The Role of Cadaver-Based Flap Course in Microsurgical Education and Practice Patterns of Attendees: A Survey Study.

BACKGROUND: In 2017, our institution initiated a cadaver laboratory-based course dedicated to teaching reconstructive microsurgery indications, preoperative planning, and flap dissection. The goals of this study are to describe the demographics and experience of participants/instructors and to evaluate the learning objectives and effectiveness of the course. METHODS: Penn Flap Course (PFC) participants were sent an anonymous survey at the inaugural PFC 2017. Then, in 2019, both instructors and participants were sent a more comprehensive survey. Surveys included questions regarding demographics, training background, experiences in practice and/or training, and course evaluation. RESULTS: At PFC 2017, participant response rate was 25% (12/44), and the primary reason for attending the course was to observe and learn from instructor dissections (66.7%). At PFC 2019, the response rate was 77.3% (17/22) for faculty and 73.0% (35/48) for participants. Both in 2017 and 2019, the vast majority of participants reported perceived improvement in understanding of flap dissection principles across all anatomic domains (94.3%-100%). In 2019, when asked about their background experience, the majority of participants reported comfort performing arterial and venous anastomosis without supervision (71%-77%) and being least comfortable with head and neck (H&N) microsurgery (mean comfort level: 5.2/10). Half of the participants (e.g., residents) find the presence of a microsurgery fellow at their institution useful to their educational experience. Instructors with additional fellowship training in microsurgery reported performing a higher volume of free flaps per week (7 vs. 2.3) and per year (94.2 vs. 27.8; p < 0.05 for both) and trend toward performing more H&N reconstruction (p = 0.057). CONCLUSION: Participants feel least comfortable with H&N microsurgical reconstruction. Surgical faculty with microsurgical fellowship training performs greater volume of microsurgical cases with a trend toward more H&N reconstruction. A cadaver/lecture-based flap course is an effective way to improve participants' perceived confidence and understanding of complex flap and microsurgical reconstructive procedures.

Evolving Trends in Autologous Breast Reconstruction: Is the Deep Inferior Epigastric Artery Perforator Flap Taking Over?

BACKGROUND: Enthusiasm for the deep inferior epigastric artery perforator (DIEP) flap for autologous breast reconstruction has grown in recent years. However, this flap is not performed at all centers or by all plastic surgeons for breast reconstruction, and it is unclear whether practice patterns have measurably changed. This study aimed to (1) evaluate changing trends in breast flap use in the United States in recent years and (2) identify how these trends have affected charges and costs associated with autologous breast reconstruction. METHODS: Patients undergoing autologous breast reconstruction [latissimus dorsi (LD), pedicled transverse rectus abdominus myocutaneous (pTRAM), free TRAM (fTRAM), and DIEP] were identified using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (2009-2011). A total of 19,182 hospital discharges were reviewed. Patient demographics, hospital teaching center status, payer status, length of stay, total charges, and total costs per discharge were reviewed. Statistical analysis was performed using linear regression, t test, and analysis of variance models. RESULTS: Between 2009 and 2011, the total number of discharges did not change significantly. Patient age distribution was similar for all flap groups. For individual flaps, there was a significant increase in DIEP flaps (P = 0.03), with a decreasing trend for other abdominal-based flaps. The patients receiving DIEP flap breast reconstruction were covered by private insurance at a higher rate than all other flap procedures (P = 0.03), whereas other potential cost determinants did not differ significantly between the groups. The mean charge per flap was $40,704 for LD, $51,933 for pTRAM, $69,909 for fTRAM, and $82,320 for DIEP. The mean cost per flap was $12,017 for LD, $15,538 for pTRAM, $20,756 for fTRAM, and $23,616 for DIEP. CONCLUSIONS: Between 2009 and 2011, the total amount of autologous breast reconstruction discharges was relatively stable, but the number of DIEP flaps increased significantly. Review of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample data shows that, compared with LD, pTRAM, and fTRAM flaps, the DIEP flap is associated with higher charges and costs.

A national snapshot of satisfaction with breast cancer procedures.

PURPOSE: Women with early-stage breast cancer face the complex decision to undergo one of three equally effective oncologic surgical strategies: breast-conservation surgery with radiation (BCS), mastectomy, or mastectomy with breast reconstruction. With comparable oncologic outcomes and survival rates, evaluations of satisfaction with these procedures are needed to facilitate the decision-making process and to optimize long-term health. METHODS: Women recruited from the Army of Women with a history of breast cancer surgery took electronically administered surgery-specific surveys, including the BREAST-Q© and a background survey evaluating patient-, disease-, and procedure-specific factors. Descriptive statistics and regression analysis were used to evaluate the effect of procedure type on breast satisfaction scores. RESULTS: Overall, 7,619 women completed the questionnaires. Linear regression revealed that women who underwent abdominal flap, or buttock or thigh flap reconstruction reported the highest breast satisfaction score, scoring an average of 5.6 points and 14.4 points higher than BCS, respectively (p < 0.0001 and p = 0.027, respectively). No difference in satisfaction was observed in women who underwent latissimus dorsi flap reconstruction compared with those who underwent BCS. Women who underwent implant reconstruction reported scores 8.6 points lower than BCS (p < 0.0001). Those with mastectomies without reconstruction or complex surgical histories scored, on average, 10 points lower than BCS (p < 0.0001). CONCLUSION: Women who underwent autologous tissue reconstruction reported the highest breast satisfaction, while women undergoing mastectomy without reconstruction reported the lowest satisfaction. These findings emphasize the value of patient-reported outcome measures as an important guide to decision making in breast surgery and underscore the importance of multidisciplinary participation early in the surgical decision-making process.

Bipaddle radial forearm flap for head and neck reconstruction.

BACKGROUND: Although the radial forearm free flap has become a workhorse flap in head and neck reconstruction, the skin grafting of the donor is the main drawback resulting in an unacceptable contour deformity and an unsightly appearance. Several technical modifications have been therefore applied to the radial forearm (RF) flap marking, elevation, and inset to overcome this major shortcoming. In this article, we report our clinical series with the bipaddle RF flap. METHODS: The authors described their 11 cases of head and neck oncologic reconstruction with the bipaddle RF flap. The skin island is designed longer and narrower and split into 2 separate skin paddles each nourished by a proximal and a distal independent perforators raising from the radial artery so that the donor site could be closed directly. The narrow design of the skin paddle and the subsequent splitting in its 2 components applying the "perforator-pedicle propeller flap method" allow for the changing of the flap shape according to the shape of the recipient site defect. RESULTS: From 2007 to 2013, the bipaddle RF flap method was used in 11 patients to restore head and neck defects following cancer ablation. The mean age of the patients was 43 years, ranging from 31 to 50 years. The location of the defects was the tongue (n = 7) and the intraoral region (n = 4). The defect sizes varied from 4 × 5 cm to 5 × 6 cm, and the flap maximum width was 3 cm with mean area of 26.4 cm. The healing was uneventful in all patients with excellent cosmetic and functional results of both donor site and recipient site after 20 months of mean follow-up. CONCLUSIONS: The bipaddle RF free flap is a reliable and versatile option for the reconstruction of a wide range of soft tissue defects of head and neck region. This method allows for a customized resurfacing of the defect because of its large variability in shape and size. The harvesting site is closed primarily, and a second donor site for skin graft is avoided.Clinical Question, Level of Evidence: Therapeutic, IV.

Early Postoperative Complications following Gracilis Free Muscle Transfer for Facial Reanimation: A Systematic Review and Pooled Data Analysis.

BACKGROUND: Multiple studies have detailed promising smile restoration following gracilis free muscle transfer for facial reanimation but information detailing the potential complications is lacking. The aim of this study is to systematically review the literature to evaluate the reported complication rate associated with this procedure. We also aim to determine the most common occurring complications. METHODS: The PubMed, Embase, and Web of Science databases were queried with multiple search strategies for published articles between January 1950 and February 2013 that detailed gracilis free muscle transfer for facial reanimation. Title, abstract, and full text review was performed. Complications were defined as any reported, identifiable adverse outcome that required an alteration in treatment for correction. RESULTS: The literature search yielded 62 studies of gracilis free muscle transfer for facial reanimation. Overall, 36 articles (58%) reported whether or not a complication had occurred. The overall complication rate based on pooled proportions was 9.6% and the most commonly occurring complications were postoperative hematoma (3.6%) and infection (3.5%). CONCLUSIONS: Our data suggests that complications after gracilis free muscle transfer for facial reanimation may be underreported and this complex procedure may in fact be associated with significant adverse outcomes as high as 9.6%.

Correlation between abdominal perforator vessels identified with preoperative CT angiography and intraoperative fluorescent angiography in the microsurgical breast reconstruction patient.

BACKGROUND: CT angiography (CTA) has become a reliable method of perforator vessel identification. Indocyanine green fluorescent angiography (ICGLA) produces a real-time image of large- and small-caliber blood vessels. The aim of this prospective study was to compare ICGLA with CTA to evaluate its reliability of vessel identification and correlation to perforator vessel size and number determined preoperatively by CTA. The effect of both imaging techniques on flap design or intraoperative plan was also evaluated. METHODS: Over a 1-year period, patients presenting for free-tissue transfer breast reconstruction underwent preoperative CTA mapping of abdominal perforators followed by intraoperative ICGLA. Using visualization software, scaling factors were calculated so CTA and ICGLA data could be compared. RESULTS: Eighteen patients (24 breast reconstructions) were included. Larger CTA perforator size was associated with larger actual size (P = 0.04). The largest CTA perforator or largest actual perforator was used 78% of the time. Increasing body mass index was not associated with larger CTA perforator size (P = 0.67) or more intense ICGLA blushes (P = 0.13). No significant correlation was found between CTA perforator location and ICGLA skin blush location, size, or intensity. CTA or SPY guided intraoperative procedure adjustments in 72% of patients. ICGLA identified poor soft-tissue perfusion and guided flap resection in 46% of patients. CONCLUSIONS: ICGLA skin blush location, size, and intensity do not correlate with CTA-identified perforating vessel location or actual perforating vessel size. Despite this, the ICGLA information was useful for evaluation of soft-tissue perfusion and flap design.

Autologous blood use for free flap breast reconstruction: a comparative evaluation of a preoperative blood donation program.

BACKGROUND: New insights into potential adverse effects of banked blood and improved infectious surveillance have led to questions regarding the utility of preoperative autologous blood donation. METHODS: A retrospective chart review of 153 patients undergoing abdominal free flap breast reconstruction was performed with the goal of determining the effect of an autologous blood donation program on clinical outcomes. Demographic and premorbid conditions were evaluated along with outcome variables including complication and transfusion rates. RESULTS: As expected, the autologous blood donor group (n = 96) was more likely to receive a blood transfusion of any kind compared with the nondonors (98% vs. 18%, P < 0.0001). Surprisingly, the mean number of allogeneic transfusions was not decreased (0.26 vs. 0.84, P = 0.066). The mean number of complications between groups were comparable (0.53 vs. 0.57, P = 0.687). CONCLUSION: We found neither significant benefit nor adverse effect from the practice of autologous blood banking for free flap breast reconstruction. The practice should be considered safe but not routinely recommended for free flap breast surgery.

A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle.

OBJECTIVE: Vascularized groin lymph node flaps have been successfully transferred to the wrist to treat postmastecomy upper limb lymphedema. This study investigated the anatomy, mechanism and outcome of a novel vascularized submental lymph node (VSLN) flap transfer for the treatment of lower limb lymphedema. METHODS: Bilateral regional submental flaps were dissected from three fresh adult cadavers for histological study. A unilateral submental flap was dissected in another six fresh cadavers after latex injection. The VSLN flap was transferred to the ankles of seven lower extremities in six patients with chronic lower extremity lymphedema. The mean patient age was 61 ± 9.4 years. The average duration of lymphedema symptoms was 71 ± 42.2 months. RESULTS: There was a mean of 3.3 ± 1.5 lymph nodes around the submental artery typically at the junction with the facial artery, on the six cadaveric histological sections. Mean of 2.3 ± 0.8 sizable lymph nodes were dissected and supplied by the submental artery in six cadaveric latex-injected submental flaps. All seven VSLN flaps survived. One flap required re-exploration for venous congestion but was successfully salvaged. There was no donor site morbidity. At a mean follow-up of 8.7 ± 4.2 months, the mean reduction of the leg circumference was 64 ± 11.5% above the knee, 63.7 ± 34.3% below the knee and 67.3 ± 19.2% above the ankle. CONCLUSION: The transfer of a vascularized submental lymph node flap to the ankle is a novel approach for the effective treatment of lower extremity lymphedema.

The application of indocyanine green fluorescence angiography in plastic surgery.

In flap reconstruction of complex defects the perfusion of the reconstructive flap is critical to the ultimate success of the reconstruction. This is especially true in perforator-based flaps where it can be difficult to assess the adequacy of perfusion in the operating room. However, the ability to definitively determine the degree of flap perfusion is imperative to clinical decision-making. An emerging technology using near-infrared angiography with indocyanine green (ICG) dye may significantly improve the immediacy and accuracy of the assessment of flap perfusion. This article reviews the current state of ICG angiography and its use in clinical practice in plastic surgery. There are 17 case series, including a total of 386 patients, published in the literature using ICG angiography in various plastic surgical procedures. ICG angiography may aid flap design and assessment in the intraoperative/postoperative settings, reduce complications, and ultimately improve outcomes.

The University of Pennsylvania Flap Course Enters Virtual Reality: The Global Impact.

The purpose of this study was to evaluate participants from the in-person Penn Flap Course (PFC) and virtual PFC to determine if the virtual PFC increased diversity in culture, sex, education, and surgical specialties internationally and within the United States. Our hypothesis is that the virtual PFC increases diversity internationally and within the United States. METHODS: A retrospective descriptive comparison was performed between participants from the in-person PFC from the years 2017 to 2019 and virtual PFC in 2020. Frequency maps were generated to determine differences in participation of cultures, sexes, education, and specialties internationally and within the United States. Net Promoter Scores (NPSs) were used to assess participant satisfaction with the virtual course. RESULTS: The in-person PFC included 124 participants from the years 2017 to 2019, whereas the virtual PFC included 770 participants in the year 2020. Compared to the in-person course, the virtual course included more cultures (countries: 60 versus 11; states: 35 versus 22), women (countries: 38 versus 7; states: 23 versus 9), students/researchers (countries: 24 versus 0; states: 9 versus 0), residents (countries: 44 versus 5; states: 26 versus 15), fellows (countries: 21 versus 2; states: 21 versus 9), attendings (countries: 34 versus 8; states: 16 versus 11), plastic surgery (countries: 54 versus 9; states: 31 versus 18), orthopedic surgery (countries: 12 versus 5; states: 11 versus 9), and other specialties (countries: 19 versus 1; states: 8 versus 2). Our overall NPS for the virtual PFC totaled 75%, categorized as "world class" based on global NPS. CONCLUSION: A virtual interface for a flap course increased participation and diversity of culture, sex, education, and specialties internationally and within the United States with "world class" participant satisfaction.

Does Realism Matter? A Randomized Controlled Trial Comparing Models for Medical Student Suture Education.

BACKGROUND: We hypothesized that medical students trained in suturing using high-fidelity models (cadaveric tissue) would demonstrate greater proficiency when compared with those trained using low-fidelity models (synthetic tissue). METHODS: Forty-three medical students were randomized into 2 groups. Group 1 consisted of students taught to perform simple interrupted sutures using synthetic tissue, and group 2 consisted of those taught using human cadaveric tissue. Suturing proficiency was measured pre- and postinstruction using the Global Rating Scale and by measuring suture accuracy. Perceived confidence in suturing was measured on a scale of 0-100. RESULTS: Perceived confidence was measured as an average of 8.26 out of 100 pretraining and significantly improved after training (56.91 out of 100); however, there was no significant difference when comparing confidence between groups posttraining (57.65 cadaveric versus 56.05 synthetic; P = 0.78), nor in the measured confidence change pre- and posttraining (P = 0.53). Posttraining, participants displayed a significant improvement in the number of adequately placed sutures; however, there was no significant difference posttraining when comparing groups (2.43 cadaveric versus 2.75 synthetic; P = 0.48). The change in adequate suture placement pre- and posttraining did not reach statistical significance between groups (P = 0.27). After instruction, participants demonstrated a significant improvement in total suture performance scores; however, there was no significant difference when comparing groups (30.04 cadaveric versus 29.80 synthetic; P = 0.90), nor in the total change pre- and posttraining (P = 0.74). CONCLUSIONS: Training medium fidelity (tissue versus synthetic) does not significantly influence a student's overall suturing performance. However, formal instruction significantly improves objective competence and perceived confidence. Regardless of the model, surgical departments should emphasize medical student exposure to basic surgical skills education.

The Use of Emotional Artificial Intelligence in Plastic Surgery.

BACKGROUND: The use of social media to discuss topics related to and within plastic surgery has become widespread in recent years; however, it remains unclear how to use this abundance of largely untapped data to propagate educational research in the field of plastic surgery. In this prospective, observational study, the authors aimed to delineate which plastic surgery-related topics evoked a significant emotional response within the study population and to assess the utility of motivational artificial intelligence within the field of plastic surgery. METHODS: Over a 4-month period (January to April of 2018), Cognovi Lab's artificial intelligence technology was used to search and analyze emotional reactions to several commonly hashtagged words. This innovative software uses several key metrics to describe its findings, including awareness, engagement, and motivation. RESULTS: Of the search terms examined, "nose job" had the most awareness during the study period, and the topic that most engaged consumers emotionally was "liposuction." Interestingly, "liposuction" ranked only fifth in terms of awareness. Consumers showed the strongest positive motivation toward the subjects of "plastic surgery" and "cosmetic surgery," and the lowest motivation toward the topic of "tummy tucks." CONCLUSIONS: This analysis by Cognovi Labs is the first quantitative effort to use the plethora of data on social media to interpret patient motivations and subsequent behavior. Moving forward, artificial intelligence technology will make it possible to predict which plastic surgery products, procedures, and practices will be successful. The findings presented in this article describe the unique viewpoint and power that this technology can deliver.

Evaluation of skin viability in nipple sparing mastectomy (NSM).

Nipple sparing mastectomy (NSM) is quickly becoming the standard of care due to earlier stage of breast cancer diagnosis, increased prevalence of prophylactic mastectomies, improved surgical techniques, and the desire of women to keep their nipples. However, the procedure is plagued with problems of nipple and skin necrosis due to the inherent ischemic nature of mastectomy. Indocyanine green (ICG) technologies offer surgeons new information that is helpful in the battle to reduce these devastating complications.

Indications and Controversies for Implant-Based Breast Reconstruction Utilizing Biological Meshes.

The advent of acellular dermal matrices (ADMs) has changed the way implant reconstruction is performed and has opened the door to muscle-sparing techniques that can be performed as an NSM (nipple-sparing mastectomy) with DTI (direct to implant) with excellent cosmesis and less patient morbidity. The article discusses differences in types of ADMs and outlines some current strategies and controversies with ADM use.

The Utility of a Master of Business Administration Degree in Plastic Surgery: Determining Motivations and Outcomes of a Formal Business Education Among Plastic Surgeons.

BACKGROUND: With the increasing complexity of health care, the knowledge of business in medicine is growing more valuable. Plastic surgeons in all practice settings are constantly forced to navigate endeavors that could be better faced with the leadership, management, and administrative skills honed through a formal business education. The purpose of this study was to gather data and draw conclusions related to the motivations and outcomes of plastic surgeons with a Master of Business Administration degree (MBA). METHODS: An online survey was distributed to plastic surgeons in the United States who have earned an MBA. The survey was divided into 4 main sections: demographics, MBA program description, objective assessment, and subjective assessment. RESULTS: The majority of plastic surgeons with an MBA are in practice at an academic medical center. The 2 most popular tracks of completing the degree are during medical school and after 5 years of practice. A large proportion of plastic surgeons with an MBA experienced changes in their existing career position, namely in patient care and business roles outside of clinical practice. The most important skills surgeons subjectively felt they had improved as a result of their business education were in the areas of leadership, management, and administration. CONCLUSIONS: Overall, all the plastic surgeons felt that their MBA experience met their expectations and would recommend the degree to fellow physicians. Prime motivations included adding a new dynamic to their existing career, satisfying entrepreneurial drive, and gaining credibility in business, with monetary gains being low on the list.

A Direct Comparison of Alloderm-Ready to Use (RTU) and DermACELL in Immediate Breast Implant Reconstruction.

The objective of this study was to compare the 2 leading human acellular dermal matrices in breast reconstruction with implants. This retrospective study draws on the experience of 2 expert surgeons with a history of long-standing use of the Alloderm-RTU (LifeCell Corporation, Branchburg, NJ) product who switched to the DermACELL acellular dermal matrix (LifeNet Health, Virgina Beach, Va) product. The consecutive nature of these data over this change allowed comparison between the 2 products without the confounding effects of patient selection or change in technique. The postoperative complications of seroma, infection, implant loss, and unplanned return to the operating room were studied, and no statistical differences were noted between these 2 products. The overall complications rates were low, with implant loss and infection less than 2% in 249 cases. Recommendations are for continued use of acellular dermal matrix in breast reconstruction and product selection based on price and availability.

Multidisciplinary approach to treatment of radiation-induced chest wall sarcoma.

Radiation-induced sarcoma (RIS) is a rare complication following therapeutic external irradiation for lung cancer patients. Patients with RIS may develop recurrence or metastasis of the previous disease and also at high risk for early chest wall complications following operation, which requires close follow-up and multidisciplinary approach. We present a challenging case of RIS with a multidisciplinary teamwork in the decision-making and successful management.

The Role of Intraoperative Perfusion Assessment: What Is the Current State and How Can I Use It in My Practice?

Evolving intraoperative technology has an increased presence and usefulness in aiding surgeon clinical judgment. Many surgical devices are readily available as an adjunct to this gold standard assessment of adequate tissue perfusion. Intraoperative perfusion monitoring provides surgeons with the ability to interpret additional information that enhances surgical decision-making in real-time. Technologies include various dye-based and non-dye-based near-infrared angiography, tissue oximetry measurements, and ultrasound-based tools. This review summarizes the available intraoperative technologies for planning and assessment of tissue perfusion in plastic and reconstructive surgery. The authors discuss the available literature for the individual devices and supporting evidence for their use. The authors recommend the evidence-based use of these tools in indicated surgical cases to improve clinical outcomes.