdsourced by means of MTurk. RESULTS: There were a total of 527 respondents. Of these respondents, 33 percent follow plastic surgeons on social media, with those aged younger than 35 years 3.9 times more likely to do so. Google was the first place people would look for a plastic surgeon (46 percent). When asked what was the most influential of all online methods for selecting a surgeon, practice website ranked first (25 percent), but social media platforms ranked higher as a whole (35 percent). Those considering surgical or noninvasive procedures are thee times more likely to select social media platforms as the most influential online method in selecting a surgeon and five times more likely to follow a plastic surgeon on social media. The majority would prefer not seeing the surgeon's private life displayed on social media (39 percent). Respondents were evenly split regarding whether graphic surgical images would lead them to unfollow accounts. Ninety-six percent of the general public were unclear of the type of board certification a plastic surgeon should hold. CONCLUSIONS: Clear differences in engagement and perception exist in the public based on age, sex, parental status, and reported country of origin. Social media will soon become a critical strategy in outreach and engagement and a valuable tool in clearing misconceptions within plastic surgery.

Are We Witnessing a Paradigm Shift?: A Systematic Review of Social Media in Residency.

As social media's applications continue to evolve, the pitfalls and dangers associated with misuse have been accentuated in the literature. Consequently, academic institutions across the nation have implemented social media policies. This study is aimed to evaluate the state of social media literature examining postgraduate trainees (residents/fellows). METHODS: A systematic search was performed identifying peer-reviewed publications presenting original research. Studies published through December 8, 2018, focusing on social media use among postgraduate trainees were considered for inclusion. RESULTS: Fifty-three studies were categorized into 4 domains: (1) resident recruitment, (2) graduate medical education, (3) professional development, and (4) academic scholarship. Thirty-four (64.15%) investigated social media's impact on professional development, of which 16 (47.05%) highlighted the detrimental potential on trainee professionalism. The remaining 18 (52.94%) focused on promoting social media training during residency, and/or enhancing social media competency to benefit professional development. Fourteen (26.42%) rationalized social media use in augmenting graduate medical education. Ten (18.87%) assessed social media's influence on resident recruitment, of which 7 (70%) depicted use as a screening instrument for program directors on resident applicants. Two (3.77%) of the studies introduced social media as a platform for academic scholarship with indicators as altmetrics. CONCLUSIONS: The well-established disadvantages of social media use by the postgraduate trainee continue to persist in the literature. However, there is recognition of social media as a valuable resource in influencing resident recruitment, graduate medical education, professional development, and academic scholarship, representing a paradigm shift-from cautiously avoidant to thoughtful capitalization on its immense potential.

Latissimus Dorsi and Immediate Fat Transfer (LIFT) for Complete Autologous Breast Reconstruction.

BACKGROUND: Despite the popularity of latissimus dorsi (LD) flap in breast reconstruction, a breast implant is often necessary to achieve sufficient volume. Prior reports describe fat grafting to the LD flap as a secondary procedure to correct contour deformities and improve volume. Our institution has instituted autologous breast reconstruction with an LD flap and immediate fat transfer (LIFT). METHODS: A retrospective review of all patients undergoing the LIFT procedure was undertaken. Patient age, total volume of fat transfer, length of follow-up, need for adjuvant therapy, and complications were recorded. The procedure begins with harvest of the LD flap and fat. Prior to disorigination of the latissimus muscle, fat is injected into the flap. Flap harvest is then completed and inset to create a breast mound. RESULTS: Eighteen patients underwent LIFT procedures over 3 years with an average follow-up of 8.7 months (range, 2-24). Four breasts (22.2%) had previously received adjuvant radiation therapy. The mean total fat grafting volume was 515.5 mL (range, 325-730) per breast. The average estimated fat graft take was 66.8% (range, 50-80%). Four patients (22.2%) experienced complications. CONCLUSION: Autologous augmentation of the LD flap with lipotransfer has been used to avoid placement of an implant. We improve the technique by performing lipotransfer during index reconstruction. Furthermore, we perform lipotransfer prior to disorigination of the LD muscle to minimize trauma to the flap and increase the efficiency of fat grafting. Our experience demonstrates that this technique is a viable autologous alternative to microsurgical breast reconstruction.

The Suture Tab Technique: Securing Implant Position in Prepectoral Breast Reconstruction.

Human acellular dermal matrix (ADM) can augment prepectoral prosthetic-based direct-to-implant breast reconstruction by providing an additional soft-tissue layer between breast implant and skin, as well as to reinforce the inframammary fold and breast pocket. Utilizing ADM in this way has helped reduce rates of implant rippling, capsular contracture, and implant extrusion. Difficulty in securing ADM-wrapped implants has caused many surgeons to improvise techniques for secure implantation. Here, we describe a simple technique for creating suture tabs within the ADM for efficient fixation of the ADM-implant construct to the chest wall.

Soft Tissue Coverage of Complex Periprosthetic Defects in Patients With Total Knee Arthroplasty: Analysis of Factors That Influence Reconstructive and Functional Outcomes.

INTRODUCTION: Wound breakdown following total knee arthroplasty (TKA) increases the risk of device exposure, infection, and major amputation. Although a variety of options to facilitate coverage of compromised knee joint prostheses exist, the relative safety, efficacy, and functional impact of each has not been determined. OBJECTIVE: This study aims to identify those perioperative factors that influence reconstructive and functional outcomes in patients with periprosthetic TKA defects. MATERIALS AND METHODS: A 5-year retrospective review of outcomes following surgical management of TKA wounds was undertaken. Data pertaining to the timing of presentation, type and frequency of operative interventions, rates of implant/limb salvage, ambulatory status, visual analogue scores (VAS) for pain, and complications were collected. RESULTS: Thirty patients were identified during the study period with a mean follow-up of 20 months. Rates of limb salvage (66.7% vs. 91.7% vs. 75% vs. 0%, P < .001) and postoperative ambulation (100% vs. 83.3% vs. 75% vs. 54.5%, P = .036) were significantly different between patients who underwent primary closure, local muscle flap coverage, free tissue transfer coverage, and above-the-knee amputation, respectively. The number of debridements prior to definitive closure did not significantly influence rates of limb salvage (P = .21). Active tobacco use (odds ratio [OR], 4; 95% confidence interval [CI], 1.13-14.2; P = .03) and time to initial presentation from the index joint replacement (OR, 0.99; 95% CI, 0.9-1.0; P = .04) adversely impacted device salvage. Both of these factors similarly influenced the overall likelihood of limb salvage (OR, 6.5; 95% CI, 1.5-28.8; P = .01; OR, 0.99; 95% CI, 0.99-1.0; P = .04). The VAS scores were not significantly different between index closure types (P = .77) but were significantly lower for patients who required < 10 debridements prior to definitive closure (P = .02). CONCLUSIONS: Early intervention with limited-frequency, and thorough debridement and prompt soft tissue coverage optimizes the chances of functional limb salvage in patients with complex periprosthetic TKA wounds. These findings may inform practice patterns and surgical treatment of patients presenting with compromised TKA and suggest that early involvement by reconstructive surgeons should be advocated to optimize reconstructive and functional outcomes in this difficult patient population.

The 4-flap Jester's Hat Technique for Nipple Reduction.

Macrothelia, or nipple hypertrophy, is a condition that may cause severe psychological distress to those who suffer from it. Although effective in their primary goal of reducing nipple diameter and projection, previously reported techniques in nipple reduction suffer from imperfect aesthetic outcomes with noticeable scarring patterns, anatomically anomalous shape, and a smoothing of the natural ruffles of the nipple. We propose a simple technique to nipple reduction that improves upon previous techniques and creates a more naturally appearing nipple. A 4-flap technique resembling a jester's hat is described whereby suture lines are concealed within the central nipple to recreate the naturally ruffled appearance of a native nipple. Four patients have undergone this technique at a single institution with 100% patient satisfaction and no postoperative complications. Nipple sensation was maintained in all patients postoperatively. A 4-flap nipple reduction technique is a viable alternative to previously described techniques, which may offer more anatomically congruent results.

Traction-assisted Internal Negative Pressure Wound Therapy With Bridging Retention Sutures to Facilitate Staged Closure of High-risk Wounds Under Tension.

BACKGROUND/OBJECTIVE: Loss of domain often complicates attempts at delayed wound closure in regions of high tension. Wound temporization with traction-assisted internal negative pressure wound therapy (NPWT), using bridging retention sutures, can minimize the effects of edema and elastic recoil that contribute to progressive tissue retraction over time. The investigators evaluated the safety and efficacy of this technique for complex wound closure. MATERIALS AND METHODS: Between May 2015 and November 2015, 18 consecutive patients underwent staged reconstruction of complex and/or contaminated soft tissue defects utilizing either conventional NPWT or modified NPWT with instillation and continuous dermatotraction via bridging retention sutures. Instillation of antimicrobial solution was reserved for wounds containing infected/exposed hardware or prosthetic devices. Demographic data, wound characteristics, reconstructive outcomes, and complications were reviewed retrospectively. RESULTS: Eighteen wounds were treated with traction-assisted internal NPWT using the conventional (n = 11) or modified instillation (n = 7) technique. Defects involved the lower extremity (n = 14), trunk (n = 3), and proximal upper extremity (n = 1), with positive cultures identified in 12 wounds (67%). Therapy continued for 3 to 8 days (mean, 4.3 days), resulting in an average wound surface area reduction of 78% (149 cm² vs. 33 cm²) at definitive closure. Seventeen wounds (94%) were closed directly, whereas the remaining defect required coverage with a local muscle flap and skin graft. At final follow-up (mean, 12 months), 89% of wounds remained closed. In 2 patients with delayed, recurrent periprosthetic infection (mean, 7.5 weeks), serial debridement/hardware removal mandated free tissue transfer for composite defect reconstruction. CONCLUSION: Traction-assisted internal NPWT provides a safe and effective alternative to reduce wound burden and facilitate definitive closure in cases where delayed reconstruction of high-tension wounds is planned.

Systematic Review and Comparative Meta-Analysis of Outcomes Following Pedicled Muscle versus Fasciocutaneous Flap Coverage for Complex Periprosthetic Wounds in Patients with Total Knee Arthroplasty.

BACKGROUND: In cases of total knee arthroplasty (TKA) threatened by potential hardware exposure, flap-based reconstruction is indicated to provide durable coverage. Historically, muscle flaps were favored as they provide vascular tissue to an infected wound bed. However, data comparing the performance of muscle versus fasciocutaneous flaps are limited and reflect a lack of consensus regarding the optimal management of these wounds. The aim of this study was to compare the outcomes of muscle versus fasciocutaneous flaps following the salvage of compromised TKA. METHODS: A systematic search and meta-analysis were performed to identify patients with TKA who underwent either pedicled muscle or fasciocutaneous flap coverage of periprosthetic knee defects. Studies evaluating implant/limb salvage rates, ambulatory function, complications, and donor-site morbidity were included in the comparative analysis. RESULTS: A total of 18 articles, corresponding to 172 flaps (119 muscle flaps and 53 fasciocutaneous flaps) were reviewed. Rates of implant salvage (88.8% vs. 90.1%, P=0.05) and limb salvage (89.8% vs. 100%, P=0.14) were comparable in each cohort. While overall complication rates were similar (47.3% vs. 44%, P=0.78), the rates of persistent infection (16.4% vs. 0%, P=0.14) and recurrent infection (9.1% vs. 4%, P=0.94) tended to be higher in the muscle flap cohort. Notably, functional outcomes and ambulation rates were sparingly reported. CONCLUSIONS: Rates of limb and prosthetic salvage were comparable following muscle or fasciocutaneous flap coverage of compromised TKA. The functional morbidity associated with muscle flap harvest, however, may support the use of fasciocutaneous flaps for coverage of these defects, particularly in young patients and/or high-performance athletes.