Free flap reconstruction of elbow soft tissue defects: Lessons learned from 15 years of experience.

BACKGROUND: The elbow is a complex joint that is vital for proper function of the upper extremity. Reconstruction of soft tissue defects over the joint space remains challenging, and outcomes following free tissue transfer remain underreported in the literature. The purpose of this analysis was to evaluate the rate of limb salvage, joint function, and clinical complications following microvascular free flap coverage of the elbow. METHODS: This retrospective case series utilized surgical logs of the senior authors (Stephen J Kovach and L Scott Levin) to identify patients who underwent microvascular free flap elbow reconstruction between January 2007 and December 2021. Patient demographics and medical history were collected from the medical chart. Operative notes were reviewed to determine the type of flap procedure performed. The achievement of definitive soft tissue coverage, joint function, and limb salvage status at 1 year was determined from postoperative visit notes. RESULTS: Twenty-one patients (14 male, 7 female, median age 43) underwent free tissue transfer for coverage of soft tissue defects of the elbow. The most common indication for free tissue transfer was traumatic elbow fracture with soft tissue loss (n = 12, [57%]). Among the 21 free flaps performed, 71% (n = 15) were anterolateral thigh flaps, 14% (n = 3) were latissimus dorsi flaps, and 5% (n = 1) were transverse rectus abdominis flaps. The mean flap size was 107.5 cm2. Flap success was 100% (n = 21). The following postoperative wound complications were reported: surgical site infection (n = 1, [5%]); partial dehiscence (n = 5, [24%]); seroma (n = 2, [10%]); donor-site hematoma (n = 1, [5%]); and delayed wound healing (n = 5, [24%]). At 1 year, all 21 patients achieved limb salvage and definitive soft tissue coverage. Of the 17 patients with functional data available, 47% (n = 8) had regained at least 120 degrees of elbow flexion/extension. All patients had greater than 1 year of follow-up. CONCLUSION: Microvascular free flap reconstruction is a safe and effective method of providing definitive soft tissue coverage of elbow defects, as evidenced by high rates of limb salvage and functional recovery following reconstruction.

Prospective Assessment of the Abdominal Hernia-Q (AHQ)-Patient Burden, Reliability, and Longitudinal Assessment of Quality of Life in Hernia Repair.

OBJECTIVE: This study assesses the user burden, reliability, and longitudinal validity of the AHQ, a novel VH patient-reported outcomes measure (PROM). BACKGROUND: We developed and psychometrically validated the AHQ as the first VH-specific, stakeholder-informed PROM. Yet, there remains a need to assess the AHQ's clinical applicability and further validate its psychometric properties. METHODS: To assess patient burden, pre- and postoperative patients were timed while completing the corresponding AHQ form. To measure test-retest reliability, a subset of patients completed the AHQ within a week of initial completion, and consecutive responses were correlated. Lastly, patients undergoing VH repair were prospectively administered the pre- and postoperative AHQ forms, the Hernia-Related Quality of Life Survey and the Short Form-12 both preoperatively and at postoperative intervals, up to over a year after surgery. Quality-of-Life scores were correlated from the 3 PROMs and effect sizes were compared using analysis of normal variance. RESULTS: Median response times for the pre- and postoperative AHQ were 1.1 and 2.7 minutes, respectively. The AHQ demonstrates high test-retest reliability coefficients for pre- and postoperative instruments ( r = 0.91, 0.89). The AHQ appropriately and proportionally measures expected changes following surgery and significantly correlates with all times points of theHernia-Related Quality of Life Survey and Short Form-12 MS and 4/5 (80%) SF12-PS. CONCLUSION: The AHQ is a patient-informed, psychometrically-validated, clinical instrument for measuring, quantifying, and tracking PROMs in VH patients. The AHQ exhibits low response burden, excellent reliability, and effectively measures hernia-specific changes in quality-of-Life following ventral hernia repair.

Does Dedicated Research Time During Residency Predict Resident Academic Productivity and a Future Academic Career?

OBJECTIVE: Dedicated research time is a component of certain plastic surgery programs, and yet, there is limited research examining its impact on academic productivity and career outcomes. This study aimed to assess the effect of dedicated research time on the academic productivity of residents and the likelihood of pursuing an academic career. METHODS: We conducted a cross-sectional study that examined bibliometric indices of integrated plastic surgery residency graduates from 2010 to 2020. Academic productivity was determined by the number of peer-reviewed publications and h-index 1 year after residency graduation. Results were analyzed using descriptive statistics, χ2 test, t test, and logistic regression. RESULTS: Data on plastic surgery residency graduates were analyzed (N = 490 from 46 programs). The mean numbers of publications and h-index per research track graduate were 26.1 and 8.23, respectively. The mean numbers of publications and h-index per nonresearch track graduate were 15.9 and 5.97, respectively. After controlling for the University of Alabama research ranking through multilinear regression analysis, we found that pursuing dedicated research time was an independent predictor of increased h-index and publication output, although it did not predict an increased likelihood of pursuing an academic career. CONCLUSIONS: Participating in dedicated research during residency increases academic productivity, irrespective of the residency program's research rank. Given this finding, offering research years can help support the mission of fostering academic opportunities within plastic surgery.

Department Versus Division: An In-Depth Analysis of Units of Plastic Surgery and Other Surgical Specialties at Their Institutions.

ABSTRACT: An increasing number of plastic and reconstructive surgery (PRS) units have transitioned from divisions to departments in recent years. This study aimed to identify quantifiable differences that may reflect challenges and benefits associated with each type of unit. We conducted a cross-sectional analysis of publicly-available data on characteristics of academic medical institutions housing PRS units, faculty size of surgical units within these institutions, and academic environments of PRS units themselves. Univariate analysis compared PRS divisions versus departments. Matched-paired testing compared PRS units versus other intra-institutional surgical departments. Compared to PRS divisions (n = 64), departments (n = 22) are at institutions with more surgical departments overall (P = 0.0071), particularly departments that are traditionally divisions within the department of surgery (ie urology). Compared to PRS divisions, PRS departments have faculty size that more closely resembles other intra-institutional surgical departments, especially for full-time surgical faculty and faculty in areas of clinical overlap with other departments like hand surgery. Plastic and reconstructive surgery departments differ from PRS divisions by certain academic measures, including offering more clinical fellowships (P = 0.005), running more basic science laboratories (P = 0.033), supporting more nonclinical research faculty (P = 0.0417), and training residents who produce more publications during residency (P = 0.002). Institutions with PRS divisions may be less favorable environments for surgical divisions to become departments, but other recently-transitioned divisions could provide blueprints for PRS to follow suit. Bolstering full-time surgical faculty numbers and faculty in areas of clinical overlap could be useful for PRS divisions seeking departmental status. Transitioning to department may yield objective academic benefits for PRS units.

Learner Drawing and Sculpting in Surgical Education: A Systematic Review.

BACKGROUND: Historically, surgery was developed through the visual work of artist-scientists, yet visual art in modern surgical education is rare. The aim of this review is to evaluate the existing literature of learner creation of visual art as an educational tool in surgery and to discuss its potential in augmenting surgical learning. METHOD: A systematic review of surgical educational interventions involving learner drawing, painting, and sculpting was conducted in 2020. RESULTS: Our search yielded 388 unique articles, and 12 met inclusion criteria. Seven articles described drawing and sculpting courses designed to develop judgement or aesthetic sense, and five described initiatives to teach or assess surgical anatomy or knowledge. Common goals included the measurement and observation of live models to enhance judgement of proportions, understanding of three-dimensional (3D) anatomical structure, hand-eye coordination, and communicative drawing ability for patient education and medical documentation. Notable outcomes included improved retention of anatomy, correlation of drawing and image labeling with in-service exam scores, and correlation of procedural drawing with ability to perform the same procedure in a simulation. CONCLUSIONS: Our review suggests that all surgical disciplines could benefit from artistic training through improved visual communication and deeper understanding of 3D anatomy. Such benefits can be translated into Accreditation Council for Graduate Medical Education (ACGME) Core Competencies to guide surgical residency programming. We propose that visual art serves as an educational tool to improve perceptual skill and anatomical understanding in the modern surgeon; however more research is needed to clarify the best modality for incorporation.

Does E-learning Improve Plastic Surgery Education?: A Systematic Review of Asynchronous Resources.

PURPOSE: E-learning is rapidly growing in medical education, overcoming physical, geographic, and time-related barriers to students. This article critically evaluates the existing research on e-learning in plastic surgery. METHODS: A systematic review of e-learning in plastic surgery was conducted using the PubMed/MEDLINE, Scopus, and Embase databases. Studies were limited to those written in English and published after 1995 and excluded short communications, letters to the editor, and articles focused on in-person simulation. RESULTS: A total of 23 articles were identified. Represented subspecialties include breast, burns, craniofacial/pediatrics, hand, and microsurgery. Most e-learning resources target surgeons and trainees, but a small number are for patients, parents, and referring physicians. Users reported high levels of satisfaction with e-learning and significant gains in knowledge after completion, although there may be more variable satisfaction with teaching technical skills. Two studies showed no differences in knowledge gains from e-learning compared with traditional learning methods. Subgroup analysis showed greater benefit of e-learning for novice learners when evaluated. Surveys of plastic surgeons and trainees showed high interest in and growing utilization of e-learning. CONCLUSIONS: Research in plastic surgery e-learning shows high user satisfaction and overall improvements in learning outcomes with knowledge gains equivalent to traditional teaching methods and greater benefit in novice learners. Thus, e-learning can serve an important role in plastic surgery education, especially in the current state of social distancing. Future work should aim to define learner preferences and educational needs and better establish how e-learning can augment plastic surgical education, particularly among other teaching methods.

Incisional Hernia Incidence, Repair Techniques, and Outcomes Based on 1600 Consecutive Patients Receiving Abdominally Based Autologous Breast Reconstruction.

BACKGROUND: As the number of postmastectomy patients who receive abdominally based autologous breast reconstruction (ABABR) increases, the frequency of unique paramedian incisional hernias (IHs) at the donor site is increasing as well. We assessed incidence, repair techniques, and outcomes to determine the optimal treatment for this morbid condition. METHODS: A total of 1600 consecutive patients who underwent ABABR at the University of Pennsylvania between January 1, 2009, and August 31, 2016, were retrospectively identified. Preoperative and operative information was collected for these patients. Incisional hernia incidence was determined by flap type and donor site closure technique. Repair techniques and postoperative outcomes for all patients receiving IH repair (IHR) after ABABR at our institution were also determined. Univariate and multivariate analyses were conducted. RESULTS: The incidence of IH after ABABR in our health system was 3.6% (n = 61). Fifteen additional patients were referred from outside hospitals for a total of 76 patients who received IHR. At the time of IHR, mesh was used in 79% (n = 60) of cases (13 biologic and 47 synthetic), with synthetics having significantly lower recurrent IH incidence (10.6% vs 38.5%, P = 0.017) when compared with biologics. Mesh position did not have any statistically significant effect on outcomes; however, sublay mesh position had zero adverse outcomes. CONCLUSIONS: Mesh should be used in all cases when possible. Although retrorectus repair with mesh is optimal, this plane is often nonexistent or too scarred in after ABABR. Thus, intraperitoneal underlay mesh with primary fascial closure or primary closure with onlay mesh placement should then be considered.

How to Develop a Risk Prediction Smartphone App.

Purpose. Powered by big data, predictive models provide individualized risk stratification to inform clinical decision-making and mitigate long-term morbidity. We describe how to transform a large institutional dataset into a real-time, interactive clinical decision support mobile user interface for risk prediction. Methods. A clinical decision point ideal for risk stratification and modification was identified. Demographics, medical comorbidities, and operative characteristics were abstracted from the electronic medical record (EMR) using ICD-9 codes. Surgery-specific predictive models were generated using regression modeling and corroborated with internal validation. A clinical support interface was designed in partnership with an app developer, followed by subsequent beta testing and clinical implementation of the final tool. Results. Individual, specialty-specific, and preoperatively actionable models incorporating clustered procedural codes were created. Using longitudinal inpatient, outpatient, and office-based data from a large multicenter health system, all patient and operative variables were weighted according to ß-coefficients. The individual risk model parameters were incorporated into specialty-specific modules and implemented into an accessible iOS/Android compatible mobile application. Conclusions. As proof of concept, we provide a framework for developing a clinical decision support mobile user interface, through the use of clinical and administrative longitudinal data. Point-of-care applications, particularly ones designed with implementation and actionability in mind, have the potential to aid clinicians in identifying and optimizing risk factors that impact the outcome of interest's occurrence, thereby enabling clinicians to take targeted risk-reduction actions. In addition, such applications may help facilitate counseling, informed consent, and shared decision-making, leading to improved patient-centered care.

Quality of Life and Concurrent Procedures in Truncal Body Contouring Patients: A Single-Center Retrospective Study.

BACKGROUND: Body contouring procedures provide patients with a meaningful improvement in health-related quality of life (QoL). We aim to compare the difference between the QoL in patients undergoing a single post-bariatric abdominal body contouring procedure (BCP) and those undergoing two or more concurrent procedures. METHODS AND MATERIALS: Patients evaluated for post-bariatric BCP were identified and administered the BODY-Q©. Patient demographics, clinical and operative characteristics, surgical outcomes, cost data, and absolute change in QoL scores were analyzed using descriptive statistics, chi-square, and Mann-Whitney U-test, between patients who underwent single (SP), double (DP), or triple (TP) concurrent procedures. RESULTS: A total of 45 patients were included. The median age was 52 years old ([IQR] ± 13). The majority were female (71.1%) and African-American (55.5%). The most common single procedure was panniculectomy (75%). Surgical site occurrences, readmissions, and the complication composite outcome did not differ between groups (p>0.05). No difference was seen between SP and DP QoL score (p>0.05). The DP had a statistically lower net QoL score compared with TP cohort in four domains. The SP had a statistically lower net QoL score compared with the TP in three domains. Average total cost for patients receiving an SP was $8,048.44, compared with $19,063.94 for DP (p<0.01), and $19,765.02 for TP (p>0.05). CONCLUSIONS: Body contouring procedures are associated with improvements in QoL irrespective of the number of concurrent procedures. Further improvement in psychological well-being occurs for patients who proceed with double concurrent procedures, albeit with an increase in cost. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Abdominal Hernia-Q: Development, Psychometric Evaluation, and Prospective Testing.

OBJECTIVE: Our study completes the development and estimates the psychometric properties of a novel, ventral hernia-specific patient reported outcomes (PRO) tool-the Abdominal Hernia-Q (AHQ). SUMMARY BACKGROUND DATA: A standardized method for measuring hernia-related PRO has not been identified. There remains a need for a broadly applicable, hernia-specific tool that incorporates patient viewpoints and offers pre- and postoperative forms. METHODS: Concept elicitation interviews, focus groups, and cognitive debriefing interviews were completed to define content. The preoperative AHQ was administered to patients scheduled to have a ventral hernia repair (VHR). The postoperative AHQ was administered to patients within 24 months post-VHR. The SF-12 and HerQLes were concurrently administered. Psychometric evaluation was performed. Subsequently, the AHQ (pre: 8 items; post: 16 items) underwent prospective testing. RESULTS: Cross-sectional evaluations of patient responses to the AHQ (pre n = 104; post n = 261) demonstrated high internal consistency (Cronbach α pre = 0.86; post = 0.90) and moderate disattenuated correlations with the HerQLes (pre r = -0.71 and post r = -0.70) and the SF-12 domains (pre and post r ≥ 0.5 for 7 of 8 domains). Principal components analyses produced 2 factors preoperatively and 3 factors postoperatively. In prospective testing (n = 67), the AHQ scores replicated the cross-sectional psychometric results and suggested sensitivity to clinical outcomes. CONCLUSIONS: Through patient involvement and rigorous, iterative psychometric evaluation, we have produced substantial data to suggest the validity and reliability of AHQ scores in measuring hernia-specific PRO. The AHQ advances the clinical management and treatment of patients with abdominal hernias by providing a more complete understanding of patient-defined outcomes.

Surgical Management and Outcomes of Cutaneous Mold Infections in Immunocompromised Children.

BACKGROUND: Cutaneous mold infections occur infrequently but can be life-threatening in immunocompromised children. The literature regarding its surgical management is limited. This study aims to describe the surgical management and outcomes of cutaneous mold infections in immunocompromised children. METHODS: Hospitalized patients receiving a skin biopsy at a single pediatric hospital in 2003 to 2017 were identified. Inclusion criteria were immunocompromised status, younger than 21 years, and surgical excision of a confirmed cutaneous mold infection. Patient information, details of immunosuppression, operative details, and 6-month postoperative and disease outcomes were collected. RESULTS: Seventeen patients (21 lesions) were identified with an average age of 6.8 years (range = 0.2-19.5 years). Affected anatomic regions included limb (15, 71%), chest (2, 10%), axilla, back, abdomen, and head (1 or 5% each). Excisions occurred, on average, within 1.7 days of initial biopsy (range = 0-7 days). When specified, margins were 0.5 to 2.0 cm, and surgeons used intraoperative fungal detection techniques in 8 cases (47%). Definitive closure was achieved by secondary intention/dressings changes (9, 43%), skin graft (7, 33%), a skin substitute (2, 10%), immediate primary closure (2, 10%), and delayed primary closure (1, 5%). Overall, 14 patients were alive 6 months after resection (82%). CONCLUSIONS: This study is the first to critically evaluate the methodology for surgical resection of cutaneous fungal infections in immunocompromised children. We suggest timely excision once diagnosed with, at minimum, 0.5-cm margins and intraoperative pathologic study when considering surgical treatment for this rare but serious infection.

Searching for an Alternative Method to Evaluate Surgical Knowledge: Does a Drawing and Labeling Quiz Predict In-Service Exam Performance and Enhance Learning?

BACKGROUND: The best methods to assess surgical knowledge are still debated. The authors used a non-multiple-choice test as a pre- and post-conference assessment to measure residents' knowledge gains with comparison to a standard summative assessment tool. METHODS: At one didactic conference, plastic surgery residents at a single institution were given a pre-test of drawing and labeling structures in the extensor mechanism of the finger and within the carpal tunnel. The quiz was followed by a lecture on the same material and a subsequent post-test. Scores were correlated with in-service exam performance. RESULTS: Pre-test scores (n = 13) were positively correlated with postgraduate year (PGY) until PGY-3. Performance on labeling structures was higher than performance on the respective drawing prompt. Residents' ability to label structures increased more strongly with PGY than their ability to draw structures. The post-test (n = 8) demonstrated that teaching improves performance on labeling questions (pre-test score = 62%; post-test score = 87%). Improvement was observed across all PGYs. Pretest results were positively correlated with in-service exam performance. CONCLUSIONS: Our study suggests that a knowledge test focused on drawing and labeling structures given to surgical residents is a valid, nontraditional method for assessing resident knowledge. Such a quiz would offer programs an alternative method for regularly evaluating residents aside from in-service questions, in order to identify residents who may need targeted training for the in-service exam and to inform teaching plans.Additionally, residents could use quiz feedback to guide study efforts and prime conference-related learning.

Free Flap Reconstruction of Complex Oncologic Scalp Defects in the Setting of Mesh Cranioplasty: Risk Factors and Outcomes.

INTRODUCTION: Soft-tissue reconstruction of the scalp has traditionally been challenging in oncologic patients. Invasive tumors can compromise the calvarium, necessitating alloplastic cranioplasty. Titanium mesh is the most common alloplastic material, but concerns of compromise of soft-tissue coverage have introduced hesitancy in utilization. The authors aim to identify prognostic factors associated with free-flap failure in the context of underlying titanium mesh in scalp oncology patients. METHODS: A retrospective review (2010-2018) was conducted at a single center examining all patients following oncologic scalp resection who underwent titanium mesh cranioplasty with free-flap reconstruction following surgical excision. Patient demographics, comorbidities, ancillary oncological treatment information were collected. Operative data including flap type, post-operative complications including partial and complete flap failure were collected. RESULTS: A total of 16 patients with 18 concomitant mesh cranioplasty and free-flap reconstructions were identified. The majority of patients were male (68.8%), with an average age of 70.5 years. Free-flap reconstruction included 15 ALT flaps (83.3%), 2 latissimus flaps (11.1%), and one radial forearm flap (5.5%). There were three total flap losses in two patients. Patient demographics and comorbidities were not significant prognostic factors. Additionally, post-operative radiation therapy, ancillary chemotherapy, oncological histology, tumor recurrence, and flap type were not found to be significant. Pre-operative radiotherapy was significantly associated with flap failure (P < 0.05). CONCLUSION: Pre-operative radiotherapy may pose a significant risk for free-flap failure in oncologic patients undergoing scalp reconstruction following mesh cranioplasty. Awareness of associated risk factors ensures better pre-operative counseling and success of these reconstructive modalities and timing of pre-adjuvant treatment.

A Systematic Review of Sensory Outcomes of Digital Nerve Gap Reconstruction With Autograft, Allograft, and Conduit.

BACKGROUND: Direct comparison of nerve autograft, conduit, and allograft outcomes in digital nerve injuries is limited. This study aims to compare the outcomes of nerve autografts, allografts, and conduits relative to primary repair (PR) through a systematic review. METHODS: A review of literature related to digital nerve gap repairs was conducted using PubMed/MEDLINE. Included articles were human clinical studies on digital nerve injuries repaired with nerve autograft, allograft, bovine collagen conduit, or PR. Patient characteristics, injury details, and complications were collected. Greater than 6-month outcomes included static 2-point discrimination, the British Medical Research Council Scale, or Semmes-Weinstein. RESULTS: Four autograft, 4 allograft, 5 conduit, and 7 PR publications were included. Allografts had the most repairs (100%) with static 2-point discrimination less than 15 mm, followed by autografts (88%), conduits (72%), and PR (63%). In British Medical Research Council Scale results, autografts (88%) and allografts (86%) were similar for patients with at least S3+ sensibility, compared to conduit (77%) and PR (39%). For Semmes-Weinstein, autografts demonstrated 93% normal sensation or diminished light touch, compared to allografts (71%), PR (70%), or conduits (46%). Conduits had the highest complication rate (10.9%), followed by autografts (5.7%), allografts (3.0%), and PRs (0.4%). CONCLUSIONS: Although a randomized clinical trial would provide strongest evidence of superiority, this review presents the highest percentage of patients with normal to near normal sensory recovery in allograft and autograft repairs with low rates of complications. Nerve conduit studies reported a higher rate of incomplete recovery of sensation and complications.

Ultrasonic debridement management of lower extremity wounds: retrospective analysis of clinical outcomes and cost.

OBJECTIVE: The aim of this study was to assess wound healing outcomes following direct, low-frequency, high-intensity, ultrasonic debridement as a surgical adjunct for non-healing lower extremity wounds. METHODS: A retrospective review was conducted for patients undergoing lower extremity wound treatment with direct, low-frequency (22.5 kHz), high-intensity (~60 W/cm2) ultrasonic debridement between January 2010 and January 2016. Clinical outcomes were assessed up to 180-days post-ultrasonic debridement. Descriptive statistics, cost and univariate analysis were performed. RESULTS: Overall, 82 wounds in 51 patients were included. Mean age was 57.0 years (range: 32-69), and average body mass index (BMI) was 30.8 kg/m². Patient comorbidities consisted of smoking (47%; n=24), hypertension (75%; n=38), diabetes (45%; n=23), and peripheral vascular disease (51%, n=26). Average wound age at initial presentation was 1013 days (range: 2-5475 days) with an average wound size of 9.0cm x 7.4cm. At 180-days post-debridement, 60% (n=49) of wounds had completely healed. Readmission (47%; n=24) and reoperation (45%; n=23) rates were characterised by the reason for readmission and reoperation respectively. Readmission for wound healing (70%, n=39) was primarily for further debridements (41%; n=16). Wound infection (30%; n=7) was the most common readmission for wound complications (30%; n=17). Reoperations primarily consisted of treatments for further wound healing 96% (n=51). Cost analysis showed a lower total treatment cost for patients with improved healing ($78,698), compared with non-improved wounds ($137,707). CONCLUSION: In a complex, heterogeneous cohort of chronic extremity wounds, the use of direct, low-frequency, high-intensity, ultrasonic debridement is a safe and reliable adjunctive therapy for the management of these wounds.

Does Size Matter: Evaluating the Difference between Right and Left Internal Mammary Veins in Free Flap Breast Reconstruction.

BACKGROUND: Venous congestion in breast free flap reconstruction continues to be a major reason for flap compromise requiring reoperative exploration and possible flap failure. We aim to investigate whether size of the internal mammary vein (IMV) (1) varies between the left and right sides, (2) changes with certain patient demographics or preoperative factors, and (3) correlates with postoperative complications. METHODS: We performed a retrospective cohort study examining all patients undergoing free flap breast reconstruction from September 2005 to March 2016 using internal mammary recipient veins. Venous coupler size was used as a surrogate measure of IMV diameter. Preoperative patient characteristics and factors were collected. Postoperative outcomes assessed included thrombosis, flap loss, fat necrosis, and mastectomy flap necrosis. Multivariate analyses were performed to evaluate if preoperative factors affected IMV diameter and to determine if coupler size and flap side were independent risk factors for postoperative complications. RESULTS: We examined 372 patients with a total of 561 flaps. One hundred eighty-nine patients received bilateral flaps with the IMV as a recipient. The right IMV (n = 286, average = 2.97 mm, standard deviation [SD] = 0.41) was significantly larger than the left (n = 275, average = 2.89, SD = 0.35, p = 0.008). Preoperative factors and postoperative complications were not statistically different between the left and right cohorts. The multivariable linear regression model with coupler size as the dependent variable found older age trended toward a larger coupler size but this was not significant (p = 0.05). In multilinear regression analysis, the postoperative outcomes did not have significant covariates. CONCLUSION: We found that IMV size significantly differs between the right and the left sides. However, incidence of postoperative complications was not significantly different between the left and right sides, and the multivariate analyses did not identify flap side as an independent risk factor for adverse outcomes. Prospective studies evaluating actual IMV diameter and associated complications may potentially elucidate clinical significance.

Targeted muscle reinnervation and regenerative peripheral nerve interfaces for pain prophylaxis and treatment: A systematic review.

OBJECTIVE: Nerve pain frequently develops following amputations and peripheral nerve injuries. Two innovative surgical techniques, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI), are rapidly gaining popularity as alternatives to traditional nerve management, but their effectiveness is unclear. LITERATURE SURVEY: A review of literature pertaining to TMR and RPNI pain results was conducted. PubMed and MEDLINE electronic databases were queried. METHODOLOGY: Studies were included if pain outcomes were assessed after TMR or RPNI in the upper or lower extremity, both for prophylaxis performed at the time of amputation and for treatment of postamputation pain. Data were extracted for evaluation. SYNTHESIS: Seventeen studies were included, with 14 evaluating TMR (366 patients) and three evaluating RPNI (75 patients). Of these, one study was a randomized controlled trial. Nine studies had a mean follow-up time of at least 1 year (range 4-27.6 months). For pain treatment, TMR and RPNI improved neuroma pain in 75%-100% of patients and phantom limb pain in 45%-80% of patients, averaging a 2.4-6.2-point reduction in pain scores on the numeric rating scale postoperatively. When TMR or RPNI was performed prophylactically, many patients reported no neuroma pain (48%-100%) or phantom limb pain (45%-87%) at time of follow-up. Six TMR studies reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores assessing pain intensity, behavior, and interference, which consistently showed a benefit for all measures. Complication rates ranged from 13% to 31%, most frequently delayed wound healing. CONCLUSIONS: Both TMR and RPNI may be beneficial for preventing and treating pain originating from peripheral nerve dysfunction compared to traditional techniques. Randomized trials with longer term follow-up are needed to directly compare the effectiveness of TMR and RPNI with traditional nerve management techniques.

Management of Artery-Only Digit Replantation: A Systematic Review of the Literature.

BACKGROUND: Artery-only replantation may be necessary in circumstances when venous repair cannot be performed due to their size or vessel injury. Venous congestion of the replanted part is inevitable. A systematic review was performed to identify techniques for mitigating congestion and analyze the outcomes of those techniques. METHODS: A comprehensive literature search was performed to identify relevant articles related to artery-only replantation. An initial query identified 1286 unique articles. A total of 55 articles were included in the final review. Included studies were categorized by decongestive technique. Data from each article included the number of patients treated, level of amputation, graft use, anticoagulation or antiplatelet therapy, replant viability, and follow-up duration. Weighted averages were determined from studies that reported five or more digits. RESULTS: A total of 1498 individual digital replantations were described. Very rarely did studies report artery-only replantation proximal to the distal interphalangeal joint. An overall survival rate of 78.5 percent was found irrespective of technique but was variable based on each particular study. Studies utilizing medicinal leech therapy were more likely to report use of intravenous anticoagulation, whereas surface bleeding techniques were more likely to report use of topical or local anticoagulant. CONCLUSIONS: Lack of a vein for anastomosis should not be regarded as a contraindication to replantation. These digits instead require a method to establish reliable drainage sufficient to allow for low resistance inflow and maintain a physiologic pressure gradient across capillary beds. The surgeon should select a decongestive technique that best suits the patient and their specific injury.