Prenatal Ultrasound Measurement of Fetal Stomach Size Is Predictive of Postnatal Development of GERD in Isolated Cleft Lip and/or Palate.

OBJECTIVE: To determine whether prenatal ultrasound measurement of fetal stomach size, as a surrogate marker of fetal swallowing, is predictive of postnatal development of gastroesophageal reflux disease (GERD) in cases of isolated cleft lip and/or palate (CL/P). DESIGN: This is a retrospective case-control study. The outcome of interest is postnatal diagnosis of GERD in isolated CL/P. The exposure of interest is prenatal stomach size measurement by ultrasound. SETTING: The study population was selected from an academic, tertiary care center between 2003 and 2011. PATIENTS/PARTICIPANTS: Cases were neonates undergoing CL/P repair during the study period. Cases with other known structural or chromosomal abnormalities were excluded. Controls were contemporary, nondiabetic neonates that matched gestational age (within one week) to cases. Each case measurement was matched ∼1:2 with control measurement. INTERVENTIONS: None. MAIN OUTCOME MEASURE: The primary outcome was difference in mean prenatal ultrasound measurement of fetal stomach size between cases and controls. We hypothesized that patients with postnatal development of GERD would have smaller mean fetal stomach size. RESULTS: There were 32 cases including 19 patients with unilateral cleft lip and palate, 8 with unilateral cleft lip, and 4 with bilateral cleft lip and palate. Cases were noted to have smaller mean anterior-posterior and transverse fetal stomach measurements as compared to controls. This was statistically significant from 16 to 21 weeks, 25 to 27 weeks, and 28 to 36 weeks (P < .01 for all). CONCLUSIONS: Prenatal ultrasound measurement of fetal stomach size as a surrogate marker of fetal swallowing is predictive of postnatal development of GERD in isolated CL/P.

Functional return after implant-based breast reconstruction: A prospective study of objective and patient-reported outcomes.

BACKGROUND: There is sparse literature studying the functional morbidity of subpectoral implant- based breast reconstruction. We aimed to prospectively investigate this technique's impact on objective upper extremity function and patient-reported outcomes. METHODS: Women undergoing mastectomy and immediate subpectoral tissue expander insertion with ADM sling were enrolled from November 2014 to August 2016. Preoperative evaluation of shoulder range of motion, pectoralis major strength, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Breast-Q surveys were conducted before surgery and at 1 month and 6 months postoperatively, or until return to baseline pectoralis major strength. RESULTS: Eighteen women (mean age, 51 years, SD 9.6, range 35-72 years) comprising 26 breast reconstructions completed postoperative follow-up. The average follow-up length was 9 months (range, 3 -18 months; SD, 144 days). At 1-month follow-up, there was a statistically significant decrease in lower and non dominant upper fiber pectoralis strength from preoperative baseline (p < 0.05). At final postoperative follow-up, 24 reconstructions (92.3%) recovered to at least 80% of preoperative strength in upper and lower fibers. From preoperative to final postoperative follow-up, QuickDASH scores showed a statistically significant (p = 0.008) increase from 4.1 (range 0-20.5, SD 6.1) to 18.7 (range 0-45.5, SD 13.4). Physical well-being: The chest was the only Breast-Q domain in which the average score significantly decreased (p = 0.02) between preoperative assessment and final follow-up. CONCLUSIONS: After implant-based breast reconstruction, patients achieve the return of objective upper extremity function, but patient-reported outcomes do not return to baseline as shown by increased QuickDASH scores. Thus, pectoralis-sparing reconstructive strategies such as prepectoral implant insertion should be pursued.

The Evolution of Iliac Bone Graft Donor Site Analgesia in Cleft Patients: Transversus Abdominis Plane Block Is Safe and Efficacious.

BACKGROUND: The transversus abdominis plane (TAP) block has been increasingly used as a means of abdominal wall analgesia. This study aims to determine if TAP block analgesia provides a benefit in cleft patients undergoing alveolar bone grafting with iliac crest cancellous bone graft. METHODS: Two groups of 20 consecutive patients undergoing alveolar bone grafting with iliac crest cancellous bone with either TAP block or indwelling catheter pain pump were examined in a retrospective fashion. Demographic data, pharmacologic use, and hospital length of stay were examined. RESULTS: Mean lengths of stay were identical between both groups. Patients in both groups received similar cumulative doses of morphine equivalents, codeine, ibuprofen, and ondansetron at 6 and 24 hours postoperatively. Transversus abdominis plane block patients received greater amounts of Tylenol at both 6 and 24 hours (P = 0.0015 and P = 0.0106). Pain scores did not differ significantly across our groups at 6 or 24 hours postoperatively. No adverse events were reported with the TAP block procedure. CONCLUSIONS: Patients undergoing TAP blocks receive the benefit of a single stage procedure without an indwelling catheter and similar 6- and 24-hour morphine usage. Given the safety profile of the procedure, its effectiveness and comfort without indwelling catheter, we advocate for TAP block analgesia as an adjunct therapy in the management of postoperative pain in this population.

Lymphovenous Anastomosis for the Treatment of Chylothorax in Infants: A Novel Microsurgical Approach to a Devastating Problem.

With the expanding horizon of microsurgical techniques, novel treatment strategies for lymphatic abnormalities are increasingly reported. Described in this article is the first reported use of lymphovenous anastomosis surgery to manage recalcitrant chylothoraces in infants. Chylothorax is an increasingly common postoperative complication after pediatric cardiac surgery, with a reported incidence of up to 9.2 percent in infants. Although conservative nutritional therapy has a reported 70 percent success rate in this patient population, failed conservative management leading to persistent chylothorax is associated with a significant risk of multisystem complications and mortality. Once conservative medical strategies are deemed unsuccessful, surgical or radiologic interventions, such as percutaneous thoracic duct embolization or ligation, are often attempted. However, these procedures lack high-level evidence in the infant population and remain a challenge, given the small size of the lymphatic vessels. As such, we report our experience with performing lymphovenous anastomoses in two infants who had developed refractory chylothoraces secondary to thoracic duct injury following cardiac surgery for congenital cardiac anomalies. In addition, this article reviews the relevant pathophysiology of chylothoraces, current treatment algorithm following failed conservative management, and potential role of the microsurgeon in the multidisciplinary management of this life-threatening problem. As part of the evolving microsurgery frontier, physiologic operations, such as lymphovenous anastomosis, may have a considerable role in the management of refractory pediatric chylothoraces. In our experience, lymphovenous anastomosis can restore normal lymphatic circulation within 1 to 2 weeks, liberate patients from mechanical ventilation, and enable expeditious return to enteral feeding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

5000 Free Flaps and Counting: A 10-Year Review of a Single Academic Institution's Microsurgical Development and Outcomes.

BACKGROUND: The establishment of an effective clinical and academic culture within an institution is a multifactorial process. This process is cultivated by dynamic elements such as recruitment of an accomplished and diverse faculty, patient geographic outreach, clinical outcomes research, and fundamental support from all levels of an institution. This study reviews the academic evolution of a single academic plastic surgery practice, and summarizes a 10-year experience of microsurgical development, clinical outcomes, and academic productivity. METHODS: A 10-year retrospective institutional review was performed from fiscal years 2006 to 2016. Microsurgical flap type and operative volume were measured across all microsurgery faculty and participating hospitals. Microvascular compromise and flap salvage rates were noted for the six highest volume surgeons. Univariate and multivariable predictors of flap salvage were determined. RESULTS: The 5000th flap was performed in December of 2015 within this institutional study period. Looking at the six highest volume surgeons, free flaps were examined for microvascular compromise, with an institutional mean take-back rate of 1.53 percent and flap loss rate of 0.55 percent across all participating hospitals. Overall, 74.4 percent of cases were breast flaps, and the remaining cases were extremity and head and neck flaps. CONCLUSIONS: Focused faculty and trainee recruitment has resulted in an academically and clinically productive practice. Collaboration among faculty, staff, and residents contributes to continual learning, innovation, and quality patient care. This established framework, constructed based on experience, offers a workable and reproducible model for other academic plastic surgery institutions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Sifting through the Evidence: A Comprehensive Review and Analysis of Neurotization in Breast Reconstruction.

BACKGROUND: An untoward outcome following breast reconstruction is diminished or complete loss of sensation. As the reconstructive paradigm continues to evolve, sensory restoration following reconstruction remains a research focus. Despite the multitude of published outcomes, there is marked heterogeneity across studies, thus confounding published outcomes. This study critically appraises the literature to summarize outcomes and establish a framework to guide clinical practice and future research. METHODS: A literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in an effort to perform a meta-analysis. The Ovid MEDLINE, PubMed, Embase, Scopus, Cochrane, and ClinicalTrials.gov online databases were queried to capture all publications between 1990 and 2017 that investigated postreconstruction breast sensation. The primary outcome of interest was breast sensation following both implant-based and autologous reconstruction with or without neurotization. Secondary outcomes of interest included time to sensory testing and patient-reported outcomes. RESULTS: Overall, 503 titles were screened, from which 37 articles were ultimately included for analysis, accounting for 1299 patients. There was major methodologic variability and inconsistent measurable outcomes across studies. It can be deduced that postoperative sensation returns spontaneously and unpredictably, neurotization enhances the magnitude and rapidity of sensory restoration when compared to nonneurotized reconstruction, and a sensate reconstruction improves patient-reported outcomes. CONCLUSIONS: Significant study design discrepancies exist, making it difficult to combine data and assess results. To effectively study breast sensation and the impact of neurotization, future investigation will depend on standardizing the way in which breast sensation is measured.

Thy1 (CD90) Expression Is Elevated in Radiation-Induced Periprosthetic Capsular Contracture: Implication for Novel Therapeutics.

BACKGROUND: Capsular contracture is a devastating complication of postmastectomy implant-based breast reconstruction. Unfortunately, capsular contracture rates are drastically increased by targeted radiotherapy, a standard postmastectomy treatment. Thy1 (also called CD90) is important in myofibroblast differentiation and scar tissue formation. However, the impact of radiotherapy on Thy1 expression and the role of Thy1 in capsular contracture are unknown. METHODS: The authors analyzed Thy1 expression in primary human capsular tissue and primary fibroblast explants by real-time quantitative polymerase chain reaction, Western blotting, and immunohistochemistry. Thy1 was depleted using RNA interference to determine whether Thy1 expression was essential for the myofibroblast phenotype in capsular fibroblasts. Furthermore, human capsular fibroblasts were treated with a new antiscarring compound, salinomycin, to determine whether Thy1 expression and myofibroblast formation were blocked by salinomycin. RESULTS: In this article, the authors show that radiation therapy significantly increased Thy1 mRNA and protein expression in periimplant scar tissue. Capsular fibroblasts explanted from scar tissue retained the ability to make the myofibroblast-produced scar-forming components collagen I and α-smooth muscle actin. Depletion of Thy1 decreased the fibrotic morphology of capsular fibroblasts and significantly decreased α-smooth muscle actin and collagen levels. Furthermore, the authors show for the first time that salinomycin decreased Thy1 expression and prevented myofibroblast formation in capsular fibroblasts. CONCLUSIONS: These data reveal that ionizing radiation-induced Thy1 overexpression may contribute to increased capsular contracture severity, and fibroblast scar production can be ameliorated through targeting Thy1 expression. Importantly, the authors' new results show promise for the antiscarring ability of salinomycin in radiation-induced capsular contracture. CLINCAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Academic Productivity, Knowledge, and Education in Plastic Surgery: The Benefit of the Clinical Research Fellow.

BACKGROUND: Academic research productivity is limited by strenuous resident and faculty schedules but nevertheless is imperative to the growth and success of our discipline. The authors report institutional experience with their clinical research fellowship model, providing two positions per year. METHODS: A critical analysis of research productivity was performed for all trainees, faculty, and research fellows from 2000 to 2015. Academic productivity was determined by the number of peer-reviewed publications, podium presentations, and h-index. Academic fate of previous research fellows was also noted. During the 16-year timeframe, 484 articles were published in print. Notably, 92 articles were published from 2000 to 2007 and 392 articles were published from 2008 to 2015 (p = 0.0066), demonstrating linear growth after instituting the research fellowship. In addition, 33 articles were published from 2002 to 2004 before leadership change, 47 from 2005 to 2007 after leadership change but before fellowship, and 58 from 2008 to 2010 in the first few years of the fellowship (p = 0.0204). RESULTS: Overall, 39.9 percent of publications appeared in Plastic and Reconstructive Surgery, with a total of 77 different peer-reviewed journal inclusions. American Association of Plastic Surgeons, American Society of Plastic Surgeons, and Northeastern Society of Plastic Surgeons podium presentations totaled 143 between 2005 and 2015. Of the eight previous fellows who applied into integrated and independent programs, 100 percent have matched. CONCLUSION: Incorporation of a formalized research fellowship into a plastic surgery program can drastically increase clinical research contribution in a reproducible fashion.

Characterizing infections in prosthetic breast reconstruction: A validity assessment of national health databases.

INTRODUCTION: Current guidelines in the United States require reporting only the 30-day postoperative outcomes to standardized databases, including the National Surgical Quality Improvement Program (NSQIP). Thus, many breast implant-related complications go unreported in standard databases. We sought to characterize late periprosthetic infections following implant-based breast reconstruction. METHODS: We conducted a retrospective analysis of all women who underwent expander/implant reconstruction from 2005 to 2014 at two institutions. All periprosthetic infections were identified and divided into early and late cohorts (≤30 days or >30 days). Infection was defined as any episode where antibiotics were initiated or a prosthetic device was explanted because of clinical evidence of the infection. RESULTS: In the 1820 patients (2980 breasts) identified, 421 periprosthetic infections occurred (14%). Of these, 173 (41%) were early and 248 (59%) were late (mean time to infection = 66.4 ± 101.9 days). Patients with late infections were more likely to be current smokers or have diabetes than patients with early infections (p < 0.034 for both). Infections caused by gram-negative bacteria and antimicrobial-resistant strains of Staphylococcus were more common in the early infection group (p < 0.001 for both). Implant loss due to infection was more common in the late infection group (p = 0.037). DISCUSSION: Late periprosthetic infections following implant-based breast reconstruction are underestimated in national outcome databases and have unique risk factors and microbiology compared to early infections. A system-level change in reevaluating and redefining a timeline for tracking and treating implant infections is necessary, given the substantial morbidity associated with, and frequency of, late periprosthetic infections.

The Evolving Role of Members of the American Board of Plastic Surgery in Burn Surgery.

INTRODUCTION: Outcomes for patients with burn injuries are optimized by multidisciplinary care in a specialized burn center. Plastic surgeons traditionally have played a significant role in the care of burn patients; however, this may be evolving. We aim to examine the role and employment satisfaction of plastic surgeons in burn surgery. METHODS: Members of the American Society of Plastic Surgery with available contact information and US senior plastic surgery residents were asked to complete a survey examining practice profiles and employment satisfaction. Responses were analyzed between groups stating that their practice did and did not involve burn surgery. RESULTS: Of the 573 attending respondents, 135 (23.6%) indicated that part of their practice included burn surgery. Nineteen (41.9%) residents indicated they desired their practice to include burn surgery. About 41.9% of respondents with less than 3 years of experience, 25% with between 3 and 10 years of experience, and 21.7% with greater than 10 years of experience practiced burn surgery. Twenty-one (15.3%) respondents were completely satisfied with their practice, 62 (45.3%) were mostly satisfied, and 36 (26.3%) were satisfied. Fourteen (10.2%) respondents were mostly dissatisfied and 4 (2.9%) were completely dissatisfied (P = 0.0315). CONCLUSIONS: Despite residents' interest and junior plastic surgeons' involvement in burn surgery, the role of burn surgery in responding plastic surgeons' practices diminished over time. Those practicing burn surgery are less likely to be satisfied and more likely to be dissatisfied with their practice. Plastic surgeons should therefore examine their role in burn surgery to optimize their desired involvement and satisfaction within the field.

Employment Satisfaction in Plastic and Reconstructive Surgery and Its Influence on Graduating Residents in an Evolving Health Care Climate.

BACKGROUND: The current state of employment satisfaction in plastic surgery has not been defined. Similarly, the factors influencing residents as they search for employment and the role of attending surgeons as mentors in this process have not been elicited. The authors aim to elucidate these measures through a survey of attending surgeons and senior residents. METHODS: A survey was created assessing employment satisfaction and was distributed to members of the American Society of Plastic Surgeons with available contact information. Responses were analyzed, with values of p < 0.05 deemed significant. RESULTS: A total of 616 plastic surgeons and senior plastic surgery residents responded. Compared with attending surgeons in private practice, those in academic practice were more satisfied with their case mix (p = 0.0005; OR, not significant) and less satisfied with their incentive structure (p = 0.0001; OR, 0.3155) and payor mix (p = 0.0005; OR, 0.6156). Employment change occurred in 225 surgeons (39.2 percent) since beginning practice. Surgeons that changed employment ranked base salary (p = 0.0031), earning potential (p = 0.0001), and incentive structure (p = 0.0001) as most important. Those that did not change employment ranked lifestyle (p = 0.0048), location (p = 0.0001), and desire to teach (p = 0.0002) as more important. Residents ranked location (p = 0.0030), desired case mix (p = 0.0131), and desire or lack of desire to teach residents (p = 0.0329) as more important than attending surgeons felt they should be, and guaranteed salary (p = 0.0178) and incentive structure (p = 0.0069) as less important. CONCLUSIONS: In an evolving health care environment, plastic surgeons' employment satisfaction is significantly dependent on a myriad of factors. Residents and their attending mentors differ significantly in perceived importance of these factors.

Lessons learned from the American College of Surgeons National Surgical Quality Improvement Program Database: has centralized data collection improved immediate breast reconstruction outcomes and safety?

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program database was implemented to longitudinally track surgical 30-day surgical outcomes and complications. The authors analyze the program-reported outcomes for immediate breast reconstruction from 2007 to 2011, to assess whether longitudinal data collection has improved national outcomes and to highlight areas in need of continued improvement. METHODS: The authors reviewed the database from 2007 to 2011 and identified encounters for immediate breast reconstruction using Current Procedural Terminology codes for prosthetic and autologous reconstruction. Demographics and comorbidities were tabulated for all patients. Postoperative complications analyzed included surgical-site infection, wound dehiscence, implant or flap loss, pulmonary embolism, and respiratory infections. RESULTS: A total of 15,978 patients underwent mastectomy and immediate reconstruction. Fewer smokers underwent immediate reconstruction over time (p=0.126), whereas more obese patients (p=0.001) and American Society of Anesthesiologists class 3 and 4 patients (p<0.001) underwent surgery. An overall increase in superficial surgical-site infection was noted, from 1.7 percent to 2.3 percent (p=0.214). Wound dehiscence (p=0.036) increased over time, whereas implant loss (p=0.015) and flap loss (p=0.012) decreased over time. Mean operative times increased over the analyzed years, as did all complications for prosthetic and autologous reconstruction. CONCLUSIONS: The American College of Surgeons National Surgical Quality Improvement Program data set has shown an increase in complications for immediate breast reconstruction over time, because of a longitudinally higher number of comorbid patients and longer operative times. This knowledge allows plastic surgeons the unique opportunity to improve patient selection criteria and efficiency. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The complex insurance reimbursement landscape in reduction mammaplasty: how does the American plastic surgeon navigate it?

BACKGROUND: Reduction mammaplasty (RM) is generally thought of as a reconstructive procedure, frequently but variably reimbursed by third-party payers. The purpose of this study was to assess US plastic surgeons' opinions of and interactions with the insurance coverage environment surrounding the reimbursement of RM. METHODS: The RM policies of 15 regional and nationwide health insurance carriers were analyzed. A survey regarding RM was distributed to all members of the American Society of Plastic Surgeons and subsequently analyzed. RESULTS: Most insurance carriers require a minimum resection weight, a minimum age, and a conservative therapy trial. A total of 757 surgeons responded to our survey. Seventy-six percent of the respondents believe that only some RM procedures should be covered by insurance. Sixty-four percent feel that symptoms are the most important factor in the surgeon's determination of medical necessity. Fifty-seven percent state that a breast resection weight of 500 g or greater is required for coverage in their region. Seventy-one percent believe that this weight should be less than 500 g per breast. If the surgeon estimates that he/she will remove 500 g per breast, the minimum weight for coverage, 61% of the surgeons would have patients sign a statement of liability for payment. If the intraoperative resection weight is inadequate, 45.6% would not remove additional tissue, risking nonpayment; 32.7% would complete the procedure and inform the patient that payment is out-of-pocket. CONCLUSIONS: Insurance reimbursement for RM varies in approval by carrier. Surgeons believe that signs and symptoms of macromastia determine medical necessity, whereas insurance carriers place a larger emphasis on resection weights.

Evolution of abdominal wall reconstruction: development of a unified algorithm with improved outcomes.

INTRODUCTION: Ventral hernia repair (VHR) continues to evolve and now frequently includes some form of component separation (CS) for large defects. To determine the optimal technique for VHR, we evaluated our outcomes before and after we refined and simplified our algorithm for repair. METHODS: One hundred five consecutive patients undergoing VHR for large midline hernias over 9 years were examined. Patients were divided into those operated on after (group 1) and before (group 2) the institution of our simplified algorithm. Our algorithm emphasizes careful patient selection and a stepwise approach including, but not limited to, bilateral CS if appropriate, preservation of large perforators, retrorectus mesh placement as appropriate, linea alba or midline fascial closure, and vertical panniculectomy. Primary outcomes evaluated included wound infection, dehiscence, and hernia recurrence. RESULTS: Seventy-eight (74.3%) patients underwent repair using our algorithm (group 1), whereas 27 (25.7%) underwent repair before utilization of this algorithm (group 2). Ninety-eight (93.3%) underwent CS, whereas 7 (6.7%) underwent another form of VHR. There was no significant difference in patient age or defect size. The mean follow-up period in days for patients in group 1 and group 2 were 184.02 and 526.06, respectively (P < 0.001). Hernia recurrence in group 1 was 2.6% versus 29.6% in group 2 (P < 0.001). The incidence of wound infection in group 1 was 10.3%, whereas that in group 2 was 33.3% (P < 0.001). The rate of wound dehiscence in group 1 was 17.9% versus 25.9% in group 2 (P < 0.001). CONCLUSIONS: Simplifying and unifying our algorithm for VHR, notably with utilization of CS, has yielded improved results. Recurrence and wound healing complications using this approach are favorable compared with published outcomes.

An unsuspected cause of meal-time morbidity: instant noodle scald burns.

Observational analysis revealed a concerning frequency of scald burns secondary to instant noodles. A literature review reveals studies with small sample sizes of pediatric populations and analysis of container engineering. The adult cohort, treatments, and short-term outcomes have been neglected. Considering these deficiencies, we reviewed our institution's experience with burns secondary to instant noodles. Patient encounters due to instant noodle burns from January 1, 2007, through May 15, 2011, were reviewed. Demographics, burn characteristics, treatment, length of stay, number of operative interventions, and complications were analyzed. Eight hundred fifty-two patients were seen (460 were admitted) for scald burns of all pathogenesis. Of these, 121 (14%) were seen for burns secondary to noodles (63 men and 58 women). Of these, 48 were older than age 4 (group 1), and 73 were younger than age 4 (group 2). TBSA was 2.34 in group 1 and 1.64 in group 2 (P = .04). The most commonly burned areas in group 1 were extremities (n = 43) and in group 2 were chest (n = 32) and extremities (n = 31). Seven patients in group 1 and two patients in group 2 required operative intervention. Length of stay in groups 1 and 2 were 3.5 and 6 days, respectively. Noodle scald burns cause morbidity at all ages. Pediatric burns due to noodles are frequently managed conservatively but more often necessitate inpatient treatment. The nonpediatric population has larger TBSA and requires more frequent operative intervention. The morbidity of noodle burns is significant. Increased public education and container re-engineering is warranted.