Orthoplastic Approach to Lower Extremity Reconstruction: An Update.

In order to address complex extremity injuries, the orthoplastic approach uses plastic, orthopedic, and microsurgical techniques and includes other disciplines to optimize limb salvage. This collaboration, if created early in treatment, allows for more expedient and individualized solutions to a variety of extremity injuries resulting in decreased hospital stay, fewer complications, and improved functional outcomes. The orthoplastic approach does not merely avoid amputation, but also improves patient function and quality of life in the short and long term.

Relevance of Academic Productivity in the Assessment of Integrated Plastic Surgery Applicants.

BACKGROUND: The academic productivity of an integrated plastic surgery applicant is strongly considered during the ranking process but is often difficult to assess. The h-index is a tool that provides an objective measure of both the quality and impact of an author's academic works. The goals of this study were to assess whether the h-index of recently matched plastic surgery interns correlates with their home and eventual residency program characteristics. METHODS: A database of all 2018 interns in integrated plastic surgery programs was created. The SCOPUS database was queried for the h-indices for each individual. RESULTS: In 2018, 77 integrated plastic surgery programs offered a total of 168 PGY1 positions; data was able to be obtained for 131 individuals. The mean h-index was 1.26 (range 0-14), with a mean of 4.22 publications (range 0-58). The h-index increased in concordance with overall number of publications. The h-index of applicants matching at Top 50 NIH Funded institutions had a significantly higher h-index (1.57) compared to those that matched to all other institutions (0.76) (p<0.05). Applicants matching at a "top 20" program as determined by Doximity reputation rankings also had a significantly higher h-index (1.96) compared to those matching at all other programs (0.83) (p< 0.05). CONCLUSIONS: The h-index of recently matched integrated plastic surgery interns correlates with several factors including program reputation and level of NIH funding. As applicants become increasingly well-qualified and the number of the publications increases commensurately, programs that place an emphasis on academic productivity may consider incorporating the h-index into their evaluation.

The forearm fillet flap: 'spare parts' reconstruction for forequarter amputations.

Radical forequarter amputation is often performed for recurrent proximal extremity tumors. A free forearm fillet flap is used to provide excellent coverage of the resultant defect without donor site morbidity. Use of a free flap from the distal portion of the extremity with proximal tumor burden is safe and effective.

Outcomes in Chest Wall Reconstruction Using Methyl Methacrylate Prostheses: A Review of the Literature and Case Series Utilizing a Novel Approach with Biologic Mesh.

BACKGROUND: Composite defects after chest wall resection may leave patients at risk with lack of protection of vital structures and potentially respiratory compromise secondary to flail segments. Reconstruction of the chest wall with various alloplastic materials is possible and well described. Here, the authors present a novel technique in chest wall reconstruction utilizing a methyl methacrylate (MMA) "sandwich" with biologic mesh. The authors also sought to determine outcomes in chest wall reconstruction with MMA to optimize surgical decision making and minimize patient morbidity. METHODS: A literature review was conducted using MEDLINE and the Cochrane Collaboration Library for primary research articles on chest wall reconstruction using MMA. Data related to surgical techniques and patient outcomes were extracted and analyzed. The authors also present their case series and outcomes utilizing a novel technique with biologic mesh. RESULTS: Seventy-four articles met inclusion criteria, which included a total of 562 patients. Reconstruction methods included three main variations of the MMA prosthesis and six institution-specific variations. Complications were reported in 13.7% of patients; the most common complications included infection (5.6%), respiratory failure (3.3%), and atelectasis (1.7%). Less commonly reported complications included prosthesis dislocation (1.2%), pneumonia (1.0%), and lung collapse (0.4%). Overall mortality due to respiratory causes was observed in nine patients (1.6%). In our case series, complications included respiratory failure and seroma was reported in one patient, with no complications at long-term follow-up. CONCLUSION: There are a variety of options available for rigid and nonrigid prosthetic repair of the chest wall. We present the first successful reported case series of reconstruction using biologic mesh as a component of the MMA sandwich prosthesis. MMA appears to be a safe and effective choice for rigid reconstruction when used alone or in conjunction with synthetic or biologic mesh.

Female-to-Male Transgender Chest Contouring: A Systematic Review of Outcomes and Knowledge Gaps.

PURPOSE: The number of gender affirmation surgeries performed in the United States is increasing. Frequently, chest contouring is the first surgery for female-to-male transgender patients; it fosters assimilation into the new gender role with a desired sense of masculinity. Creating an aesthetic male chest requires adjustment of breast tissue volume, proper nipple-areolar complex placement, and abolishment of the inframammary fold. Although much has been published on various techniques and outcomes, there is no consensus on how to approach transmale top surgery. We have reviewed the most up-to-date literature and in so doing have uncovered significant knowledge gaps. METHODS: An electronic literature review was performed. PubMed search keywords included combinations of "female-to-male," "transgender surgery," "chest contour," and "nipple-areolar complex." Articles were included if the patients were transgender female to male. RESULTS: Our literature search yielded 67 unique articles, 22 of which met our inclusion criteria. A total of 2447 unique patients were analyzed. The articles discussed aspects of chest surgery in female-to-male transsexuals including mastectomy and nipple aesthetics. Relevant data trends were extracted and subsequently investigated. DISCUSSION: Female-to-male transgender patients often undergo chest contouring as their initial gender affirmation surgery. As the surgical treatment of gender dysphoria continues to grow, it is imperative for plastic surgeons to understand the surgical options and associated outcomes for transmasculine top surgery. Future research is needed to improve patient selection, surgical decision making, and patient-reported outcomes for different chest contouring techniques. In addition, there is a significant knowledge gap for the ideal nipple-areolar complex shape, size, and location.

Indocyanine Green Laser Angiography in the Setting of Tumescence.

Objective: Indocyanine green laser angiography utilizes fluorescent dye to assess tissue perfusion in real time. While various studies have recommended against the concurrent use of indocyanine green angiography with vasoconstrictors, few studies have described the intraoperative effect of tumescent wetting solutions on indocyanine green angiography and its subsequent impact on scan interpretation and clinical decision-making. Methods: A retrospective medical record review was performed for cases in which indocyanine green angiography was utilized to assess an area where epinephrine-based tumescent solution had been used. Results: The authors report 2 cases that utilized epinephrine-based tumescent solution along with intraoperative indocyanine green angiography assessment of the region. The first case was a bilateral reduction mammoplasty, whereas the second case was a nipple-sparing mastectomy with immediate tissue expander reconstruction. In both cases, intraoperative angiography predicted poor tissue perfusion while clinical examination showed good perfusion. Clinical examination was followed in both cases, with no additional tissue being removed. Neither case resulted in tissue necrosis despite angiography results. Conclusions: While indocyanine green angiography is a powerful tool in tissue perfusion assessment, there are some situations in which clinical examination must be used to determine tissue viability.

Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty.

BACKGROUND: The transgender patient seeking transition from male to female suffers a significant stigma from the prominent male thyroid cartilage. Natal men and women may seek elective reduction of the "Adam's apple" as well. There are various techniques for performing chondrolaryngoplasty, but these techniques and their associated outcomes are poorly described in the literature. METHODS: A literature review was performed for articles related to esthetic chondrolaryngoplasty. Data related to outcomes and complications were extracted. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The authors also present the case of a transgender 58 year-old male-to-female patient who underwent chondrolaryngoplasty. RESULTS: Four case series, including 69 patients who had esthetic chondrolaryngoplasty, were identified that met inclusion criteria. Qualitative assessment of patient satisfaction was reported in two studies (n = 62), with a 98.4% satisfaction rate. The most common complications were odynophagia in 20.3% of patients, hoarseness in 36.2% of patients, and laryngospasm in 1.4% of patients. Of patients that had postoperative hoarseness, 96% had resolution within 20 days. In our patient's case, chondrolaryngoplasty was performed with a tracheal shave in combination with high-speed burring for fine contouring. The patient experienced hoarseness for 1 week postoperatively that self-resolved. CONCLUSION: Overall, chondrolaryngoplasty for reduction of the thyroid cartilage appears to be a safe and effective procedure. The complications that occurred in identified case series were mild and self-limiting. Although serious complications are certainly possible, we were not able to identify their occurrence in the literature. Recent modifications in chondrolaryngoplasty involve protecting the anterior commissure tendon to prevent iatrogenic voice modification.

Peripheral Pruning: A Safe Approach to Thinning Extra-Large Anterolateral Thigh Flaps.

BACKGROUND: Thinning of anterolateral thigh (ALT) flaps has been described to achieve optimal contouring. Previous studies caution against thinning large flaps owing to the risk of vascular compromise leading to partial or total flap necrosis. This study aims to demonstrate a reliably safe method for thinning extra-large (>240 cm) flaps. METHODS: A retrospective review of 53 consecutive ALT flaps performed at a single institution was completed. Of these flaps, 18 (34%) were thinned primarily by sharp excision of sub-Scarpa's fat along the periphery of the flap using loupe magnification. A central cuff of fat is left to surround and protect the perforator. RESULTS: There were 53 total flaps in our series. Eighteen of the flaps were thinned by peripheral pruning. Eleven (61%) of the flaps reconstructed defects of the lower extremity, whereas 4 (22%) reconstructed upper extremity defects and 3 (17%) reconstructed scalp defects (Table 1). The mean size of the thinned flap group was 35% larger than the nonthinned group (n = 18, 261 cm ± 109 cm vs n = 35, 192 cm ± 146 cm). Ten thinned flaps (55%) were extra large, with flap areas over 240 cm. The average amount of excised fat weighed 41 g ± 18 g. The average body mass index in the thinned flap group was 28.8 kg/m, which is classified as overweight. The average body mass index in the nonthinned flap group was 24.6 kg/m, which is classified as normal weight (Table 2). There were no cases of partial flap necrosis in the thinned flap group. A single case of total flap loss occurred in the thinned flap group secondary to hematoma formation during administration of therapeutic heparin for a mechanical heart valve. There were no other complications in the thinned flap group. CONCLUSIONS: This is the first study to demonstrate a reliable technique for primary thinning of extra-large ALT flaps in the Western population. No complications related to thinning were observed. Peripheral pruning of sub-Scarpa's fat is a safe and reliable method of thinning extra-large ALT flaps without increasing the risk of flap necrosis.

An Analysis of Malpractice Litigation and Expert Witnesses in Plastic Surgery.

Objective: Expert witness testimony is crucial for juror decision making. The goals of this study were to examine the trends in malpractice litigation in plastic surgery and to examine the characteristics of expert witnesses in litigation. Methods: The Westlaw legal database was queried for jury verdict and settlement reports related to plastic surgery cases from 2009 to 2015. Cases were examined for expert witness testimony, procedure performed, alleged injury, cause of action, verdict, and indemnity payments. Results: Ninety-three relevant cases were examined. Mean plaintiff award was $1,036,469, whereas mean settlement was $633,960. The most commonly litigated procedures involved breast surgery (34.4%), liposuction (18.3%), and body contouring (14.0%). Cases involving body contouring (risk ratio [RR] = 1.48; 95% CI, 1.04-2.10) were more likely to result in favor of the defendant, whereas cases involving breast surgery (RR = 0.27; 95% CI, 0.13-0.57) were more likely to result in favor of the plaintiff (P < .05). Cases in which there was claimed pain (RR = 1.22; 95% CI, 1.01-1.48) or emotional distress (RR = 1.38; 95% CI, 1.11-1.70) were more likely to result in favor of the plaintiff (P < .05). The party of a lawsuit was more likely to win the case if its expert witness was a plastic surgeon (P < .05). Conclusion: Plastic surgery litigation tends to favor defendants. Most litigation involves breast surgery, liposuction, and body contouring. The type of procedure and alleged claim affect case success. Parties with a plastic surgeon as an expert witness tend to be more successful in litigation.

Sclerotherapy for the Management of Seromas: A Systematic Review.

Objective: Despite improved recognition of risk factors, plastic surgeons commonly encounter seromas postoperatively and must decide upon management. Current recommendations for minimally invasive, chemical management originate from the literature on management of pneumothorax and pleural effusions. A handful of published reports have suggested the efficacy of sclerotherapy in seroma management. The aim of this study was to assess the literature on the use of sclerosants to treat subcutaneous fluid collections. Methods: A systematic review of the literature was performed on the PubMed, MEDLINE, and Cochrane databases for primary research articles on sclerotherapy for seroma treatment between January 1975 and January 2017. Exclusion criteria were surgical treatment, sclerotherapy for seroma prevention, hematoma, or absence of detailed documentation. Data related to seroma location, sclerosant, and resolutions were extracted. Results: The literature search yielded 7 relevant articles of level IV evidence and 12 case reports, with a total of 84 patients treated with sclerotherapy for persistent seromas. Slerosant included talc, tetracycline antibiotics, ethanol, polidocanol, erythromycin, OK-432, fibrin glue, and povidone-iodine. All agents achieved high rates of success. Repeat aspirations and instillations were easily performed when required. Complications, while uncommon, included pain, tightness or discomfort of the treated area, and infection. Conclusion: Sclerotherapy appears to be effective and safe for recurrent seromas. While a variety of sclerosing agents may be applied successfully, talc and tetracyclines remain popular choices. Because of the small scale and retrospective nature of the published literature, larger, randomized, comparative studies are necessary to assess and optimize this treatment approach.

Functional Latissimus Dorsi Transfer for Upper-Extremity Reconstruction: A Case Report and Review of the Literature.

Objective: The latissimus dorsi flap is a workhorse for plastic surgeons, being used for many years for soft-tissue coverage of the upper extremity as well as for functional reconstruction to restore motion to the elbow and shoulder. The authors present a case of functional latissimus dorsi transfer for restoration of elbow flexion and review the literature on technique and outcomes. Methods: A literature review was performed using MEDLINE and the Cochrane Collaboration Library for primary research articles on functional latissimus dorsi flap transfer. Data related to surgical techniques and outcomes were extracted. Results: The literature search yielded 13 relevant studies, with a total of 52 patients who received pedicled, functional latissimus dorsi flaps for upper-extremity reconstruction. The most common etiology requiring reconstruction was closed brachial plexus injury (n = 13). After flap transfer, 98% of patients were able to flex the elbow against gravity and 82.3% were able to flex against resistance. In the presented case, a 77-year-old man underwent resection of myxofibrosarcoma of the upper arm with elbow prosthesis placement and functional latissimus dorsi transfer. The patient was able to actively flex against gravity at 3-month follow-up. Conclusions: A review of the literature shows that nearly all patients undergoing functional latissimus dorsi transfer for upper-extremity reconstruction regain at least motion against gravity whereas a large proportion regain motion against resistance. Considerations when planning for functional latissimus dorsi transfer include patient positioning, appropriate tensioning of the muscle, safe inset, polarity, management of other affected upper-extremity joints, and educating patients on the expected outcomes.

Delay techniques for nipple-sparing mastectomy: A systematic review.

BACKGROUND: Rare but serious complications of nipple-sparing mastectomy (NSM) include necrosis of the nipple-areolar complex (NAC) and mastectomy skin flaps. NAC and mastectomy flap delay procedures are novel techniques designed to avoid these complications and may be combined with retroareolar biopsy as a first-stage procedure. We performed a systematic review of the literature to evaluate various techniques for NAC and mastectomy flap delay. METHODS: PubMed and Cochrane databases were searched from January 1975 through April 15, 2016. The following search terms were used for both titles and key words: 'nipple sparing mastectomy' AND ('delay' OR 'stage' OR 'staged'). Two independent reviewers determined the study eligibility, only accepting studies involving patients who underwent a delay procedure prior to NSM and studies with objective results including specific outcomes of NAC and mastectomy flap necrosis. RESULTS: The literature search yielded 242 studies, of which five studies met the inclusion criteria, with a total of 101 patients. Various techniques for NSM delay have been described, all of which involve undermining the nipple and surrounding mastectomy skin to some degree. Partial NAC necrosis was reported in a total of 9 patients (8.9%). Mastectomy flap necrosis was reported in a total of 8 patients (7.9%). Three of five studies reported positive retroareolar biopsy findings in a total of 7 patients (6.9%). CONCLUSIONS: Delay procedures for NSM have a good safety profile and may be considered in patients at risk for NAC or mastectomy flap necrosis, such as patients with pre-existing breast scars, active smoking, prior radiation, or ptosis. These procedures have the added benefit of allowing a retroareolar biopsy to be sent for permanent sections prior to mastectomy, allowing the surgical team to plan for the removal of the NAC at the time of mastectomy if indicated and eliminating the risk of a false-negative result on frozen section analysis.

Breast Massage, Implant Displacement, and Prevention of Capsular Contracture After Breast Augmentation With Implants: A Review of the Literature.

Objective: Capsular contracture, the most common complication following breast augmentation with implants, is a complex inflammatory reaction that ultimately leads to fibrosis at the contact site between the implant and tissue. A number of peri-, pre-, and postoperative techniques have been postulated and implemented by many surgeons to reduce the incidence of capsular contracture. Breast massage and implant displacement technique is a commonly recommended practice that has not been well studied in regard to capsular contracture prevention. The authors present a review of the literature addressing methods and efficacy of massage and implant displacement techniques after breast augmentation. Methods: A literature review was performed using PubMed and the Cochrane Collaboration Library for primary research articles on breast massage or implant displacement after breast augmentation with implants for breast contracture prevention between January 1975 and March 2017. Exclusion criteria were studies that were focused on the treatment rather than prevention of breast contracture, addressed other strategies of preventing contracture as the main focus, or did not report the number of patients studied. Information related to massage technique and capsular contracture outcomes was extracted. Results: The literature search yielded 4 relevant studies, with a total of 587 patients. Outcomes evaluated included massage technique, onset of massage, frequency of massage, and incidence of capsular contracture. Breast massage was introduced between 2 days and 2 weeks postoperatively, performed twice daily, and lasted from 2 to 5 minutes for each breast. Final postoperative follow-up concluded between 6 and 36 months. The average capsular contracture rate was similar, 31% (range, 0-35) in the massage group versus 40% (range, 30-90) in the nonmassage group. Conclusions: While multiple techniques have been proposed and practiced in the prevention of capsular contracture, breast massage and implant displacement techniques remain controversial. While there is a method to measure adequacy of breast massage pressure, it is not widely utilized. The available data do not support breast massage to prevent capsular contracture; more studies with standardized techniques are needed to better assess the efficacy of breast massage in preventing capsular contracture.

Application of the h-Index in Academic Plastic Surgery.

BACKGROUND: The h-index is a measure designed to assess the quantity and significance of an individual's academic contributions. The objective of this study was to determine whether the h-index of plastic surgeons correlates with academic rank and whether there is a difference based on academic rank, residency training model, sex, geographic region, faculty size, and departmental status. METHODS: A database of all US academic plastic surgeons was created. The rank and sex of each surgeon were obtained, as were characteristics of their plastic surgery program. The Scopus database was queried to determine each surgeon's h-index. RESULTS: The 592 plastic surgeons in our database had a mean h-index of 8.97. The h-index increased with academic rank: 4.59 for assistant professors, 9.10 for associate professors, and 15.30 for professors. There was no significant difference in the h-index between chairpersons and chiefs. Plastic surgeons on faculty in integrated plastic surgery programs had significantly higher h-indices (9.64) than those at traditional programs (6.28). Those who were on faculty at larger programs also had higher h-indices. Male plastic surgeons had higher h-indices (9.57) than did female plastic surgeons (6.07), although this was insignificant when taking other variables into account. There was no correlation between the h-index and location or departmental status. CONCLUSIONS: The h-index of plastic surgeons seems to correlate with academic rank and has potential as a tool to measure academic productivity within plastic surgery. Plastic surgeons on faculty in integrated plastic surgery programs, those at larger programs, and male plastic surgeons tend to have higher h-indices. The difference between sexes seems to be, at least in part, due to the higher number of men in high academic positions. There does not seem to be a regional difference with regard to h-indices or a difference with regard to departmental status.

Impact of Subspecialty Fellowship Training on Research Productivity Among Academic Plastic Surgery Faculty in the United States.

PURPOSE: The impact of subspecialty fellowship training on research productivity among academic plastic surgeons is unknown. The authors' aim of this study was to (1) describe the current fellowship representation in academic plastic surgery and (2) evaluate the relationship between h-index and subspecialty fellowship training by experience and type. METHODS: Academic plastic surgery faculty (N = 590) were identified through an Internet-based search of all ACGME-accredited integrated and combined residency programs. Research output was measured by h-index from the Scopus database as well as a number of peer-reviewed publications. The Kruskal-Wallis test, with a subsequent Mann-Whitney U test, was used for statistical analysis to determine correlations. RESULTS: In the United States, 72% (n = 426) of academic plastic surgeons had trained in 1 or more subspecialty fellowship program. Within this cohort, the largest group had completed multiple fellowships (28%), followed by hand (23%), craniofacial (22%), microsurgery (15%), research (8%), cosmetic (3%), burn (2%), and wound healing (0.5%). Higher h-indices correlated with a research fellowship (12.5; P < .01) and multiple fellowships (10.4; P < .01). Craniofacial-trained plastic surgeons demonstrated the next highest h-index (9.8), followed by no fellowship (8.4), microsurgery (8.3), hand (7.7), cosmetic (5.2), and burn (5.1). CONCLUSION: Plastic surgeons with a research fellowship or at least 2 subspecialty fellowships had increased academic productivity compared with their colleagues. Craniofacial-trained physicians also demonstrated a higher marker for academic productivity than multiple other specialties. In this study, we show that the type and number of fellowships influence the h-index and further identification of such variables may help improve academic mentorship and productivity within academic plastic surgery.

Bowler's Thumb: Case Report and Review of the Literature.

OBJECTIVE: Traumatic neuropathy of the ulnar digital nerve of the thumb occurs in patients who undergo chronic frictional irritation of the nerve. The condition is aptly termed bowler's thumb, as it commonly afflicts patients who bowl and keep their thumb in the ball for an extended period of time. It is a pathology that rarely appears in the literature and for which standard treatment is unclear. METHODS: A 68-year-old man with a history of avid bowling presented with a chief complaint of left thumb numbness and tingling for several months. Physical examination demonstrated a small tender mass along the ulnar surface of the left thumb with a positive Tinel's sign and diminished 2-point discrimination distal to the mass. The patient's symptoms did not improve with conservative measures. Here, we describe his surgical treatment and review the current literature. RESULTS: Our patient underwent neurolysis of the ulnar digital nerve of the thumb, with placement of a porcine extracellular matrix nerve wrap. The patient reported improvement of symptoms within 2 weeks and was able to return to his previous level of activity. In the literature, treatment has included from conservative measures such as pressure relief and splinting to surgical intervention including neurolysis, transposition, or neurectomy with nerve grafting. CONCLUSIONS: We present neurolysis for treating bowler's thumb as a viable option that may relieve symptoms rapidly while obviating need for adductor transection. Porcine extracellular matrix nerve wrap can be placed in an attempt to prevent recurrence of neuroma, but long-term follow-up is necessary.