Standard Fixed Enoxaparin Dosing for Venous Thromboembolism Prophylaxis Leads to Low Peak Anti-Factor Xa Levels in Both Head and Neck and Breast Free Flap Patients.

BACKGROUND: Venous thromboembolism (VTE) is a serious complication, particularly in cancer patients undergoing free flap reconstruction. Subcutaneous enoxaparin is the conventional prophylaxis for VTE prevention, and serum anti-factor Xa (afXa) levels are being increasingly used to monitor enoxaparin activity. In this study, free flap patients receiving standard enoxaparin prophylaxis were prospectively followed to investigate postoperative afXa levels and 90-day VTE and bleeding-related complications. METHODS: Patients undergoing free tissue transfer during an 8-month period were identified and prospectively followed. Patients received standard fixed enoxaparin dosing at 30 mg twice daily in head and neck (H&N) and 40 mg daily in breast reconstructions. Target peak prophylactic afXa range was 0.2 to 0.5 IU/mL. The primary outcome was the occurrence of 90-day postoperative VTE- and bleeding-related events. Independent predictors of afXa level and VTE incidence were analyzed for patients that met the inclusion criteria. RESULTS: Seventy-eight patients were prospectively followed. Four (5.1%) were diagnosed with VTE, and six (7.7%) experienced bleeding-related complications. The mean afXa levels in both VTE patients and bleeding patients were subprophylactic (0.13 ± 0.09 and 0.11 ± 0.07 IU/mL, respectively). Forty-six patients (21 breast, 25 H&N) had valid postoperative peak steady-state afXa levels. Among these, 15 (33%) patients achieved the target prophylactic range: 5 (33%) H&N and 10 (67%) breast patients. The mean afXa level for H&N patients was significantly lower than for breast patients (p = 0.0021). Patient total body weight was the sole negative predictor of afXa level (R 2 = 0.47, p < 0.0001). CONCLUSION: Standard fixed enoxaparin dosing for postoperative VTE prophylaxis does not achieve target afXa levels for the majority of our free flap patients. H&N patients appear to be a particularly high-risk group that may require a more personalized and aggressive approach. Total body weight is the sole negative predictor of afXa level, supporting a role for weight-based enoxaparin dosing.

Flap Closure of Spinal Defects in High-Risk Patients: A 10-Year Institutional Experience.

BACKGROUND: Complication rates after spinal surgery are high, in part because of surgical advancements that have made procedures available to a broader range of medically complicated patients. The high rates of infection, hematoma, and dehiscence resulting in open wounds after spinal surgery often warrant plastic surgery involvement. In this study, we aim to examine the effects of preoperative and operative risk factors on complication rates, reoperation rates, and hospital length of stay after flap reconstruction of spinal defects. METHODS: A retrospective review was performed of 373 patients who required flap reconstruction for spinal wound closure at our institution between 2003 and 2013. Data regarding demographics, comorbidities, operative variables, and postreconstructive course were collected. RESULTS: Of the 373 patients, 97.3% had at least 1 comorbid condition associated with poor wound healing, 91.2% had a significant wound condition at the time of reconstruction, and 81.8% had a history of 2 or more spinal surgeries. After reconstruction, average hospital stay was 14 days, with 35% of patients developing complications and 30% requiring reoperation. Risk factors including elevated body mass index, diabetes, tobacco use, steroid use, low prealbumin level, therapeutic anticoagulation, infection, history of spine surgery, multilevel spinal reconstruction, and spinal hardware were associated with complications, reoperations, and prolonged length of stay. CONCLUSIONS: Local muscle flap coverage is an effective strategy for the reconstruction of spinal defects in medically complex patients. To reduce the inherently high risks associated with paraspinous reconstruction in this challenging population, special consideration should be given to preoperative and operative variables associated with poor outcomes. Early coordination between spine and plastic surgeons should be considered in patients at high-risk of wound complications.

Quick Calculation of Breast Resection Mass Using the Schnur Scale.

In 1991, Dr Paul Schnur and his colleagues published an article correlating the weight of breast tissue to be removed in a breast reduction operation with the total body surface area (BSA) of the patient. They presented a very cogent argument for selecting three groups of patients: those with medical indications for operation, those who merit review, and those whose operation could be considered cosmetic. The Schnur Sliding Scale is widely used by insurance companies in the western United States in the process of preauthorizing breast reduction operations, and its use may be spreading eastward. The Schnur group presented a nomogram for calculating BSA and a scale in the form of a table for guiding a determination of whether the patient is a reconstructive patient as opposed to an aesthetic patient. We have combined the scale and the BSA nomogram for a simplified nomogram calculator that facilitates rapid determination of anticipated tissue weight of resection for a patient of a given size. This calculator yields the required weight of tissue to remove with just knowledge of the patient's height and weight and the use of a straight edge. We demonstrate and compare performance of this calculation by hand and by nomogram. There is ample evidence that the practice of applying the Schnur Sliding Scale may be prohibitive to symptomatic patients seeking reduction mammaplasty and should be abandoned. While this practice continues, our simplified Schnur Sliding Scale nomogram is meant to help easily determine the insurer-required minimum breast resection weight and thereby both improve patient counseling prior to planning surgery and assist the surgeon with achieving insurer reimbursement for the procedure while avoiding rejected claims.

Graphical Calculation of Estimated Energy Expenditure in Burn Patients.

BACKGROUND: Historically, estimated energy expenditure (EEE) has been related to the percent of body surface area burned. Subsequent evaluations of these estimates have indicated that the earlier formulas may overestimate the amount of caloric support necessary for burn-injured patients. Ireton-Jones et al derived 2 equations for determining the EEE required to support burn patients, 1 for ventilator-dependent patients and 1 for spontaneously breathing patients. Evidence has proved their reliability, but they remain challenging to apply in a clinical setting given the difficult and cumbersome mathematics involved. This study aims to introduce a graphical calculation of EEE in burn patients that can be easily used in the clinical setting. METHODS: The multivariant linear regression analysis from Ireton-Jones et al yielded equations that were rearranged into the form of a simple linear equation of the type y = mx + b. By choosing an energy expenditure and the age of the subject, the weight was calculated. The endpoints were then calculated, and a graph was mapped by means of Adobe FrameMaker. RESULTS: A graphical representation of Ireton-Jones et al's equations was obtained by plotting the weight (kg) on the y axis, the age (years) on the x axis, and a series of parallel lines representing the EEE in burn patients. The EEE has been displayed graphically on a grid to allow rapid determination of the EEE needed for a given patient of a designated weight and age. Two graphs were plotted: 1 for ventilator-dependent patients and 1 for spontaneously breathing patients. Correction factors for sex, the presence of additional trauma, and obesity are indicated on the graphical calculators. CONCLUSIONS: We propose a graphical tool to calculate caloric requirements in a fast, easy, and portable manner.

Simplified Calvarial Reconstruction: Coverage of Bare Skull With GammaGraft Promotes Granulation and Facilitates Skin Grafting.

Repair of scalp defects with exposed calvaria remains a difficult clinical problem. Herein, we present a simple alternative method of scalp reconstruction. Coverage of bare skull with GammaGraft (Promethean LifeSciences, Inc, Pittsburgh, PA) promotes the evolution of granulation tissue and permits subsequent skin grafting without need for burring, drilling, or other manipulation of the outer table of the calvaria. A retrospective review of patients undergoing scalp reconstruction utilizing GammaGraft and subsequent skin grafting was performed at our institution. From our cohort, 5 patients treated with GammaGraft and subsequent skin grafting had both immediate and long-term follow-up available. Indications for scalp reconstruction included erosions of prior skin grafts and direct excision of full-thickness scalp and pericranium. Average time to definitive skin grafting was 3 weeks; repeat application of GammaGraft was required in some patients with reapplication to subsequent smaller wounds as healing occurred. Complications were minor and consisted of ongoing wound drainage. Alternative flap reconstruction was not required in any patient due to treatment failures. No major complications, wound infections, or early reoperations occurred in any of the patients; 1 patient to date has required repeat reconstruction due to recurrent disease. Coverage of bare skull with GammaGraft and subsequent skin grafting provides a simple and elegant solution to an often too difficult clinical problem. Confirmed by results in out limited series, the utilization of GammaGraft in calvarial reconstruction represents an alternative method in surgical care of complex scalp defects with exposed bone.

Upper-extremity transplantation using a cell-based protocol to minimize immunosuppression.

OBJECTIVE: To minimize maintenance immunosuppression in upper-extremity transplantation to favor the risk-benefit balance of this procedure. BACKGROUND: Despite favorable outcomes, broad clinical application of reconstructive transplantation is limited by the risks and side effects of multidrug immunosuppression. We present our experience with upper-extremity transplantation under a novel, donor bone marrow (BM) cell-based treatment protocol ("Pittsburgh protocol"). METHODS: Between March 2009 and September 2010, 5 patients received a bilateral hand (n = 2), a bilateral hand/forearm (n = 1), or a unilateral (n = 2) hand transplant. Patients were treated with alemtuzumab and methylprednisolone for induction, followed by tacrolimus monotherapy. On day 14, patients received an infusion of donor BM cells isolated from 9 vertebral bodies. Comprehensive follow-up included functional evaluation, imaging, and immunomonitoring. RESULTS: All patients are maintained on tacrolimus monotherapy with trough levels ranging between 4 and 12 ng/mL. Skin rejections were infrequent and reversible. Patients demonstrated sustained improvements in motor function and sensory return correlating with time after transplantation and level of amputation. Side effects included transient increase in serum creatinine, hyperglycemia managed with oral hypoglycemics, minor wound infection, and hyperuricemia but no infections. Immunomonitoring revealed transient moderate levels of donor-specific antibodies, adequate immunocompetence, and no peripheral blood chimerism. Imaging demonstrated patent vessels with only mild luminal narrowing/occlusion in 1 case. Protocol skin biopsies showed absent or minimal perivascular cellular infiltrates. CONCLUSIONS: Our data suggest that this BM cell-based treatment protocol is safe, is well tolerated, and allows upper-extremity transplantation using low-dose tacrolimus monotherapy.

Surgical Management of Hand Deformity in Epidermolysis Bullosa: Initial Experience and Technique.

Epidermolysis bullosa describes a rare group of genetic mucocutaneous disorders characterized by excessive epithelial fragility resulting in mechanically induced blistering and abnormal wound healing.1,2 Its prevalence and incidence are 8.2 and 19.6 per 1,000,000 live births, respectively.2 Gene therapy, protein replacement, and cell therapy strategies have been investigated, but there is currently no cure.2.

Ocular outcomes after gold weight placement and facial nerve resection.

OBJECTIVE: To assess the effectiveness of acute gold weight placement after facial nerve resection and to determine the role of concomitant lower eyelid procedures. STUDY DESIGN: Retrospective review. SUBJECTS AND METHODS: Twenty-two patients who received an upper eyelid gold weight at the time of parotidectomy and facial nerve resection were reviewed to assess ocular outcomes. RESULTS: After gold weight placement, twelve patients (12 of 22, 54.5%) subsequently presented with symptomatic ectropion (n = 9) and/or lagophthalmos (n = 5). Nine patients received a lower eyelid procedure (7 tarsal strips only, 1 tarsal strip combined with a lateral tarsorrhaphy, and 1 lateral tarsorrhaphy only). Six patients, in addition to a gold weight, also underwent a static sling to the midface at the time of facial nerve resection. None of these 6 received a subsequent lower eyelid procedure. Two patients required gold weight upsizing. Two patients required weight removal. CONCLUSIONS: Insertion of 1.2 gm upper eyelid weight with placement of midface sling is recommended at the time of facial nerve resection. Due to the need to tighten the lower eyelid in many of these patients, we now also consider performing a tarsal strip procedure at the time of facial nerve resection in any patient with pre-existing lower lid laxity.

A Closer Look at the 2013 to 2014 Integrated Plastic Surgery Match.

BACKGROUND: Plastic surgery has become an increasingly competitive, yet limited information is available in the literature on successfully matched plastic surgery applicants. The goal of this study was to analyze which factors predicted a successful National Residency Match Program match during the 2013 to 2014 cycle. METHODS: An electronic questionnaire was distributed to successfully matched medical students in plastic surgery. Information obtained included (1) academic performance, (2) medical school criteria, (3) visiting subinternship rotation criteria, and (4) research performance. Match "success" was defined as matching into one of the applicant's top three ranked programs RESULTS: Data were available for 127 matched students. Average Step 1 score was 247.93 (95 percent CI, 244.3 to 251.56). Step 1 scores correlated with the number of interviews received (r(2) = 0.355; p = 0.039). An odds ratio of 2.2 was observed for residents who had a plastic surgery residency program affiliated with their medical school and match success. Step 1 score (r(2) = 0.045; p = 0.798), Step 2 score (r(2) = 0.131; p = 0.505), Alpha Omega Alpha membership (r(2) = 0.011; p = 0.905), and number of publications (r(2) = 0.121; p = 0.458) did not correlate significantly with match success. CONCLUSIONS: Successful applicants had a Step 1 score that was 1 SD greater than the U.S. mean. Having a plastic surgery residency program affiliated with an applicant's medical school was an important predictor of match success. Objective measures (step scores, Alpha Omega Alpha membership, and number of publications) were not predictive of match success.

Apoptosis and plastic surgery.

Apoptosis, or programmed cell death, is a phenomenon that is integral to development and cellular homeostasis. In the last decade, many of the essential molecules and pathways that control this phenomenon have been elucidated. Because apoptosis is involved in almost all physiologic and pathologic processes, the understanding of its regulation has significant clinical ramifications. This article reviews the basic understanding of programmed cell death in terms of the effector molecules and pathways. Areas of interest to plastic surgeons are reviewed as they pertain to apoptosis. These areas include allotransplantation, craniofacial and limb development, flap survival, wound healing, stem cell science, and physiologic aging. These topics have not yet been studied extensively in the context of cell death. In this review article, other related and more comprehensively studied scientific areas are used to extrapolate their relevance to apoptosis. Apoptosis is an increasingly better understood process. With the knowledge of how programmed cell death is controlled, combined with the improved ability to effectively perform genetic manipulation and to design specific chemical approaches, apoptosis is gaining clinical relevance. In the next few years, practical clinical breakthroughs will help the medical community to understand the phenomenon of apoptosis and how it relates to the needs of patients.

Management of cutaneous human papillomavirus infection: surgery.

Surgical management is typically required when the clinician encounters an increased quantity of warts, large surface areas of affected, or when malignant transformation is suspected. Basic surgical techniques, such as cryosurgery, electrosurgery and surgical excision, are successful and relatively quick methods for removing warts and uncomplicated cutaneous malignancies. Mohs micrographic surgery is an amenable option when cutaneous malignancies are located in high-risk areas such as periocular or perinasal regions, lips, ears, digits and genitalia, tend to be larger in size, are recurrent, possess aggressive histological features, such as moderate-to-poor differentiation, or demonstrate perineural invasion. Situations involving a larger tumor burden, or requiring complicated surgical reconstruction in the operating room, may necessitate the assistance of plastic and reconstructive surgery. Herein, we describe treatment modalities employed in the surgical management of cutaneous human papillomavirus infection and include surgical teaching cases.

The scope of plastic surgery according to 2434 allopathic medical students in the United States.

BACKGROUND: The general public and physicians often equate plastic surgery with cosmetic surgery. The authors investigate whether this perception is present in U.S. medical students. METHODS: A national survey of first- and second-year allopathic medical students was conducted. Students were asked to determine whether 46 specific procedures are performed by plastic surgeons: 12 aesthetic and 34 reconstructive procedures, which were further separated into three subgroups (general reconstruction and breast, craniofacial, and hand and lower extremity). RESULTS: Of the questionnaires sent out, 2434 from 44 medical schools were returned completed (23 percent response rate); 90.7 percent of aesthetic, 66.0 percent of general reconstruction and breast, 51.0 percent of craniofacial, and 33.4 percent of hand and lower extremity procedures were correctly identified. There was no relationship with self-reported interest in plastic surgery (1 = not at all interested to 10 = extremely interested) and the number of correctly identified aesthetic procedures. However, there was a nonlinear relationship with correctly identified reconstructive procedures; compared to those with an interest level of 1 to 5, those who chose 10 scored on average 6.5 points higher (14.2 versus 20.7) (p < 0.01). An anticipated career in surgery was associated with more correctly identified procedures across all sections but neither year (first versus second) nor region (Northeast, South, Central, West) with any section. CONCLUSIONS: U.S. medical students are unaware of the true scope of plastic surgery. Early exposure to basic aspects of plastic surgery could serve as a means of increasing interest and knowledge in the field and help educate future generations of referring physicians.

Massive scrotal edema: an unusual manifestation of obstructive sleep apnea and obesity-hypoventilation syndrome.

Obstructive sleep apnea (OSA) may occur in association with obesity-hypoventilation (Pickwickian) syndrome, a disorder of ventilatory control affecting individuals with morbid obesity. Through the pressor effects of chronic hypercapnia and hypoxemia, this syndrome may result in pulmonary hypertension, right heart failure, and massive peripheral edema. We present a case of severe scrotal edema in a 36-year-old male with OSA and obesity-hypoventilation syndrome. A tracheostomy was performed to relieve hypoxemia and led to dramatic improvement of scrotal edema. No scrotal surgery was necessary. Followup at two months showed complete resolution of scrotal edema, improvement in mental status, and normalization of arterial blood gas measurements. This case demonstrates that OSA and obesity-hypoventilation syndrome may present with massive scrotal edema. Furthermore, if OSA is recognized as the cause of right heart failure, and if the apnea is corrected, the resultant improvement in cardiac function may allow reversal of massive peripheral, including scrotal, edema.

Automated facial image analysis: detecting improvement in abnormal facial movement after treatment with botulinum toxin A.

The purpose of this study was to evaluate the ability of Automated Facial Image Analysis (AFA) to detect changes in facial motion after Botox injections in patients with facial nerve disorders accompanied by abnormal muscle activity. Eight subjects received Botox for oral to ocular synkinesis (n = 6), ocular to oral synkinesis (n = 1), and/or depressor anguli oris overactivity (n = 3). Subjects were video-recorded during 2 directed facial action tasks before and after Botox treatment. AFA measurement and Facial Grading System (FGS) scores were used to evaluate the effects of Botox. After Botox, AFA detected a decrease in abnormal movements of the eyelids in all patients with oral to ocular synkinesis, a decrease in oral commissure movement for the patients with ocular to oral synkinesis, and an increase in oral commissure movement in all patients with depressor overactivity. The FGS scores failed to demonstrate any change in facial movement for the case of ocular to oral synkinesis and for 2 cases of depressor overactivity. AFA enables recognition of subtle changes in facial movement that may not be adequately measured by observer based ratings of facial function.

Omental transposition flap for salvage of ventricular assist devices.

BACKGROUND: The use of ventricular assist devices for patients with end-stage cardiac failure awaiting heart transplantation has become increasingly common. Ventricular assist devices improve the longevity and the quality of life for these patients. In addition, they serve as a bridge to cardiac allograft transplantation until a donor heart is found. However, ventricular assist device-related infections remain a major problem complicating their long-term use. Clinical infection and sepsis can critically threaten these patients with ventricular assist devices. Infection can delay immediate transplantation and potentially require the removal of the device for definitive treatment of the problem. METHODS: Patients who underwent insertion of a ventricular assist device at the University of Pittsburgh Medical Center were identified through accessing the medical records archives of the hospital. Review of patients' medical records was conducted to obtain patient demographics, preoperative diagnosis and disease state, type of ventricular assist device inserted, postoperative day of ventricular assist device infection onset, infectious organism identified, timing of omental flap procedure after the initial insertion, duration of ventricular assist device support before cardiac transplantation, and patient follow-up. RESULTS: There were 76 patients who underwent a ventricular assist device insertion procedure during the 4-year period between January of 2000 and January of 2004. Of the 76 patients who received a device, 11 (14 percent) had evidence of clinical infection secondary to insertion. Two of these 11 patients died before surgical intervention, four had their devices explanted, and the remaining five underwent omental flap transposition with bilateral pectoralis major advancement flaps in surgically addressing their infections. Of the five patients with infections who received omental transposition flaps, two went on to undergo successful transplantation, two continue to await cardiac allograft transplantation, and one died as a result of an unknown cause. CONCLUSIONS: The authors present their experience with five patients who received omental transposition flaps to cover infected ventricular assist device pumps and the associated tubing in large, open sternoabdominal wounds. Treatment included the direct application of an omental transposition flap over the infected device with use of a bilateral pectoralis advancement flap to aid in complete sternal and skin closure of the sternal wound defect. In each of these cases, the use of the omental flap was followed by resolution of the mediastinal infection. In addition, the treatment with an omental flap prevented the removal of infected devices in patients who were otherwise pump dependent during their waiting periods for transplantation. The use of omental transposition flaps can be an effective technique in salvaging infected ventricular assist devices and preserving this valuable device for patients awaiting a cardiac transplant.

One-stage reanimation of the paralyzed face using the rectus abdominis neurovascular free flap.

BACKGROUND: Functional free muscle transfer for the surgical correction of long-standing facial paralysis has gained validity over the past three decades. These traditionally multistep reconstructions often achieve clinical success, but at the cost of significant morbidity and lengthy recovery periods. To address this dilemma, the authors propose reconstruction using the rectus abdominis and accompanying intercostal nerve in a one-stage neurovascular free flap reanimation procedure. METHODS: Between 1998 and 2001, five patients with long-standing unilateral facial paralysis at the University of Pittsburgh Facial Nerve Center underwent reanimation using the authors' protocol. Preoperative and postoperative assessments included clinical evaluation using the Facial Grading System and electromyography. The patients were followed for a mean of 16 months. RESULTS: At the final postoperative visit, all five patients demonstrated improved levator electromyographic potential, with a median 67 percent improvement. All five patients further demonstrated an increase in zygomaticus electromyographic potential, with a median 225 percent improvement. All five patients demonstrated increased Facial Grading System score at most recent follow-up. CONCLUSIONS: The one-step reanimation using free rectus abdominis neurovascular free flap demonstrated a consistent positive outcome in electromyographic and clinical assessments. The additional benefits of reduced recovery time and anatomical reliability of the flap render the authors' method preferable to other traditional methods of surgical reanimation of the paralyzed face.

Prognosis as a determinant of free flap utilization for reconstruction of the lateral mandibular defect.

BACKGROUND: The purpose of this study was to determine whether patients with a poor prognosis for survival were more likely to undergo reconstruction with a pectoralis flap versus a free flap and whether the use of a pectoralis flap offered any perioperative advantage, such as a reduction in medical complications. METHODS: Fifty-five consecutive patients who underwent immediate reconstruction after a lateral mandibulectomy were retrospectively reviewed. RESULTS: Age >or=70 years (p = .03), moderate or severe comorbidity (p = .02), and involvement of the base of tongue by tumor (p = .04) were significantly associated with decreased utilization of a free flap (n = 36). Comorbidity was the main determinant of medical complications (p = .001) and length of hospital stay (p = .03). CONCLUSIONS: Expectations of prognosis bias the surgeon's decision regarding flap selection. Reconstruction with a pectoralis flap does not necessarily contribute toward the desired outcome of reduced medical complications. Any functional comparison between reconstructive groups needs to account for those differences in health status and prognosis that might explain any observed postoperative differences.