Vastus Lateralis Muscle Flap for High-Risk Patients Undergoing Orthopaedic Hip Surgery.

INTRODUCTION: Chronic infections and soft-tissue defects are serious complications after total hip arthroplasties (THAs) that may require hip disarticulation (HD). HD is a relatively high-risk procedure with poor long-term outcomes and survival. This is the first study to analyze the effect of an ipsilateral, pedicled vastus lateralis (VL) muscle flap in preventing HD in patients with recurrent complications after THA. METHODS: This retrospective case review analyzed the 6-month postoperative outcomes of 14 patients who underwent soft-tissue hip reconstruction with a VL muscle flap by a single surgeon. RESULTS: Most (86%) patients fully recovered after 6 months with preserved hip range of motion, no pain, and no weakness on ambulation. Two (14%) patients ultimately required HD despite introducing a VL flap. DISCUSSION: A VL muscle flap is an effective treatment of nonhealing THA and prophylactic intervention for patients at high risk for HD. The VL muscle is optimal because of its large size allowing reduction of soft-tissue dead space, its local anatomical location to the hip, and its exceptional vascularity. Additional prospective studies are necessary to determine the most appropriate population for this technique.

The Case for Onlay Biologic Mesh in Abdominal Wall Reconstruction Using Progressive Tension Suture Fixation.

BACKGROUND: After many years of debate, underlay and sublay placement of mesh slowly emerged as the standard of care in abdominal wall reconstruction because of lower hernia recurrence rates. However, onlay has the advantages of being faster, less invasive, and technically easier compared with underlay and sublay. Therefore, if a similar recurrence could be achieved, then onlay should be a consideration. In this study, we present a new onlay method using multipoint progressive tension suture fixation. METHODS: This was a retrospective chart review of patients who underwent abdominal wall reconstruction from 2012 to 2019. Inclusion criteria included onlay mesh placement and at least 1 year of follow-up. The core principles of the surgical technique are establishing myofascial continuity by component separation and reinforcing the repair with onlay mesh that is fixated with multipoint progressive tension sutures. RESULTS: The number of patients after exclusions was 59, and the average body mass index was 32.52 ± 6.44 kg/m2. More than half (62.7%) of patients had a history of hypertension, 95% had at least 1 prior abdominal/pelvic surgery, and 61% had at least 1 prior hernia repair. Postoperative complications included 20.3% of patients requiring drainage of a fluid collection in the clinic setting, and 29.3% of patients requiring return to the operating room for any reason (including superficial wound debridement). The average defect size was 231.88 ± 195.86 cm2, the mean follow-up was 3.11 ± 1.83 years, and the recurrence rate was 5.1%. CONCLUSIONS: We report a hernia recurrence rate of 5.1% in a high-risk population with complex defects at a mean of 3.1 years of follow-up using onlay mesh fixated with multipoint progressive tension sutures. This recurrence rate is similar to that reported for both underlay and sublay techniques. However, the onlay approach is technically easier, faster, and less invasive compared with underlay and sublay techniques, which may translate into wider reproducibility, lower costs, and improved patient safety.

Mandibular Distraction Osteogenesis as a Primary Intervention in Infants With Pierre Robin Sequence.

BACKGROUND: Pierre Robin sequence (PRS) is a triad of congenital facial abnormalities that can present as a syndrome (syndromic PRS [sPRS]) or an isolated entity (isolated PRS [iPRS]). Patients with PRS can develop airway and feeding problems that may result in failure to thrive. Mandibular distraction osteogenesis (MDO) is a method for improving the functional issues associated with breathing and feeding. There is a Paucity of literature evaluating the outcomes of MDO between sPRS and iPRS patients. METHODS: An institutional review board-approved retrospective review of PRS patients managed by a single surgeon and treated with MDO between January 2015 and December 2019 at a tertiary referral hospital was performed. The patients were stratified into iPRS or sPRS based on gene testing. Airway outcome measures included avoidance of tracheostomy, relief of sleep apnea, and oxygen saturation improvement. Primary feeding measures included achievement of full oral feeds and growth/weight gain. Statistical analysis included t tests and χ2 tests where appropriate using SPSS. RESULTS: Over the study period, of the 29 infants with PRS, 55% identified as iPRS and 45% as sPRS. There were no significant differences in the patient characteristics, apnea-hypoxia index (22.27 ± 12.27) and laryngeal view (3 ± 0.79) pre-MDO. After MDO, 83% of the subjects achieved a positive feeding outcome and 86% achieved a positive airway outcome with no statistical significance between sPRS and iPRS (P = 0.4369). There was a statistically significant change post-MDO in apnea-hypoxia index (5.24 ± 4.50, P = 0.02) and laryngeal view (1.59 ± 1.00, P = 0.01). CONCLUSIONS: Our recent experience would lead us to believe that sPRS patients have greater morbidities and challenging clinical developments that, when properly evaluated, can be managed by MDO. There is a potential role for MDO in reducing the need for traditional surgical interventions for respiratory and feeding problems in both iPRS and sPRS patients.

Ranking United States Plastic Surgery Residency Programs Based on Academic Achievement of Faculty Members.

INTRODUCTION: The Doximity Residency Navigator is currently the only resource that ranks plastic surgery residency programs. Given the paucity of objective program rankings, in this study, we devised a new algorithm to rank plastic surgery programs based on academic achievement of faculty members. METHODS: The Fellowship and Residency Electronic Interactive Database was used to obtain the following information on plastic surgery programs: the amount of 2017 National Institute of Health and Veterans Administration funding, lifetime and 5-year faculty h-indices, and the number of faculty on editorial boards of journals. Based on all of this information, an overall ranking of the top 25 plastic surgery programs was created. RESULTS: The top program for annual National Institutes of Health and Veteran Affairs funding was the University of Southern California (integrated and independent). The top programs for faculty lifetime h-index were the University of Michigan (integrated) and New York University (independent). The top program for faculty 5-year h-index was the University of Pennsylvania (integrated and independent). The top program for the number of faculty members who are on the editorial boards of major journals was Harvard University (integrated and independent). The top program overall was Harvard University (integrated and independent). CONCLUSION: We ranked plastic surgery residency programs based on objective data related to faculty academic achievement. Academic achievement rankings are just one of numerous other factors that medical students should synthesize when making informed decisions when applying to residency.

Examining the Correlation between Altmetric Score and Citations in the Plastic Surgery Literature.

BACKGROUND: Social media are transforming the dissemination of published research. This influence brought the advent of a new metric, altmetrics, which seeks to quantify the influence of research in real time based on an article's attention online. This study aims to determine the correlation between altmetrics ratings for articles with traditional bibliometrics of impact factor and citation rate. METHODS: The 10 most cited articles in the top 15 plastic surgery journals were determined for 2013 and 2016. The 2013 articles allow for a 5-year lag time, whereas 2016 data provide another timepoint for comparison. Altmetric scores and citation count were collected for each article. Impact factor and Twitter account age were determined for each journal. Statistical analysis was completed using descriptive statistics, and Pearson and Spearman correlation coefficients. RESULTS: In both 2013 and 2016, there was a weak positive correlation between citations and Altmetric score (r = 0.2620, p = 0.0012; r = 0.3564, p < 0.0001, respectively) and between impact factor and the Altmetric score (r = 0.2419, p = 0.0040; r = 0.3887, p = < 0.0001, respectively). Twitter was the main contributor to the Altmetric score in both 2013 and 2016. CONCLUSIONS: Altmetric scores and traditional bibliometrics are not strongly correlated with one another in the plastic surgery literature at this point in time. Still, the short- and long-term impact of a publication might be determined through the combined analysis of citation count, impact factor, and Altmetric scores.

Studying Institutional Situational Awareness Through Anonymous Incident Reporting.

BACKGROUND AND OBJECTIVES: The efficacy of anonymous incident reporting (AIR) is critical to creating a culture of safety. Prior studies have sought to establish AIR in a similar manner as aviation, nuclear power, and other industries. However, health care presents unique challenges that differ greatly from these industries. We present a straightforward method using statistical process control to study the progression and efficacy of AIR. METHODS: This study represents a retrospective review of all anonymous incident reports and surgical critical events from 2012 to 2017 at a single-institution, 500-bed, university-based, metropolitan Veterans Affairs Administration Medical Center located in Texas. This work was approved by the Veterans Administration Quality Board and deemed to be an appropriate quality improvement project. This project did not require institutional review board approval. RESULTS: There was an exponential increase in AIRs in the first 15 months from 1 report per month to 168 reports in the ninth month (1425% increase). The results then plateaued over time (first year: 1017, second year: 1634, and third year: 1938-common-cause variation). A logarithmic regression was performed for progression of AIRs per month yielding the equation y = -7E-13ln(x) + 142.92, Pearson Correlation Coefficient = 0.55, where y represents number of reports and x time by month. The highest number of Critical Incident Tracking Notification System (CITNS) reports was observed early in the self-reporting process and decreased over time (first year: 5, second year: 2, third year: 1, fourth year: 1, and fifth year: 0). The numbers of AIR and CITNS reports were found to be inversely related with a Pearson correlation coefficient of -0.4. CONCLUSIONS: Statistical process control can be applied to an institution's AIR program to study progression and situational awareness.

Alloderm and Cortiva Have Similar Perioperative Wound Complications in Abdominal Wall Reconstruction.

BACKGROUND: Although controversial, the use of acellular dermal matrices (ADMs) for abdominal wall reconstruction (AWR) is increasing. There are now many different ADMs available, but there is a lack of studies directly comparing ADMs in terms of outcomes. MATERIALS AND METHODS: A retrospective chart review was performed to compare perioperative wound complications (up to 120 d postoperatively) between patients who underwent AWR with the human noncrosslinked ADMs Alloderm or Cortiva from January 2012 to March 2020. Surgical technique uniformly consisted of open component separation, onlay implantation of ADM, and progressive tension suture fixation of ADM. RESULTS: After exclusions, 53 patients were in the Alloderm group, and 29 patients were in the Cortiva group. The overall perioperative wound complication rate between Alloderm (51.92%) and Cortiva (72.41%) was not significantly different (P = 0.09921). The average follow-up for Alloderm was 76.69 ± 29.52 d and for Cortiva was 66.93 ± 35.16 d (P = 0.2088). There were no cases that required explantation of ADM. CONCLUSIONS: Given the similar perioperative wound complication profiles, the more cost-effective ADM may be a consideration for use in AWR. The fact that there were zero instances of ADM explantation also supports the use of ADM in these high-risk cases.

Differences in Highly-Cited and Lowly-Cited Manuscripts in Plastic Surgery.

BACKGROUND: There is a paucity of research comparing journal articles that accrue numerous citations with those that accrue few citations over time. Understanding differences between journal articles can help direct investigators in designing and conducting their research. METHODS: Using advanced bibliometric tools, we queried four plastic surgery journals (Journal of Reconstructive Microsurgery, Annals of Plastic Surgery, Plastic and Reconstructive Surgery, and Microsurgery) for primary research articles published between 1998 and 2008 accruing zero or one citations with at least a 10-y lag time. Forty-seven articles were identified as low citation and were compared with an equal number of articles in the same journals that accrued the highest number of citations in the same period as high citation (HC). The data were analyzed using Student t-tests, Wilcoxon rank sum tests, chi-square tests, and Fisher exact tests. The level of significance was established at P < 0.05. RESULTS: When compared with the HC cohort, the low citation articles were more likely to be nonclinical (P < 0.001), have no plastic surgery authors (P = 0.0026), and focus on the field of microsurgery (P = 0.003). The HC cohort was more likely to have higher sample sizes (P = 0.0339), focus on aesthetic/cosmetic surgery (P = 0.003), have a higher number of other disciplines included on authorship (P < 0.001), references (P = 0.0451), manuscript pages (P < 0.001), and words in the abstract (P < 0.001). CONCLUSIONS: A small number of articles published in four plastic surgery journals were uncited during a 10-y period. There are qualitative and quantitative differences between highly and lowly cited articles in the plastic surgery literature. Investigators should consider these differences when designing and conducting studies.

Dermal Autografts in Breast Reconstruction: A Review of Past and Current Trends.

Breast cancer affects 1 in 8 women. As the treatment of breast cancer evolves, breast reconstruction does as well. Implant-based reconstructions are increasing, leading to increased use of acellular dermal matrix (ADM) for better implant positioning. Acellular dermal matrices are derived from cadaveric skin and are processed to be immunologically inert. However, ADM can be costly and can have complications such as seroma and infection. This has led to the development of dermal autografts. These were first used in postmastectomy breast reconstruction in women with redundant breast skin that was deepithelialized and used for lower pole coverage of tissue expanders and implants. This evolved into harvesting dermal autografts from the abdomen. Later studies evaluated the use of meshed dermal autografts. Histological analysis of ADM versus dermal autografts shows that there are increased vessels within dermal autografts compared with ADM. This potentially contributes to the decreased complication rate seen with autografts. In addition, one study showed equivalent results in aesthetic outcomes and capsular contracture between ADM and dermal autograft. Analysis of cost has shown that ADM is significantly more costly than harvesting a dermal autograft. Physician reimbursement is also higher for dermal autografts. This review article seeks to summarize key studies that highlight the feasibility of using dermal autografts in breast reconstruction.

Recurrent myxoid liposarcoma of the hand.

Malignant hand tumors are rarely observed in clinical practice which makes distinguishing them from benign soft tissue masses particularly challenging. A 41-year-old male presented with joint pain and swelling of his left index metacarpophalangeal joint. Radiological studies showed pronounced swelling around the affected joint with no bony abnormality, but incision and drainage of the site yielded negative cultures. Subsequent gross total resection confirmed the diagnosis of myxoid liposarcomas after cytogenetic pathology examination. Recurrence occurred after 1 year, followed by second resection and adjuvant radiotherapy. At 2 years follow-up, the patient was recurrence free. In conclusion, myxoid liposarcoma should be in the differential diagnosis of an older patient with erythema and swelling surrounding a subfascial mass of the hand.