Partial hand replantation using free microsurgical replantation with staged heterotopic banking of amputated parts: towards improving long term outcomes.

In hand trauma, the uninjured forearm has been touted as the ideal site for ectopic banking in digit/hand amputations. Here, we describe the temporary ectopic implantation and subsequent replantation of a partially amputated hand and highlight the "Three R's" - Recovery, Rehabilitation, and Revision over the first year of recovery.

The Lambda Cord: An Anatomic Configuration of Radial-Sided Dupuytren Disease.

The thumb and first webspace are involved in a relatively low proportion of cases of Dupuytren disease of the hand (3%-28%). Given the rarity, there has been a paucity of literature regarding anatomic cord configurations and the surgical technique for the management of such radial-sided diseases. There are unique anatomic considerations in the thumb that warrant understanding prior to safe surgical exploration. A case of an anatomic variant of Dupuytren disease involving the thumb and first webspace treated with a webspace skin-sparing partial fasciectomy is described. The current literature regarding surgical management of Dupuytren disease affecting the thumb and first webspace is also briefly presented.

The use of abdominal wall tissue expansion prior to herniorrhaphy in massive ventral hernia defects.

BACKGROUND: Massive ventral hernias pose a challenging reconstructive problem. In comparison to bridging mesh repair, the primary fascial repair is associated with significantly reduced rates of hernia recurrence. This study will review our experience with massive ventral hernia repairs using tissue expansion and anterior component separation as well as present the largest case series to date. METHODS: A retrospective review was conducted of 61 patients who underwent abdominal wall tissue expansion prior to herniorrhaphy at a single institution between 2011 and 2017. Demographics, perioperative co-variates, and outcomes were recorded. Univariate and subgroup analysis was performed. Kaplan-Meier survival analysis was used to assess the time to recurrence. RESULTS: Sixty-one patients underwent abdominal wall expansion via tissue expanders (TE). Of these, 56 subsequently underwent staged anterior component separation for attempted closure of large ventral hernia. Major complications of TE placement included TE replacement (4,6.6%), TE leak (2,3.3%), and unplanned readmission (3,4.9%). Higher BMI groups were significantly associated with comorbid hypertension (BMI<30 kg/m2, 22.7%; BMI 30-35 kg/m2, 68.7%; BMI>35 kg/m2, 64.7%; P = 0.004). 15 patients (32.6%) had hernia recurrence and 21 patients (34.4%) still required bridging mesh during herniorrhaphy after tissue expansion. CONCLUSION: The use of tissue expansion prior to herniorrhaphy can be effective in achieving durable closure for most massive abdominal wall defects - especially those associated with musculofascial, soft tissue, or skin deficiencies. In this proof-of-concept analysis, we found that the efficacy and safety profile of this technique compares favorably to other methods for massive hernia repair in the literature.

Reflections on a Career in Plastic Surgery: A National Survey of Retired Surgeons.

Introduction: Retired plastic surgeons can provide valuable insights for the greater plastic surgery community. The purpose of this study was to gather demographics, personal reflections, and advice for a career in plastic surgery from retired American plastic surgeons. Methods: An email survey was distributed to 825 members of the American Society of Plastic Surgeons during September 2021. The survey distribution was designed to engage members of the plastic surgery community, who were retired from surgical practice in the United States. The form consisted of 29 questions, five of which were free response. Descriptive statistical analyses were performed. Results: A total of 214 completed surveys were received, with a response rate of 25.9%. The average age at retirement was 67.6 years. The majority of respondents were men (87.6%) and White (93.3%); 46.9% of surgeons practiced at individual private practice. Ninety percent of surgeons indicated that they would choose to practice as a plastic surgeon again. Free responses provided positive career reflections and advice for young plastic surgeons regarding navigating the changing landscape of healthcare. Conclusions: Retired plastic surgeons are interested in engaging with the plastic surgery community and demonstrate continued interest in the future of the field. Efforts can be made to avail the field of their expertise and experience.

Technique of Abdominal Wall Tissue Expansion for the Treatment of Massive Complicated Ventral Hernias.

Abdominal wall tissue expansion is a unique technique that seeks to augment and expand both the fascial and subcutaneous tissues/skin layers to achieve durable closure of otherwise challenging ventral hernias. In addition to allowing primary fascial closure in a majority of cases, this technique enables reduced tension on the closure, potentially decreasing the recurrence rate. This article describes the senior author's surgical technique for abdominal wall tissue expansion in massive complicated ventral hernias. The plastic surgeon is at a unique advantage to assist with the repair of massive complicated ventral hernias given their comfort with complex tissue handling and expandable devices. This specialized technique thus provides an opportunity for plastic surgeons to serve as expert co-surgeons with general surgery colleagues to help achieve superior outcomes in patients with these challenging hernias.

Quantifying Lymph Nodes During Lymph Node Transplantation: The Role of Intraoperative Ultrasound.

Quantifying lymph nodes in vascularized lymph node transfer (VLNT) has been performed using preoperative percutaneous ultrasound. The higher resolution and accuracy of intraoperative ultrasound (IOUS) over transcutaneous ultrasound has been demonstrated in the radiology literature for the identification and characterization of finer structures including hepatic lesions, pancreatic lesions, and biliary or pancreatic ducts. We hypothesize that IOUS during VLNT would be a superior method to quantify and map lymph nodes in our flaps. A prospectively collected database of patients undergoing VLNT over 3 years (October 2014 to October 2017) was reviewed. Patients who underwent IOUS during flap harvest, before pedicle ligation to simultaneously map and quantify the number of lymph nodes were included in the study. Twenty-one patients with an average age of 58.7 years and a mean BMI of 32.3 underwent VLNT with IOUS for chronic lymphedema during the study period. Extremity lymphedema was classified as Campisi IB (n = 7), IIA (n = 7), IIB (n = 5), and IIIA (n = 2). There were 14 superficial circumflex iliac artery flaps, including 4 performed concomitantly with a deep inferior epigastric perforator flap, 1 transverse cervical artery flap, and 6 omental flaps. The average number of lymph nodes transferred per IOUS was 4.3 for superficial circumflex iliac artery flaps, 4 for the transverse cervical artery flap, and 5.2 for the omental flaps. Intraoperative ultrasound allows the lymphatic surgeon to precisely map the location of lymph nodes which can guide intraoperative decision making. As there is no data correlating the number of lymph nodes transferred and outcomes after VLNT, developing a precise intraoperative quantification method is important.

Does industry funding mean more publications for subspecialty academic plastic surgeons?

BACKGROUND: Conflict of interest among physicians in the context of private industry funding led to the introduction of the Physician Payments Sunshine Act in 2010. This study examined whether private industry funding correlated with scholarly productivity in the respective subspecialties of plastic surgery and the wider academic plastic surgery community. MATERIALS AND METHODS: Full-time plastic surgeons and their academic attributes were identified via institutional websites. Fellowship-trained individuals were segregated into subspecialties of microsurgery, craniofacial surgery, hand surgery, esthetic surgery, and burn surgery. The Center for Medicare and Medicaid Services Open Payment database was used to extract industry funding information. Each individual's bibliometric data were then collected through Scopus to determine the correlation between selected surgeon characteristics, academic productivity, and industry funding. RESULTS: Nine hundred and thirty-five academic plastic surgeons were identified, with 532 having defined subspecialty training. Academic bibliometrics among subspecialty surgeons were comparable among the five groups with esthetic and craniofacial surgeons displaying a preponderance of attaining more industry funding (P = 0.043) and career publications respectively, with the latter not attaining statistical significance (P = 0.12). Overall, research-specific funding (P = 0.014) and higher funding amounts (P < 0.0001) correlated with higher Hirsch indices in tandem with higher academic rank. A funding level of $2000 appeared to be the approximate cutoff above which scholastic productivity became apparent. CONCLUSIONS: Our study demonstrated in detail the association between industry funding and academic bibliometrics in academic plastic surgery of every subspecialty. Even at modest amounts, industry support, especially when research designated, positively influenced research and therefore, academic output.

Novel Method Suggests Global Superiority of Short-Duration Antibiotics for Intra-abdominal Infections.

Desirability of outcome ranking and response adjusted for duration of antibiotic risk (DOOR/RADAR) are novel and innovative methods of evaluating data in antibiotic trials. We analyzed data from a noninferiority trial of short-course antimicrobial therapy for intra-abdominal infection (STOP-IT), and results suggest global superiority of short-duration therapy for intra-abdominal infections.

Surgical wound assessment by sonography in the prediction of surgical wound infections.

BACKGROUND: Surgical site infections (SSIs) are important sources of morbidity, prolonged hospital stays, and readmissions, so they have become a major economic burden. We hypothesized that surgical wound assessment by sonography (SWATS) used at the bedside would detect wound fluid collections and that the presence of such collections would predict SSI better than standard clinical examination. If so, SWATS might be used to indicate early intervention that could prevent SSI morbidity. METHODS: A prospective, single-institution observational study was conducted on adult inpatients following open abdominal surgery for trauma, gastrointestinal pathology, or biliary pathology at high risk (>5%) for SSI using traditional wound classifications. After informed consent was obtained, SWATS was performed using a smartphone-based ultrasound system on postoperative Day 2 to 4 and again before discharge or at postoperative Day 30, whichever came first. Primary treating physicians delivered standard wound care and were blinded to SWATS. SSI was diagnosed if treatment was implemented for suspected or documented wound infection by the treating physician. Results were analyzed by χ test and two-sample pooled variance t test where appropriate, with significance set at p < 0.05. RESULTS: Forty-nine patients were studied. Nineteen patients had peri-incisional fluid collections found by SWATS. Eight of these patients went on to develop an SSI. SSI was significantly associated with the presence of fluid collections on SWATS (p = 0.009). SWATS had a sensitivity of 72.7% (0.43-0.92), a specificity of 71.1% (0.62-0.77), a positive predictive value of 42.1% (0.25-0.53), and a negative predictive value of 90.0% (0.79-0.97). CONCLUSION: SWATS has a high negative predictive value that may allow it be an effective screening tool for developing SSI in high-risk surgical wounds. SWATS has the potential to be a useful and cost-effective adjunct to the clinician by objectively suggesting need for early therapy. Further study with larger sample sizes and randomized, SWATS-based interventions are required to validate this small study and determine its place in clinical care. LEVEL OF EVIDENCE: Diagnostic study, level IV.