Canadian Trends in Free Flap Management for Microsurgical Lower Limb Reconstruction.

Introduction: Free tissue transfers have become a mainstay in lower limb salvage, allowing safe and reliable reconstruction after trauma, tumor extirpation, and complex wounds. The optimal perioperative (PO) management of these flaps remains controversial. This study aims to assess the current state of practice among Canadian microsurgeons. Methods: Sixty-four Canadian microsurgeons were approached to complete an online questionnaire regarding their PO management of fasciocutaneous free flaps used for lower limb reconstruction. Trends in dangling timing and duration, use of venous couplers, compressive garments, thromboprophylaxis, and surgeons' satisfaction with their protocol were assessed. Results: Twenty-eight surgeons responded. Fifty-seven percent did not have a specific mobilization protocol. Dangling was mainly initiated on postoperative days 5 to 6 (44%). The most common protocol duration was 5 to 6 days (43%). The concern for prolonged venous pooling was the main reason for delay of dangling (71%). Compressive garments were placed routinely by 12 surgeons (43%) with 20% starting before dangling, 46% with dangling, and 33% after dangling. Venous couplers were routinely used by 24 surgeons (85.7%). Trends in management were influenced by previous training in 53.6% of cases (vs evidence-based medicine 7.1%). Although 89.3% were satisfied with their approach, 92.8% would consider changing practice if higher-level evidence was available. Conclusions: The majority of Canadian microsurgeons initiate dangling early and utilize venous couplers. However, the use of compressive garments is limited. Trends in management are largely based on personal experience. Nearly all surgeons would consider changing their practice if higher-level evidence was available.

Introduction: Les transferts de tissus libres sont devenus une clé de voûte du sauvetage du membre inférieur, permettant une reconstruction sûre et fiable après un traumatisme, l'extirpation d'une tumeur et des blessures complexes. La gestion périopératoire optimale (PO) de ces volets reste controversée. Cette étude vise à évaluer l'état actuel des pratiques parmi les chirurgiens canadiens pratiquant la microchirurgie. Méthodes: Soixante-quatre spécialistes canadiens de microchirurgie ont été approchés et il leur a été demandé de répondre à un questionnaire en ligne sur leur gestion PO des lambeaux fascio-cutanés libres utilisés pour la reconstruction du membre inférieur. Les tendances concernant des échéances et des durées du protocole de jambe pendante, l'utilisation de coupleurs veineux, les vêtements compressifs, la thromboprophylaxie et la satisfaction des chirurgiens envers leur protocole ont été évaluées. Résultats: Vingt-huit chirurgiens ont répondu. Cinquante-sept pour cent (57 %) n'avaient pas de protocole de mobilisation précis. Le protocole de jambe pendante sans appui a été instauré aux jours postopératoires 5 ou 6 (44 %). La durée la plus courante du protocole était de 5 à 6 jours (43 %). La préoccupation d'une accumulation prolongée de sang veineux était la principale raison pour retarder l'exercice de jambe pendante (71 %). Douze (12) chirurgiens (43 %) ont mis en place de manière régulière des vêtements compressifs: 20 % d'entre eux ont commencé avant de laisser pendre le membre, 46 % en même temps et 33 % après avoir laissé pendre le membre. Des coupleurs veineux ont été utilisés en routine par 24 chirurgiens (85,7 %). Les tendances en matière de gestion ont été influencées par la formation antérieure dans 53,6 % des cas (contre la médecine fondée sur des données probantes: 7,1 %). Même si 89,3 % des chirurgiens étaient satisfaits de leur approche, 92,8 % d'entre eux envisageraient de modifier leur pratique si des données probantes de plus haut niveau étaient disponibles. Conclusions: La majorité des spécialistes canadiens de la microchirurgie instaurent précocement la mise en décharge hors du lit du membre inférieur et utilisent des coupleurs veineux. Cependant, l'utilisation de vêtements compressifs est limitée. Les tendances en matière de gestion reposent largement sur l'expérience personnelle. Presque tous les chirurgiens envisageraient de modifier leur pratique si des données probantes de plus haut niveau étaient disponibles.

Analysis of Craniofacial Remodeling in the Aging Midface Using Reconstructed Three-Dimensional Models in Paired Individuals.

BACKGROUND: Aging leads to a panoply of changes of facial morphology. The present study was conducted to analyze modifications of the facial skeleton with aging, using high-resolution imaging and comparing the same individuals at two time points. METHODS: The electronic medical record system was reviewed since its inception in 2001 for patients for whom two computed tomographic scans of the midface were obtained at least 9 years apart. The computed tomographic scans were converted into three-dimensional craniofacial models for each patient, using the initial and the follow-up computed tomographic scan data. The models were used to highlight areas of bone growth and bone resorption using a color scale and to perform a cephalometric analysis. RESULTS: Seven patients with a mean age of 61 years and computed tomographic scans on average 10.3 years apart were included. Bone resorption was consistently present (100 percent) at the pyriform aperture and the anterior wall of the maxilla. Resorption was noted at the superocentral (71 percent), inferolateral (57 percent), and superomedial (57 percent) aspects of the orbital rim. Resorption occurred earlier at the inferolateral orbital rim followed by the superomedial orbital rim in later decades of life. Paired-analysis of change in the orbital rim height and width demonstrated a mean decrease over time but was not significant. CONCLUSION: Bone remodeling in the same individual, over a period of 10 years, was characterized by resorption at the pyriform aperture; anterior wall of the maxilla; and superocentral, superomedial, and inferolateral aspects of the orbital rims.

Factors Influencing the Rate of Post-Mastectomy Breast Reconstruction in a Canadian Teaching Hospital.

BACKGROUND: Post-mastectomy breast reconstruction (PMBR) improves psychosocial well-being, quality of life, and body image. Reconstruction rates vary widely (up to 42% in the United States), but the few Canadian studies available report rates of 3.8% to 7.9%. We sought to evaluate the current state of breast reconstruction in 1 Canadian teaching hospital and factors determining patients' access to reconstruction. METHODS: We performed a retrospective chart review of all patients with breast cancer undergoing mastectomy alone or mastectomy and reconstruction at a Canadian hospital between 2010 and 2013. We calculated rates of breast reconstruction and compared patient characteristics between the 2 groups, and then performed a multiple logistic regression to determine factors increasing the odds of receiving breast reconstruction. RESULTS: A total of 152 patients underwent 154 total or modified radical mastectomies. We obtained a rate of PMBR of 21%, 14% immediate reconstruction, and 8% delayed. Statistical analysis showed that compared to patients with mastectomy alone, patients who received PMBR were significantly younger, with a larger percentage having bilateral mastectomies, non-invasive breast cancer, and residing further from the hospital. Patients less than 50 years old and those with bilateral mastectomies had significantly greater odds of having a reconstruction. CONCLUSIONS: Our Canadian tertiary care institution has a high volume of breast surgery and an active breast reconstruction team. However, the rate of immediate reconstruction remains low compared to similar centers in the United States. We recommend a united effort to increase awareness regarding PMBR and address common misconceptions hindering patients' access to breast reconstruction. LEVEL OF EVIDENCE: Epidemiologic study, Level III.

HISTORIQUE: La reconstruction mammaire postmastectomie (RMPM) améliore le bien-être psychosocial, la qualité de vie et l'image corporelle. Le taux de reconstructions varie considérablement (jusqu'à 42 % aux États-Unis), mais les quelques études canadiennes signalent un taux de 3,8 % à 7,9 %. Les auteurs ont cherché à évaluer la situation relative aux reconstructions mammaires dans un hôpital universitaire canadien et les facteurs déterminant l'accès à la reconstruction. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des dossiers de toutes les patientes atteintes d'un cancer du sein qui avaient subi une simple mastectomie ou une mastectomie suivie d'une reconstruction dans un hôpital canadien entre 2010 et 2013. Ils ont calculé le taux de reconstructions mammaires et comparé les caractéristiques des patientes des deux groupes, puis ont procédé à une régression logistique multiple pour déterminer les facteurs qui accroissaient la probabilité de reconstruction mammaire. RÉSULTATS: Au total, 152 patients ont subi 154 mastectomies radicales totales ou modifiées. Les chercheurs ont obtenu un taux de RMPM de 21 %, soit 14 % de reconstructions immédiates et 8 % de reconstructions tardives. L'analyse statistique a révélé que, par rapport aux patientes qui avaient subi une simple mastectomie, celles qui avaient reçu une RMPM étaient considérablement plus jeunes, et un plus fort pourcentage avait subi une mastectomie bilatérale, était atteint d'un cancer du sein non invasif et habitait loin de l'hôpital. Les patientes de moins de 50 ans et celles qui avaient subi une mastectomie bilatérale couraient une plus grande chance de subir une reconstruction. CONCLUSIONS: Notre établissement de soins tertiaires canadien effectue un fort volume de chirurgies du sein et dispose d'une équipe de reconstruction mammaire active. Cependant, le taux de reconstructions immédiates demeure faible par rapport à celui de centres similaires aux États-Unis. Nous recommandons d'adopter un front uni pour mieux faire connaître la RMPM et calmer les erreurs courantes qui empêchent les patients d'avoir accès à la reconstruction mammaire. Qualité des preuves : Étude épidémiologique, niveau III.

Super-drained distally based neurofasciocutaneous sural flap: a case series and review of literature.

OBJECTIVE: The distally based neurofasciocutaneous sural flap is central to the armamentarium for the reconstruction of leg's distal third, ankle, and hindfoot. Despite the use of adapted techniques aimed at increasing the flap's reliability, venous congestion remains a frequently encountered problem. We present a venous super-drainage technique used by the senior author to reduce venous congestion and improve flap reliability when harvesting larger flaps. METHODS: A retrospective chart review, from January 2002 to October 2008, at 2 tertiary care centers, was conducted on all cases of inferior limb reconstruction with reverse sural flaps on defects greater than 10 × 5 cm. In addition, a literature review was carried out to examine the average sural flap surface area and reported complications published from 1992 to 2012. We then compared our results with those published in the literature. RESULTS: A total of 15 flaps were identified. Mean flap dimensions were 14 × 8.5 cm (mean area = 115.27 cm(2); 95% confidence interval, 99.28-131.26). None of the flaps developed complications (arterial or venous insufficiency, partial/complete necrosis). The average flap surface area in the literature is 55.08 cm(2), with a 22% rate of total complications. We harvested significantly larger flaps (P < .001) with a significantly lower total complication rate (P < .05) when compared with that reported in the literature. CONCLUSION: Anastomosing the proximal end of the lesser saphenous vein with a vein at the defect site improves venous outflow, effectively reducing the incidence of venous congestion, increases the potential flap size, and improves reliability.

A comparison and cost analysis of cranioplasty techniques: autologous bone versus custom computer-generated implants.

BACKGROUND: Cranioplasty can be performed either with gold-standard, autologous bone grafts and osteotomies or alloplastic materials in skeletally mature patients. Recently, custom computer-generated implants (CCGIs) have gained popularity with surgeons because of potential advantages, which include preoperatively planned contour, obviated donor-site morbidity, and operative time savings. A remaining concern is the cost of CCGI production. The purpose of the present study was to objectively compare the operative time and relative cost of cranioplasties performed with autologous versus CCGI techniques at our center. METHODS: A review of all autologous and CCGI cranioplasties performed at our institution over the last 7 years was performed. The following operative variables and associated costs were tabulated: length of operating room, length of ward/intensive care unit (ICU) stay, hardware/implants utilized, and need for transfusion. RESULTS: Total average cost did not differ statistically between the autologous group (n = 15; $25,797.43) and the CCGI cohort (n = 12; $28,560.58). Operative time (P = 0.004), need for ICU admission (P < 0.001), and number of complications (P = 0.008) were all statistically significantly less in the CCGI group. The length of hospital stay and number of cases needing transfusion were fewer in the CCGI group but did not reach statistical significance. CONCLUSION: The results of the present study demonstrated no significant increase in overall treatment cost associated with the use of the CCGI cranioplasty technique. In addition, the latter was associated with a statistically significant decrease in operative time and need for ICU admission when compared with those patients who underwent autologous bone cranioplasty. LEVEL OF EVIDENCE: IV, therapeutic.

Abdominal compartment syndrome following abdominoplasty: A case report and review.

Abdominoplasty is among the most commonly performed aesthetic procedures in plastic surgery. Despite high complication rate, abdominal contouring procedures are expected to rise in popularity with the advent of bariatric surgery. Patients with a history of gastric bypass surgery have an elevated incidence of small bowel obstruction from internal herniation, which is associated with non-specific upper abdominal pain, nausea, and a decrease in appetite. Internal hernias, when subjected to elevated intra-abdominal pressures, have a high-risk of developing ischemic bowel. We present a case report of patient with previous laparoscopic Roux-en-y gastric bypass who developed acute ischemic bowel leading to abdominal compartment syndrome following abdominoplasty. To the best of our knowledge, this is the first reported case in the literature. We herein emphasise on the subtle symptoms and signs that warrant further investigations in prospective patients for an abdominal contouring procedure with a prior history of gastric bypass surgery.

An atypical growth of a giant fibroadenoma after trauma.

BACKGROUND: Fibroadenomas are the most common benign breast lesion in female adolescents. However, it is important to recognize that a small percentage have been shown to progress to giant fibroadenomas. Giant fibroadenomas can spontaneously infarct leading to significant morbidity and are also difficult to distinguish from the more aggressive phyllodes tumors. CASE: We describe the first case, to the best of our knowledge, of a 12-year-old girl who presented with a giant fibroadenoma complicated by a central infarct and an intra-lesional hemorrhage from a trauma to the breast. SUMMARY AND CONCLUSION: The complicated giant fibroadenoma with an intra-lesional hemorrhage has characteristics of both benign and malignant lesions, and is difficult to distinguish by history and physical alone. Ultrasonography is a valuable tool yet the core needle biopsy remains the gold standard to confirm the diagnosis.

Salter-harris type 2 fracture of the proximal phalanx of the thumb with a rotational deformity: a case report and review.

Hand fractures are the most common site of injury in the pediatric population. They commonly involve the epiphyseal growth plates, and their standard classification is that of Salter-Harris (SH). Rotational deformities after SH fractures are rarely reported in literature. However, only 5 degrees of angulation can cause evident rotational deformity. This could be seen clinically and reconfirmed with radiologic evaluation. Up to this date, there are only a few cases of SH fractures with rotational deformity that have been described. We present 2 cases of SH type 2 with evidence of rotational deformity, which were reduced under local anesthesia in the emergency department. A review of literature is performed. Thus, examination for rotational deformities in SH fractures should be kept in mind. A satisfactory closed reduction under local anesthesia can be obtained.