Head and Neck Reconstruction: Does Surgical Specialty Affect Complication Rates?

BACKGROUND: Reconstruction of head and neck defects resulting from resection of head and neck masses is performed by both plastic surgeons and otolaryngologists. The American College of Surgeons National Surgical Quality Improvement (NSQIP) database allows one to directly compare the outcomes for a given procedure based upon specialty. The purpose of this study is to compare outcomes and resource utilization of microvascular head and neck reconstruction between plastic surgery and otolaryngology. METHODS: Institutional review board approval was obtained and NSQIP was queried from 2005 to 2015 with inclusion of Current Procedural Terminology codes for free tissue transfer performed for head and neck reconstruction. Outcomes were compared between cases having otolaryngology and plastic surgery as performing the free flap reconstruction. RESULTS: During 2005 to 2015, a total of 2,322 flaps were performed, 893 by plastic surgery and 1,429 by otolaryngology. Average length of stay (LOS) was 13.7 and 11.4 days for plastic surgery and otolaryngology, respectively. It was found that plastic surgery performed more osteocutaneous flaps than otolaryngology. Higher rates of superficial surgical site infection, deep surgical site infections, wound dehiscence, myocardial infarction, bleeding complications, sepsis, unplanned return to the operating room, and unplanned readmission were observed for patients treated by otolaryngology (p < 0.05). CONCLUSION: This study shows plastic surgery patients have superior outcomes with regards to free tissue transfers of the head and neck when compared with otolaryngology patients. Although plastic surgery patients experienced a longer LOS, the significantly lower complication rate supports an overall more optimal resource utilization. Future studies may elucidate potential cost savings in patients treated by plastic surgery.

Examining the Role of Antimicrobial Irrigation and Capsular Contracture: A Systematic Review and Meta-analysis.

PURPOSE: The purpose of this study was to conduct a meta-analysis to determine if irrigation of breast implant pockets with antibiotics reduces the rate of capsular contracture (CC). Capsular contracture is the most common complication after primary augmentation mammoplasty, yet its etiology remains cryptogenic. METHODS: PubMed was searched for publications from January 1 of 2000 through October of 2015. Studies with the following criteria were included: primary breast augmentation with implants, use of antimicrobial irrigation (AMI), and documentation of CC. The primary outcome studied was incidence of CC. The quality of included studies was assessed independently. Studies were meta-analyzed to obtain a pooled odds ratio (OR) describing the effect of AMI on CC. RESULTS: The meta-analysis included 8 studies and 10,923 patients. A total of 5348 patients received AMI, and 5575 patients did not. Our analysis revealed that the combined AMI, the antibiotic irrigation subgroup, and the iodine subgroup were associated with an increased propensity for CC [OR, 2.60; 95% confidence interval (CI), 2.3-2.94, I = 97%, P < 0.00001; OR, 1.42; 95% CI, 1.14-1.78, I = 89%, P < 0.00001; OR, 0.54; 95% CI, 0.24-1.22, P = 0.05; I = 73], respectively. CONCLUSIONS: Antimicrobial irrigation of implant pockets fails to reduce the propensity for CC. The authors recommend that further prospective multicenter trials be conducted to further elucidate the role of antibiotic irrigation in CC.

Left-Sided Breast Irradiation does not Result in Increased Long-Term Cardiac-Related Mortality Among Women Treated with Breast-Conserving Surgery.

BACKGROUND: Standard therapy following lumpectomy for breast cancer has included adjuvant whole-breast radiotherapy. Recent, long-term studies have suggested a possible association between left-sided whole breast radiotherapy and long-term cardiac-related mortality. We sought to determine whether left-sided breast cancers treated with breast-conserving treatment have worse cardiac-related outcomes. METHODS: The surveillance, epidemiology, and end results database was queried for female breast cancer cases diagnosed from 1990 to 1999. Subjects who underwent lumpectomy and adjuvant radiotherapy were included for study and grouped according to laterality. The primary outcome measure was the rate of cardiac-related mortality. Secondary outcome measures were overall and cancer-specific survival. A Cox proportional hazards model was constructed to analyze the primary outcome measure and included age, race, grade, stage, hormone receptor status, and histologic subtype. RESULTS: A total of 66,687 subjects were identified. These were divided equally by laterality groups: 33,866 left (50.8 %) and 32,801 right (49.2 %). Median follow-up was 15.5 years, and the groups were otherwise well-matched. Left-sided cancer was not associated with poorer survival for any of the metrics. Fifteen-year overall survival and disease-specific survival were 62.8 and 87.0 % for left-sided and 63.0 and 87.1 % for right-sided breast cancers, respectively (p = 0.260, p = 0.702). Rate of cardiac-related mortality at 5-, 10-, and 15-year follow-up were 1.5, 4.3, and 7.7 % for left-sided cancers and 1.6, 4.4, and 8.0 % for right-sided cancers, respectively (p = 0.435). CONCLUSIONS: In this large population-based study, women receiving left-sided external beam radiation for breast cancer did not have an increase in cardiac-related mortality.

Evaluation of Antibiotic Irrigation Versus Saline Irrigation in Reducing the Long-Term Incidence and Severity of Capsular Contraction After Primary Augmentation Mammoplasty.

BACKGROUND: Capsular contracture is the most frequent complication after primary augmentation mammoplasty. The practice of irrigating implant pockets with a triple antibiotic solution has been widely adopted in an attempt to prevent capsular contracture, despite a limited understanding of the inciting pathophysiology. Capsular contracture is commonly attributed to subclinical infection, immunologic response to breast implants, and chronic inflammatory changes caused by the presence of the implants. The purpose of this study was to evaluate if antibiotic irrigation was superior to saline in reducing the long-term incidence and severity of capsular contracture after primary augmentation mammoplasty. METHODS: A retrospective cohort study enrolling patients having undergone primary augmentation mammoplasty by the authors between 2011 and 2012 for all women satisfying inclusion and exclusion criteria was conducted using prospectively collected quality assurance data. Surgical technique between surgeons was controlled such that the only difference was the use of antibiotic irrigation in the treatment group. Analysis with predetermined 95% confidence intervals was performed using χ test and analysis of variance. RESULTS: Fifty-five patients underwent surgery. Twenty-eight patients treated with saline (control) were included, ranging in age from 22 to 50 years with a mean follow-up time of 2.8 years. Twenty-seven patients were treated with triple antibiotic solution (treatment) ranging in age from 22 to 56 years with a mean follow-up time of 2.6 years. Rates of capsular contracture were 3.6% (control group) and 3.7% (treatment group). χ statistic was found to be 0.0014 (P = 0.97) and analysis of variance F value was 1 (P = 0.39). CONCLUSIONS: There was no difference between triple antibiotic and saline irrigation in the incidence or severity of capsular contracture at 2.8 years follow-up when high-quality surgical technique is used.

Learning the oral and cutaneous signs of micronutrient deficiencies.

Wound healing is a complex process that is influenced by multiple systemic factors, including nutritional status. While nutritional support is commonly recognized as an important aspect of comprehensive wound management, the focus is typically on replacement of macronutrients, specifically calories and protein. Our experience strongly suggests that micronutrients are equally important, that micronutrient deficiencies are common, and that correction of these deficiencies frequently leads to wound healing when incorporated into a comprehensive wound management program. This article provides guidelines for assessment and management of micronutrient deficiencies.

Nerve Allografts: Current Utility and Future Directions.

Processed nerve allograft is a widely accepted tool for reconstructing peripheral nerve defects. Repair parameters that need to be considered include gap length, nerve diameter, nerve type (motor, sensory, or mixed), and the soft tissue envelope. Although the use of processed nerve allograft must be considered based on each unique clinical scenario, a rough algorithm can be formed based on the available animal and clinical literature. This article critically reviews the current surgical algorithm, defines the role of processed nerve allograft compared with nerve autograft, and discusses how this role may change in the future.

Operative Trends in Orthopaedic Hand Surgery Fellowships.

Objective Since 1958, more than 50 postresidency fellowship programs in hand surgery have been introduced within the United States. Ongoing changes in health care and medical education necessitate the evaluation of these fellowships. The purpose of this study is to identify trends in operative experience over time regarding procedure volume, surgery type, and anatomic region. Materials and Methods National Accreditation Council for Graduate Medical Education (ACGME) case logs of graduating orthopaedic hand surgery fellows were evaluated for years 2011 to 2019. Procedures were grouped according to ACGME-defined categories for hand surgery. The mean number of procedures per fellow in each category was trended over time using a Mann-Kendall test. Results All 1,257 fellows were included. The mean number of procedures completed annually by each fellow increased from 797.6 in 2011 to 945.6 in 2019 ( p < 0.01). Over the course of the study period, there were increases in the number of "soft tissue," "fracture," and "nerve" procedures ( p < 0.001), while the number of "congenital" procedures decreased ( p < 0.05). Additionally, small but statistically significant increases were found in "amputation," "Dupuytren's," and "decompression of tendon sheath/synovectomy/ganglions" procedures ( p < 0.01). Conclusion There has been an increase in the number of procedures performed by orthopaedic hand surgery fellows over the past decade. This appears to be due to the increase in nerve, fracture, and soft tissue categories, and there has been a decrease in the number of congenital cases completed. These data confirm that the operative experiences for most hand surgery fellows are robust and growing over time.

Initial Treatment Choice Affects Cost-Effectiveness and Reintervention Rates for Dupuytren Contracture: A National Census Among Veterans Affairs Patients.

BACKGROUND: A multitude of treatments for Dupuytren contracture are available, including both invasive and minimally invasive options. This study compares the reintervention rates and costs associated with various treatment options for Dupuytren disease (DD) within the Veterans Affairs (VA) Health Administration. METHODS: Using the Corporate Data Warehouse, a national census was performed including all patients treated for DD in years 2014 to 2020 within the VA health care system. Patients treated with collagenase clostridium histolyticum (CCH), percutaneous needle aponeurotomy (PNA), open fasciotomy, palmar fasciectomy, single finger fasciectomy, and multifinger fasciectomy were compared. The total cost of initial treatment was compared between modalities. The 5-year reintervention rates were compared using a Kaplan-Meier analysis. RESULTS: During the study period, 8530 patients were treated for DD (3501 fasciectomy, 3351 CCH, 880 PNA, 798 fasciotomy). The overall median treatment cost was found to be the least for PNA (P < .0001). The 5-year reintervention rates were significantly lower for single finger fasciectomy (6.5%), operative fasciotomy (8.2%), and palmar fasciectomy (9%) when compared with PNA (12.3%), multifinger fasciectomy (13.1%), and CCH (14.4%) (P < .001). However, reintervention rates were comparable between patients treated with PNA, multifinger fasciectomy, and CCH (P > .05). CONCLUSIONS: Within the VA population, PNA is the most affordable procedure per treatment episode and is associated with reintervention rates that are comparable to those of CCH. Multifinger fasciectomy, CCH, and PNA had comparable reintervention rates. The differences in reintervention rates may partially be explained by patients' willingness to consider additional treatment to correct any remaining or recurrent deformity.

Quality Improvement: A Primer for Plastic Surgeons.

SUMMARY: It is the duty of all health care workers to improve the quality of care and patient outcomes. Quality improvement is a component of health policy required by residency accrediting bodies and is a mandatory component of postgraduate medical education. It is imperative for plastic surgeons to develop skills in quality improvement to ensure that they can cope with increased patient volumes while ensuring that their patients have access to care that is safe, equitable, effective, efficient, timely, and patient-centered. This article discusses techniques and tools often used in quality improvement. Challenges encountered with quality improvement initiatives are discussed, and recommendations on how to handle them as they occur are offered. This primer provides a foundation for plastic surgeons and their staff to guide their quality improvement efforts. A hypothetical quality improvement project is used as an example to illustrate the concepts of quality improvement in this primer.

Residency Training and Hand Surgery Practice Patterns: A National Surgical Quality Improvement Program Database Analysis.

Introduction Fellowship-trained hand surgeons may have residency training in either orthopedic, plastic, or general surgery, generating significant variability in education background. To study the effect of different training backgrounds on practice pattern variations, we utilized the NSQIP (National Surgical Quality Improvement Database) database to assess hand surgery volumes and case variety by specialty. Materials and Methods NSQIP years 2008 to 2017 was queried with hand surgery current procedural terminology codes defined by the American Board of Orthopedic Surgery. Procedures were grouped according to type and specialty, and relative rates calculated. Hand society membership data were used to determine if procedural volume for each specialty in each category and overall contribution to the volume of hand surgery performed nationally was distributed in accordance with membership data. Results A total of 145,015 hand surgeries were performed; 13,267 (9.1%) by general surgeons, 28,402 (19.6%) by plastic surgeons, and 103,346 (71.3%) by orthopedic surgeons. Orthopedic surgeons performed significantly more bone, fracture, joint, and tendon cases. General surgeons and plastic surgeons performed higher than expected numbers of soft tissue coverage and cases overall with respective excesses of 183 and 22%. Conclusion Hand surgery is an available fellowship pathway from multiple residencies. Fellowship training does not level the field of real-world practice patterns. Residency training experiences significantly impact practice.

Thrombolytic Salvage of the Frostbitten Upper Extremity: A Systematic Review.

BACKGROUND: Vascular thrombosis secondary to frostbite can lead to ischemic tissue damage in severe cases. Threatened extremities may be salvaged with thrombolytics to restore perfusion; however, current data are limited to single institution case series. The authors performed a systematic review to determine the efficacy of thrombolytic therapy in treating upper extremity frostbite. METHODS: PubMed, EBSCO, and Google Scholar were queried using the keywords "thrombolytics," "frostbite," "fibrinolytics," and "tPA." Exclusion criteria were failure to delineate anatomic parts injured, failure to report number of limbs salvaged, animal studies, and non-English language publications. Thrombolytic therapy was defined as intraarterial (IA) or intravenous (IV) administration of tissue plasminogen activator (tPA), alteplase, urokinase, streptokinase, or any tPA derivative. RESULTS: A total of 42 studies were identified, with 13 satisfying inclusion criteria. Eight studies reported catheter-directed IA thrombolysis, four reported systemic IV administration, and 1 reported both methods. A total of 157 patients received thrombolytics. In all, 73 upper extremity digits were treated by IA route and 136 digits were treated by IV route. Overall upper extremity digit salvage rate was 59%. There was a significantly higher salvage rate in digits treated by the IA route compared to the IV route. CONCLUSIONS: Thrombolytics, particularly when administered by the intra-arterial route, are emerging as a promising treatment of severe frostbite of the upper extremity, increasing digit salvage rates.

An Analysis of Complications and Bone Defect Length With the Use of Induced Membrane Technique in the Upper Limb: A Systematic Review.

Background: The induced membrane technique was originally described as a technique for the reconstruction of long bone defects. The authors performed a systematic review to determine whether the use of the induced membrane technique is effective in large bony defects in the upper extremity. Methods: A qualitative systematic review was conducted using PubMed, EBSCO, and Google Scholar databases to record all studies reporting on complications of the induced membrane technique in the upper extremity. Studies written after 1990 in English language journals met the inclusion criteria. Exclusion criteria were non-English language publications, animal studies, failure to identify the location of the bone defect, failure to identify whether complications were associated with the procedure, and failure to define the length of bone defect. Results: A total of 1422 studies were identified in the original search. Twelve studies satisfied the criteria for inclusion. A total of 70 patients with 83 upper extremity cases were reported: 1 proximal interphalangeal joint, 22 phalanges, 8 metacarpals, 37 forearms, 14 humeri, and 1 clavicle. The mean bone defect size was 4.0 cm (SD, 1.5). The most common complication was infection. We found that complication rates were independent of the location of the bone defect. Complication rates in the upper extremity ranged from 0% to 100%, with a total weighted mean of 10%. Conclusion: The induced membrane technique is an emerging possible treatment of large bone defects in the upper extremity. More research is needed to determine the outcomes of the induced membrane technique in the upper extremity.

Preparation for Hand Surgery Fellowship: A Comparison of Resident Training Pathways.

BACKGROUND: Hand surgery is a unique subspecialty in which one can train after completion of either a plastic, orthopedic, or general surgical residency. This study compared hand surgery experience in residency among these different training pathways. METHODS: The Accreditation Council for Graduate Medical Education case logs of graduating residents in general surgery, orthopedics, and plastic surgery were evaluated for years 2009 through 2018. Cases were grouped according to the Accreditation Council for Graduate Medical Education-defined categories for hand surgery. Comparisons between specialties were made using a one-tail analysis of variance with a 95 percent confidence interval. RESULTS: There were 19,159 total residents studied: 11,189 general surgery, 7290 orthopedic, and 1040 plastic surgery. General surgery performed the fewest total hand surgeries per individual resident, while plastic surgery performed the most. Plastic surgery performed more operations than orthopedics in all categories studied including tendon, nerve, amputation, soft tissue, fracture, vascular cases, with p < 0.01 for each category. CONCLUSIONS: There are significant differences in the preparation of resident trainees for entry into a hand surgery fellowship, and the lack of uniform exposure to hand surgery represents an opportunity for improvement. Fellowship directors and the tripartite specialty board should embrace the differences among general surgery, orthopedic, and plastic surgery graduates early in the fellowship year and address the expected differences. Trainees' education should be optimized on an individualized basis with targeted education, additional educational courses, and encouraging trainees to seek out clinical challenges to foster their continued professional growth.

What urologists need to know about male to female genital confirmation surgery (vaginoplasty): techniques, complications and how to deal with them.

Vaginoplasty is the most commonly performed genital surgery for gender affirmation. Male-to-female (MTF) patients are roughly four times more likely to undergo genital surgery than female-to-male (FTM) patients. Penile inversion vaginoplasty is the most common technique used today, although there are also lesser used alternative methods including visceral interposition and pelvic peritoneal vaginoplasty. In general, outcomes are excellent, and many of the complications are self-limited. Most surgeons performing genital surgery for gender dysphoria adhere to the World Professional Association for Transgender Health (WPATH) guidelines for determining who is a candidate for surgery. Currently, there are no absolute contraindications to vaginoplasty in a patient who is of the age of majority in their country, only relative contraindications which include active smoking and morbid obesity. Important complications include flap necrosis, rectal and urethral injuries, rectal fistula, vaginal stenosis, and urethral fistula. When performed correctly in excellent surgical candidates by skilled surgeons, vaginoplasty can be a rewarding surgical endeavor for the patient and surgeon.

Depression is associated with worse outcomes among women undergoing breast reconstruction following mastectomy.

BACKGROUND: The causes of depression after breast reconstruction include worse outcomes, longer recovery times, and, sometimes, additional operations. Despite a plethora of data examining the effect of depression after breast reconstruction, there is little information to assess if concurrent depression affects patient outcomes in a similar manner. Thus, we sought to answer this question: Do depressed women undergoing breast reconstruction have worse outcomes? METHODS: The United States National Inpatient Sample was queried during 2010-2013 for all patients undergoing breast reconstruction after mastectomy. Patients with a diagnosis of depression at the time of breast reconstruction were compared to those who did not have depression at the time of breast reconstruction; patients who had any of the corresponding ICD-9 procedure codes for breast reconstruction and the single diagnostic code for depression included in their electronic medical record were included in the database sample. Significance testing and risk-adjusted multivariate logistic regression were performed with SPSS. RESULTS: A total of 175,508 patients were included in this study, of which 35,473 had depression at the time of breast reconstruction and 140,035 did not. Depression was associated with an increased age, length of stay, greater cost of care, more comorbidities, and higher incidence of pulmonary, hematologic, gastrointestinal, infectious, wound, and venous thromboembolic complications, p<0.05. Pulmonary, genitourinary, and hematologic complications, infection, VTE, wound, and transfusion were associated with depression when a multivariate risk-adjusted regression was performed. CONCLUSION: A co-morbid diagnosis at the time of breast reconstruction should prompt the breast reconstruction team to ensure that depressed patients have their depression managed and all co-morbidities optimized and treated prior to undergoing breast reconstruction to ensure optimal patient outcomes.

Thrombolytic Salvage of Threatened Frostbitten Extremities and Digits: A Systematic Review.

Frostbite is a cold injury that results in soft tissue loss and can lead to amputation. Vascular thrombosis following injury causes ischemic tissue damage. Despite understanding the pathology, its treatment has remained largely unchanged for over 30 years. Threatened extremities may be salvaged with thrombolytics to restore perfusion. The authors performed a systematic review to determine whether thrombolytic therapy is effective and to identify patients who may benefit from this treatment. The Pubmed, EBSCO, and Google Scholar databases were queried using the key words "thrombolytics," "frostbite," "fibrinolytics," and "tPA." Studies written after 1990 in English met inclusion criteria. Exclusion criteria were failure to delineate anatomic parts injured, failure to report number of limbs salvaged, animal studies, and non-English language publications. Thrombolytic therapy was defined as administration of tPA, alteplase, urokinase, or streptokinase. Forty-two studies were identified and 17 included. Included were 1 randomized trial, 10 retrospective studies, 2 case series, and 4 case reports. One thousand eight hundred and forty-four limbs and digits in 325 patients were studied and 216 patients treated with thrombolytics and 346 amputations performed. The most common means of thrombolysis was intra-arterial tPA. The most common duration of therapy was 48 hours. Limb salvage rates ranged from 0% to 100% with a weighted average of 78.7%. Thrombolytics are a safe and effective treatment of severe frostbite. They represent the first significant advancement in frostbite treatment by preventing otherwise inevitable amputations warranting both greater utilization and further research to clarify the ideal thrombolytic protocol.