Co-surgeon versus Single-surgeon Outcomes in Free Tissue Breast Reconstruction: A Meta-analysis.

BACKGROUND: Autologous breast reconstruction offers superior long-term patient reported outcomes compared with implant-based reconstruction. Universal adoption of free tissue transfer has been hindered by procedural complexity and long operative time with microsurgery. In many specialties, co-surgeon (CS) approaches are reported to decrease operative time while improving surgical outcomes. This systematic review and meta-analysis synthesizes the available literature to evaluate the potential benefit of a CS approach in autologous free tissue breast reconstruction versus single-surgeon (SS). METHODS: A systematic review and meta-analysis was conducted using PubMed, Embase, and MEDLINE from inception to December 2022. Published reports comparing CS to SS approaches in uni- and bilateral autologous breast reconstruction were identified. Primary outcomes included operative time, postoperative outcomes, processes of care, and financial impact. Risk of bias was assessed and outcomes were characterized with effect sizes. RESULTS: Eight retrospective studies reporting on 9,425 patients were included. Compared with SS, CS approach was associated with a significantly shorter operative time (SMD -0.65, 95% confidence interval [CI] -1.01 to -0.29, p < 0.001), with the largest effect size in bilateral reconstructions (standardized mean difference [SMD] -1.02, 95% CI -1.37 to -0.67, p < 0.00001). CS was also associated with a significant decrease in length of hospitalization (SMD -0.39, 95% CI -0.71 to -0.07, p = 0.02). Odds of flap failure or surgical complications including surgical site infection, hematoma, fat necrosis, and reexploration were not significantly different. CONCLUSION: CS free tissue breast reconstruction significantly shortens operative time and length of hospitalization compared with SS approaches without compromising postoperative outcomes. Further research should model processes and financial viability of its adoption in a variety of health care models.

Closed Incision Negative Pressure Therapy Versus Traditional Dressings for Low Transverse Abdominal Incisions Healing by Primary Closure: A Systematic Review and Meta-Analysis.

Background: Closed incision negative pressure therapy (ciNPT) devices may reduce wound healing complications when applied to closed surgical incisions. The aim of this review was to assess the effects of ciNPT versus standard dressings in patients undergoing primary closure of high tension, lower transverse abdominal incisions. Methods: This review was registered a priori on PROSPERO (CRD42021252048). A search of the following databases was performed in February 2021: Medline, EMBASE, and CENTRAL. Unpublished trials were searched using clinicaltrials.gov. All randomized and nonrandomized studies comparing ciNPT to standard dressings were included. Two independent reviewers performed screening and data extraction. Outcomes evaluated the incidence of wound dehiscence, surgical site infection, total abdominal complications, time to drain removal, and seroma formation. Main Results: Ten studies were included in quantitative and narrative synthesis. Observational study evidence suggests ciNPT likely reduces the incidence of wound dehiscence (odds ratio [OR] 0.57 [0.44-0.96], P = .03) and total abdominal complications (OR 0.34 [0.21-0.54], P < .01). Decreased incidence of seroma formation favored ciNPT (OR 0.65 [0.24-1.76], P = .40); however, this did not achieve significance. Randomized and non-randomized study evidence was very uncertain about the effect of ciNPT on the remaining outcomes. Conclusions: The current best randomized study evidence is very uncertain about the effect of ciNPT on these outcomes. Observational study evidence suggests ciNPT likely results in a statistically significant reduction in abdominal wound dehiscence and total abdominal complications. Additional randomized trials are warranted to limit the impact of bias on the overall certainty of the evidence.

Historique : Les dispositifs de traitement par pression négative sur des plaies d'incision fermées (TPNPIf) pourraient réduire les complications liées à la cicatrisation des plaies lorsqu'ils sont appliqués à des incisions chirurgicales fermées. La présente analyse visait à évaluer les effets du TPNPIf par rapport aux pansements habituels après la suture primitive d'incisions abdominales transversales basses. Méthodologie : La présente analyse a été enregistrée à l'avance dans PROSPERO (CRD42021252048). Les chercheurs ont fouillé les bases de données Medline, EMBASE et CENTRAL en février 2021. Ils ont extrait les études non publiées à l'aide de clinicaltrials.gov. Ils ont inclus toutes les études randomisées et non randomisées comparant les TPNPIf aux pansements habituels. Deux réviseurs indépendants ont procédé à la sélection et à l'extraction des données. Comme mesures de résultats, les chercheurs ont évalué l'incidence de déhiscence des plaies, d'infection au foyer de l'opération, de complications abdominales totales, de période jusqu'au retrait du drain et de formation de sérome. Principaux Résultats : Dix études ont été incluses dans la synthèse quantitative et narrative. Selon les données tirées d'études observationnelles, le TPNPIf réduit probablement l'incidence de déhiscence des plaies [RC 0,57 (0,44, 0,96), P = ,03] et les complications abdominales totales [RC 0,34 (0,21, 0,54), P < ,01]. La diminution de l'incidence de formation de sérome favorisait le TPNPIf [RC 0,65 (0,24 à 1,76), P = ,40], mais n'était pas statistiquement significative. La certitude établie par les données des études randomisées et non randomisées était très faible quant à l'effet du TPNPIf sur les autres résultats. Conclusions : Selon les meilleures données sur les études randomisées actuelles, l'effet du TPNPIf sur les résultats est très incertain. Selon les données sur les études observationnelles, le TPNPIf entraîne probablement une réduction statistiquement significative de la déhiscence des plaies abdominales et des complications abdominales totales. D'autres études aléatoires devront être réalisées pour réduire les répercussions des biais sur la certitude globale des données probantes.

Multidisciplinary Practice Variations of Anti-Thrombotic Strategies for Free Tissue Transfers.

Background: Venous thrombosis, the leading cause of free flap failure, may have devastating consequences. Many anti-thrombotic agents and protocols have been described for prophylaxis and treatment of venous thrombosis in free flaps. Methods: National surveys were distributed to microsurgeons (of both Plastics and ENT training) and hematology and thrombosis specialists. Data were collected on routine screening practices, perceived risk factors for flap failure, and pre-, intra-, and post-operative anti-thrombotic strategies. Results: There were 722 surveys distributed with 132 (18%) respondents, consisting of 102 surgeons and 30 hematologists. Sixty-five surgeons and 9 hematologists routinely performed or managed patients with free flaps. The top 3 perceived risk factors for flap failure according to surgeons were medical co-morbidities, past arterial thrombosis, and thrombophilia. Hematologists, however, reported diabetes, smoking, and medical co-morbidities as the most important risk factors. Fifty-four percent of physicians routinely used unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) as a preoperative agent. Surgeons routinely flushed the flap with heparin (37%), used UFH IV (6%), or both (8%) intra-operatively. Surgeons used a range of post-operative agents such as UFH, LMWH, aspirin, and dextran while hematologists preferred LMWH. There was variation of management strategies if flap thrombosis occurred. Different strategies consisted of changing recipient vessels, UFH IV, flushing the flap, adding post-operative agents, or a combination of strategies. Conclusions: There are diverse practice variations in anti-thrombotic strategies for free tissue transfers and a difference in perceived risk factors for flap failure that may affect patient management.

Contexte: La thrombose veineuse, principale cause de l'échec des volets libres, peut avoir des conséquences catastrophiques. De nombreux agents et protocoles antithrombotiques ont été décrits pour la prévention et le traitement de la thrombose veineuse dans les volets libres. Méthodes: Des enquêtes nationales ont été distribuées à des chirurgiens spécialistes de microchirurgie (ayant à la fois une formation en chirurgie plastique et ORL) et à des spécialistes en hématologie et thrombose. Les données collectées ont porté sur les pratiques usuelles de sélection, les facteurs de risque perçus d'échec des volets, ainsi que sur les stratégies antithrombotiques pré-, per- et postopératoires. Résultats: Sur les 722 enquêtes distribuées, il y a eu 132 répondants (18 %) consistant en 102 chirurgiens et 30 hématologistes. Soixante-cinq chirurgiens et neuf hématologues réalisent ou gèrent régulièrement des patients avec des volets libres. Les trois plus importants facteurs de risque perçus d'échec du volet, selon les chirurgiens, étaient les comorbidités médicales, un antécédent de thrombose artérielle et la thrombophilie. De leur côté, les hématologues ont indiqué que le diabète, le tabagisme et les comorbidités médicales étaient les facteurs de risque les plus importants. Cinquante-quatre pour cent des médecins utilisent régulièrement de l'héparine non fractionnée ou de l'héparine de bas poids moléculaire (HBPM) comme agent préopératoire. Les chirurgiens rincent régulièrement le volet à l'héparine (37 %), utilisent de l'héparine non fractionnée par voie IV (6 %) ou les deux (8 %) en peropératoire. Les chirurgiens utilisent un éventail d'agents postopératoires, tels que l'héparine non fractionnée, l'HBPM, l'aspirine et le dextran tandis que les hématologues préfèrent l'HBPM. Des variations dans les stratégies de gestion ont été observées en cas de survenue d'une thrombose du volet. Différentes stratégies ont consisté à changer les vaisseaux receveurs, administrer de l'héparine non fractionnée IV, rincer le volet, ajouter des agents postopératoires, ou combiner ces stratégies. Conclusions: Il y a différentes variations dans la pratique de stratégies antithrombotiques pour les transferts de tissus libres et une différence dans les facteurs de risque perçus d'échec du volet qui peuvent avoir des répercussions sur la gestion des patients.

What Does It Take to Become an Academic Plastic Surgeon in Canada: Hiring Trends Over the Last 50 Years.

Objective: Academic plastic surgery positions have become highly competitive secondary to delayed retirement, stagnant hospital funding, and an increasing number of plastic surgery graduates. Little information is available to help residents navigate this challenging landscape. Our objectives were to evaluate the training backgrounds of all Canadian academic plastic surgeons and to develop recommendations for residents interested in an academic career. Methods: All Canadian academic plastic surgeons were included. Training histories were obtained from institutions' websites. Surgeons were subsequently emailed to confirm this information and complete missing details. Multivariate regressions were designed to analyze the effect of gender and FRCSC year on graduate and fellowship training and time to first academic position. Results: Training information was available for 196 surgeons (22% female), with a 56% email response rate; 91% of surgeons completed residency in Canada; 94% completed fellowship training, while 43% held graduate degrees; 74% were employed where they previously trained. Female gender significantly lengthened the time from graduation to first academic job, despite equal qualification. Younger surgeons were more likely to hold graduate degrees (P < .01). Conclusions: We identified objective data that correlate with being hired at an academic centre, including training at the same institution, obtaining a graduate degree during residency, and pursuing fellowship training. In addition, we demonstrated that women take significantly longer to acquire academic positions (P < .01), despite equal qualification. Trainees should consider these patterns when planning their careers. Future research should explore gender-based discrepancies in hiring practices.

Objectif: Les postes universitaires en chirurgie plastique sont hautement convoités en raison des retraites reportées, du gel du financement des hôpitaux et d'un nombre grandissant de diplômés en chirurgie plastique. Il y a peu d'information visant à aider les résidents à s'y retrouver dans ce contexte difficile. Nos objectifs consistaient à évaluer la formation de tous les chirurgiens plasticiens universitaires au Canada et de mettre au point des recommandations à l'intention des résidents souhaitant mener une carrière universitaire. Méthodologie: Tous les chirurgiens plasticiens universitaires du Canada ont été inclus. L'historique de formation a été obtenue auprès des sites Web des établissements. On a ensuite fait parvenir aux chirurgiens un courriel visant à confirmer ces renseignements et à compléter l'information manquante. Des régressions multifactorielles ont été conçues pour analyser l'effet du sexe et de l'année d'obtention du titre FRCSC sur l'accès à la formation aux cycles supérieurs et l'octroi des bourses de formation, ainsi que sur le délai précédant le moment où les chirurgiens plasticiens décrochent leur premier poste universitaire. Résultats: Les renseignements sur la formation étaient disponibles pour 196 chirurgiens (dont 22 % de sexe féminin), et le taux de réponse par courriel a été de 56 %. Quatre-vingt-onze pour cent des chirurgiens ont terminé leur résidence au Canada. Quatre-vingt-quatorze pour cent des chirurgiens avaient reçu une bourse de formation, tandis que quarante-trois pour cent détenaient des diplômes d'études supérieures. Soixante-quatorze pour cent des chirurgiens sont devenus des employés de l'établissement où ils avaient déjà suivi une formation. À compétences égales, les chirurgiens de sexe féminin tardaient beaucoup plus à décrocher un premier emploi universitaire après l'obtention de leur diplôme que ceux de sexe masculin. Plus les chirurgiens étaient jeunes, plus ils étaient susceptibles de détenir un diplôme d'études supérieures (p < 0,01). Conclusions: Nous avons obtenu des données objectives présentant une corrélation avec l'embauche dans un centre universitaire, y compris une formation au même établissement, l'obtention d'un diplôme d'études supérieures durant la résidence et le maintien d'une bourse de formation. En outre, nous avons montré que même à compétences égales, les femmes prennent beaucoup plus de temps à décrocher des postes universitaires (p < 0,01). Les étudiants doivent tenir compte de ces profils dans leur planification de carrière. Des recherches futures devront explorer les écarts entre les sexes pour ce qui est des pratiques d'embauche.

Job Satisfaction Among Plastic Surgery Residents in Canada.

Objective: Resident wellness is a focus of medical training and is prioritized in both Canadian and American accreditation processes. Job satisfaction is an important component of wellness that is not examined in the literature. The purpose of this study was to analyze job satisfaction in a national sample of plastic surgery residents, and identify factors that influence satisfaction. Methods: We designed a cross-sectional survey adapted from existing instruments, with attention to thorough item generation and reduction as well as pilot and clinical sensibility testing. All plastic surgery residents at Canadian institutions were surveyed regarding overall job satisfaction as well as personal- and program-specific factors that may affect satisfaction. Predictors of satisfaction were identified using multivariable regression models. Results: The response rate was 40%. Median overall job satisfaction was 4.0 on a 5-point Likert scale. Operative experience was considered both the most important element of a training program, and the area in most need of improvement. Senior training year (P < .01), shorter commute time (P = .04), fewer duty hours (P = .02), fewer residents (P < .01), and more fellows (P < .01) were associated with significantly greater job satisfaction. Conclusions: This is the first study to gather cross-sectional data on job satisfaction from a national sample of plastic surgery residents. The results from this study can inform programs in making tangible changes tailored to their trainees' needs. Moreover, our findings may be used to inform a prospectively studied targeted intervention to increase job satisfaction and resident wellness to address North American accreditation standards.

Objectif: Le bien-être des résidents est un point central de la formation en médecine et représente une priorité dans le processus d'agrément canadien et américain. La satisfaction au travail constitue un volet important du bien-être qui n'est pas évalué dans les publications. La présente étude visait à analyser la satisfaction au travail dans un échantillon national de résidents en plasturgie et à déterminer les facteurs qui influent sur la satisfaction. Méthodologie: Les chercheurs ont conçu un sondage transversal adapté d'outils existants, en s'attardant à la production et à la réduction de points approfondis et à un test de sensibilité clinique. Tous les résidents en plasturgie des établissements canadiens ont reçu un sondage sur leur satisfaction au travail et sur les facteurs personnels et propres à leur programme, susceptibles d'influer sur leur satisfaction. Les chercheurs ont déterminé les prédicteurs de satisfaction au moyen de modèles de régression multivariables. Résultats: Le taux de réponse s'élevait à 40%. La satisfaction au travail médiane globale obtenait un résultat de 4,0 sur l'échelle de Likert de cinq points. L'expérience opératoire était considérée à la fois comme l'élément le plus important d'un programme de formation et comme le secteur qui a le plus besoin d'être amélioré. L'année de formation senior (P < .01), une durée de déplacement plus courte (P = .04), un moins grand nombre d'heures de garde (P = .02) et de résidents (P < .01) et un plus grand nombre de boursiers postdoctoraux (P < .01) ont été associés à une satisfaction au travail considérablement plus marquée. Conclusions: C'est la première étude pour colliger des données transversales sur la satisfaction au travail auprès d'un échantillon national de résidents en plasturgie. Les résultats de cette étude peuvent éclairer les programmes pour apporter des changements tangibles adaptés aux besoins de leurs stagiaires. De plus, nos observations pourraient éclairer une intervention prospective ciblée pour accroître la satisfaction au travail et le bien-être des résidents afin de satisfaire aux normes d'agréments nord-américaines.

Cost-effectiveness Analysis of Abdominal-based Autogenous Tissue and Tissue-expander Implant following Mastectomy.

BACKGROUND: Patients who had undergone both autologous abdominal tissue (AAT) and tissue expander and implant (TE/I) breast reconstruction reported satisfaction with their reconstruction. While aesthetics and quality of life are important, the cost associated with these procedures must also be considered when choosing one method over the other. The objective of this study was to determine whether AAT-based breast reconstruction is cost-effective compared with 2-stage TE/I reconstruction at a 12-month follow-up. METHODS: Thirty-five patients consented and complied to participate in the study with a follow-up of 12 months. The effectiveness of both AAT and TE/I was measured using the Health Utilities Index Mark 3 (HUI-3). From the HUI-3 results, quality-adjusted life years were calculated for each reconstructive approach. Direct healthcare and productivity costs were captured from surgeon billing codes, patient files, and patient diaries. The perspectives of both the Ministry of Health and of society were considered. RESULTS: From the perspectives of both the Ministry of Health and of society, AAT was less effective and more costly when compared with TE/I. CONCLUSIONS: In this economic evaluation, TE/I dominated AAT, in that TE/I was more effective and less costly as compared with AAT from the perspectives of both the Ministry of Health and of society at 12 months of follow-up. This conclusion should be interpreted with caution due to a small sample size, the short timespan of the study, and the nonrandomized study design.

Comparing the Clinical and Cost-Effectiveness of Abdominal-based Autogenous Tissue and Tissue-Expander Implant: A Feasibility Study.

BACKGROUND: To determine the superiority of autologous abdominal tissue (AAT) or tissue-expander implant (TE/I) reconstruction, a robust comparative cohort study is required. This study sought to determine the feasibility of a future large pragmatic cohort study comparing clinical and cost-effectiveness of AAT and TE/I at 12 months postoperative. METHODS: Potential participants were screened during consultation with their surgeon. Three health-related quality-of-life scales, the Health Utility Index Mark 3, the 12-Item Short Form Health Survey, and the BREAST-Q were used preoperatively, 1, 6, and 12 months postoperatively. Direct medical costs and postoperative patient/caregiver productivity loss were collected using patient diaries. Feasibility was assessed through patient recruitment rates and compliance of patients and study staff to complete required study documentation. RESULTS: Sixty-three patients consented to participate, 44 completed baseline questionnaires; the feasibility objective of recruiting 80% of eligible patients was not met. A 90% completion rate for patient questionnaires was seen at 1-month follow-up and decreased up to 12 months. Quality-adjusted life years were calculated at 0.77 and 0.89 for the AAT and TE/I group, respectively. Case report form completion by study staff and patient diary completion was moderate and low, respectively. Collaborating with hospital case-costing specialists to identify direct medical costs was reliable and efficient. CONCLUSIONS: A future large-scale study is feasible. However, due to a diminishing rate of questionnaire completion, almost twice as many patients need to be recruited than expected to have adequate power. Cost data collection from hospital sources was reliable. Case report forms need to be tailored more toward a busy hospital setting.

Secondary Implant Augmentation in the Subpectoral Plane following Abdominal-based Perforator Flaps for Breast Reconstruction.

BACKGROUND: Abdominal-based perforator flaps are the gold standard for autologous breast reconstruction. However, among patients with a small-to-medium amount of redundant abdominal tissue, this may result in an inadequate breast mound. Secondary implant augmentation has been reported as one method to augment volume, address breast mound asymmetry, and enhance overall aesthetic outcome. We aim to analyze postoperative complications associated with the secondary implant augmentation following a primary breast reconstruction with abdominal perforator flaps. METHODS: This retrospective study included patients who underwent secondary implant augmentation following abdominal-based perforator flap breast reconstruction. Patient characteristics, immediate versus delayed reconstruction, type of flap used, indication for secondary augmentation as well as perioperative and postoperative complication including flap or implant loss were reviewed and analyzed. RESULTS: Twenty-four patients met inclusion criteria. Forty flaps were performed (16 bilateral and 8 unilateral). A total of 36 implants were placed in subpectoral plane in a secondary revision procedure. The mean time between secondary augmentation and index procedure was 22 months. Average implant volume was 270 g. No intraoperative complication or flap loss was recorded. Postoperative surgical site infection occurred in a total of 4 patients (17%) with 3 patients requiring explantation of a total of 4 implants. CONCLUSIONS: Secondary augmentation of abdominal-based perforator flap using a permanent implant is an effective method to address volume and asymmetry and to enhance aesthetic outcome. In our study, however, we observed a higher than expected rate of postoperative infection.

Pregnancy and parental leave among plastic surgery residents in Canada: a nationwide survey of attitudes and experiences.

SUMMARY: Small surgical residency programs like plastic surgery can be challenging environments to accommodate parental leave. This study aimed to report the experiences, attitudes and perceived support of Canadian plastic surgery residents, recent graduates and staff surgeons with respect to pregnancy and parenting during training. Residents and staff surgeons were invited via email to participate in an online survey. The results presented here explore experiences of pregnancy and parental leave of current plastic surgery residents and staff surgeons. Residents' and staff surgeons' perceptions of program director support, policies, negative comments and the impact of parental leave on the workload of others were also explored. Although the findings suggest that there may be improvements in the support of program directors, there continues to be a negative attitude in surgical culture toward pregnancy during residency. The perceived confusion of respondents with respect to programspecific policies emphasizes the need for open conversations and standardization of parental leave.

The Reporting Quality of Randomized Controlled Trial Abstracts in Plastic Surgery.

BACKGROUND: When evaluating randomized controlled trials (RCTs), clinicians will often refer to the abstract for an initial assessment of the results and to determine whether a full-text review is warranted. OBJECTIVES: This project aims to assess the reporting quality of RCT abstracts published within the top 5 plastic surgery journals utilizing the Consolidated Standards of Reporting Trials (CONSORT) for abstracts checklist. METHODS: A computerized database search of OVID MEDLINE was performed. All primary RCTs published within the top 5 plastic surgery journals (by 2016 International Scientific Indexing impact factor) from 2011 to 2018 were included. Two reviewers, blinded to journal and author, independently and in duplicate, scored abstracts employing the 16-item CONSORT for abstracts checklist. RESULTS: This review identified 126 RCTs that satisfied the inclusion criteria. Included studies were distributed across 5 journals: Plastic and Reconstructive Surgery (n = 83), JAMA Facial Plastic Surgery (n = 8), Aesthetic Surgery Journal (n = 33), Journal of Reconstructive Microsurgery (n = 2), and the Journal of Hand Surgery-European Volume (n = 0). Mean overall item adherence across all abstracts was 7 (SD ± 2). The most poorly reported items were "trial registration," "method of randomization," and "source of trial funding" and appeared in 4%, 2.4%, and 0% of abstracts, respectively. CONCLUSIONS: There is limited adherence to the CONSORT for abstracts checklist among RCT abstracts published within the top 5 plastic surgery journals. Given the reliance of clinicians on abstract reporting, omitting essential trial details can lead to an inaccurate interpretation of trial results and improper application in clinical practice. Active endorsement of the CONSORT for abstracts checklist is required to improve the quality of RCT abstract reporting.

Perioperative Pregabalin and Intraoperative Lidocaine Infusion to Reduce Persistent Neuropathic Pain After Breast Cancer Surgery: A Multicenter, Factorial, Randomized, Controlled Pilot Trial.

Persistent postsurgical pain is defined as pain localized to the area of surgery of a duration of ≥2 months and is, unfortunately, a common complication after breast cancer surgery. Although there is insufficient evidence to support any preventative strategy, prior literature suggests the possible efficacy of intravenous lidocaine and perioperative pregabalin in preventing persistent pain after surgery. To determine feasibility of conducting a larger definitive trial, we conducted a multicenter 2 × 2 factorial, randomized, placebo-controlled pilot trial of 100 female patients undergoing breast cancer surgery. Patients were randomized to receive an intraoperative lidocaine infusion (1.5 mg/kg bolus followed by 2 mg/kg/h) or placebo and perioperative pregabalin (300 mg preoperatively, 75 mg twice daily for 9 days) or placebo. All feasibility criteria were surpassed; recruitment of 100 patients was accomplished within 42 weeks, with a follow-up rate of 100% and study drug compliance of ≥80%. At 3 months, 53% of patients reported persistent neuropathic pain. Although there was no interaction between lidocaine and pregabalin, lidocaine decreased the development of persistent neuropathic pain (43.1% vs 63.3%; relative risk = .68; 95% confidence interval = .47-1.0). Pregabalin did not reduce persistent pain (60% vs 46%; relative risk = 1.3; 95% confidence interval = .90-1.90) and neither pregabalin nor lidocaine impacted acute postoperative pain, opioid consumption, pain interference, or quality of life. Our pilot trial successfully demonstrated feasibility and provided promising data for conducting further trials of intraoperative lidocaine infusions during breast cancer surgeries. Clinical trial number: NCT02240199 PERSPECTIVE: This article reports the findings of a pilot randomized, controlled trial evaluating the effects of perioperative pregabalin and intraoperative lidocaine infusions in patients undergoing breast cancer surgery. This trial demonstrated the feasibility of conducting a larger trial and provided promising data that these interventions may decrease the development of persistent pain.

Surgical outcomes of VRAM versus gracilis flaps for the reconstruction of pelvic defects following oncologic resection✰.

PURPOSE: Pelvic reconstruction following abdominoperineal resection or pelvic exenteration is associated with signification surgical site morbidity. Immediate pelvic reconstruction with a muscle flap is now the gold standard, associated with reduced perineal morbidity compared to primary closure alone.2,3 The purpose of the present study was to directly compare outcomes of VRAM and gracilis flap pelvic reconstruction following oncologic resection. METHODS: A multicenter retrospective review was performed of 88 patients who underwent abdominoperineal resection or pelvic exenteration and immediate pelvic reconstruction, either with a VRAM (N = 61) or Gracilis flap (N = 27). Electronic medical records were analyzed for patient demographics, intraoperative data, and postoperative outcomes. Mortality, minor complication rate, major complication rate and time to complete wound healing was compared between groups. RESULTS: Overall, there was no significant difference in the minor complication rate (44% gracilis vs 48% VRAM, p = 0.8), major complication rate (19% gracilis vs 13% of VRAM, p = 0.53), 30-day mortality (0% VRAM vs 0% gracilis, p = 1.0) and median time to complete wound healing (68 days vs 67 days, p = 0.19) between the gracilis and VRAM groups. Muscle-only gracilis flaps had a significantly reduced healing time compared to musculocutaneous gracilis flaps (48 days vs 85 days, p = 0.007). CONCLUSIONS: The workhorse flap in pelvic reconstruction remains the VRAM. While previous studies have alluded to the inferiority of thigh based flaps compared to the VRAM, we demonstrate here that pelvic reconstruction with the gracilis flap can be performed with comparable donor and recipient complication rates and similar time to complete wound healing as the VRAM.

The success of salvage procedures for failing digital replants: A retrospective cohort study.

BACKGROUND: The success of salvage procedures for failing digital replants (FR) is poorly documented. We sought to evaluate the success of salvage procedures for FR and factors contributing to successes and failures of replants. METHODS: Adult patients who presented to our center between January 1, 2000 and December 31, 2015, suffered ≥1 digital amputation(s), and underwent digital replantation were included. Preoperative, perioperative, and postoperative details were recorded. Digits were monitored postoperatively via nursing and physician assessments. The presumed reason for failure, details, and outcomes of salvage attempts were recorded for FR. Length of hospital stay and complications were also recorded. RESULTS: Fifty-two patients and 83 digits were included. Fifty-two digits (63%) were compromised (arterial ischemia in 15 digits; venous congestion in 37 digits) and 48 digits had salvage therapy. Twenty-one FR (44%) were salvaged via operative (1 of 2; 50%), nonoperative (19 of 43; 44%), and combined (1 of 3; 33%) therapies. FR patients were more likely than those with successful replants to receive a blood transfusion (52 vs. 23%; p = .009) with more transfused units (3.45 ± 3.30 vs. 0.86 ± 0.95; p = .001). Length of stay was prolonged for FR patients (9 [range: 2-22] vs. 7 [range: 3-19] days; p = .039). Ultimately, 59% (49 of 83) of replants were successful, where 25% (21 of 83) were successfully salvaged. CONCLUSION: Nonoperative and operative salvage therapies improve the rate of replant survival. We suggest close postoperative monitoring of all replants and active salvage interventions for compromised replants in the postoperative period.

Barriers, beliefs and practice patterns for breast cancer reconstruction: A provincial survey.

BACKGROUND: The purpose of this study was to characterize beliefs and practice patterns for breast cancer reconstruction among physicians who treat patients with breast cancer, in order to delineate current clinical practice. This survey was administered prior to Cancer Care Ontario guideline publication. METHOD: Survey questions addressed four domains: survival, delayed or obscured recurrence detection, delayed adjuvant therapy, and aesthetics. The survey was administered to 1160 Ontario plastic and general surgeons and radiation and medical oncologists. Data were compared to published guidelines. RESULTS: The overall response rate was 48%, with 57% of respondents treating breast cancer. Of those treating breast cancer, 75% are affiliated with an academic center. Immediate breast reconstruction (IBR) is not available to 28%. Autologous reconstruction is thought to interfere with recurrence detection by 23% (oncologists 30%, surgeons 19%, p = 0.04). For patients not expected to require radiation therapy, IBR is not supported by 30%. Autologous IBR is believed to delay delivery of adjuvant chemotherapy by 45% (oncologists 55%, surgeons 41%, p = 0.02). Up to 42% of respondents believe delays in adjuvant therapy delivery following IBR are due to insufficient health care resources (ie. coordinating an oncologic and reconstructive surgeon). Radiation therapy following reconstruction is believed to have negative aesthetic outcomes, and increase the need for revision surgery. CONCLUSIONS: Unfavourable beliefs about certain clinical actions do not align with recent provincial guideline recommendations. Insufficient healthcare resources are perceived to be a significant barrier to IBR and timely care.

Reduced venous thrombosis and re-exploration time with anastomotic coupling device: A cohort study.

OBJECTIVE: In the anastomotic coupling device literature, no comparative study has reported operative times, included consecutive patients, or used a matched comparison group. Our objective was to analyze patency and operative time in free flaps with venous anastomoses performed with ACD versus hand-sewn. METHODS: For consecutive free flaps, re-explorations and complications were reviewed in duplicate. Operative times for ACD versus hand-sewn were compared for: (1) matched unilateral DIEPs, and (2) re-explorations. RESULTS: Overall, 147 ACD and 144 hand-sewn flaps were included. Venous thrombosis was significantly lower with ACD (1/147[1%] vs.9/144[6%], P < 0.01). There was no difference in re-exploration for venous insufficiency, or overall re-exploration. Re-exploration time was significantly shorter with ACD (69mins vs.205mins, P = 0.009). CONCLUSIONS: ACD significantly decreases venous thrombosis compared to hand-sewn veins, and significantly shortens re-exploration time. Outcomes allow an estimate of cost utility for the ACD in decreasing venous thromboses and shortening re-exploration time. © 2015 Wiley Periodicals, Inc. Microsurgery 36:372-377, 2016.

An evaluation of accessibility and content of microsurgery fellowship websites.

BACKGROUND: Websites for residency and fellowship programs serve as effective educational and recruitment tools. OBJECTIVE: To evaluate the accessibility and content of fellowship websites that are commonly used by microsurgery applicants for career development. METHODS: A list of one-year microsurgery fellowship websites (MFWs) was compiled by visiting the centralized American Society for Reconstructive Microsurgery (ASRM) website, followed by performing an extensive 'Google' search in October 2015. Accessibility of MFWs was assessed. Website content regarding key recruitment and education variables was also comprehensively reviewed. Website content was correlated with program characteristics using t tests and ANOVA (two-tailed; P<0.05 was considered to be statistically significant). RESULTS: A list of 53 eligible programs was compiled. Only 15 of 51 (29%) ASRM program links were functional. On average, the combined content from ASRM website and individual MFWs had 2.91 of 6 recruitment variables and 1.32 of 6 education variables, respectively. The majority of programs listed 'eligibility criteria' (87%) and 'general information' (87%). 'Evaluation criteria' were most poorly reported (4%). Recruitment score was higher for United States programs compared with international counterparts (51% versus 33%, respectively; P=0.02). It was also higher in programs that focus on 'extremity' versus 'breast' (58% versus 37%; P=0.0028). Education scores did not differ according to location, program size, subspecialty of focus or participation in the Microsurgery Match process. CONCLUSION: Information regarding recruitment and education on most MFWs is scarce. Academic institutions should keep website content up to date and comprehensive to better assist candidates in the application process.

HISTORIQUE: Les sites Web pour les programmes de résidence et de surspécialisation sont des outils de formation et de recrutement efficaces. OBJECTIF: Évaluer l'accessibilité et le contenu des sites Web de surspécialisation souvent utilisés par les candidats en microchirurgie en vue de leur perfectionnement de carrière. MÉTHODOLOGIE: Les chercheurs ont compilé la liste des sites Web de surspécialisation en microchirurgie (SSW) d'un an à partir du site Web centralisé de l'American Society for Reconstructive Microsurgery (ASRM), puis ont effectué une recherche complète dans Google en octobre 2015. Ils ont évalué l'accès au SSW et procédé à une analyse détaillée des variables liées au recrutement clé et à la formation. Ils ont corrélé le contenu des sites Web avec les caractéristiques des programmes au moyen du test de Student et de l'analyse de variance (bilatéraux; P<0,05 était considéré comme statistiquement significatif). RÉSULTATS: Les chercheurs ont compilé une liste de 53 programmes admissibles. Seulement 15 liens sur les 51 programmes de l'ASRM (29 %) étaient fonctionnels. En moyenne, le contenu combiné du site Web de l'ASRM et des SSW individuels disposait de 2,91 des six variables de recrutement et de 1,32 des six variables de formation, respectivement. La majorité des programmes comportaient un volet « Critères d'admissibilité ¼ (87 %) et un volet « Renseignements généraux ¼ (87 %). Les « critères d'évaluation ¼ étaient moins bien définis (4 %). Le score de recrutement était plus élevé aux États-Unis que dans les programmes internationaux (51 % par rapport à 33 %, respectivement; P=0.02). Il était également plus élevé dans les programmes axés sur les membres que sur les seins (58 % par rapport à 37 %; P=0,0028). Les scores de formation étaient similaires à l'égard du lieu, de la dimension du programme, de la surspécialisation d'intérêt ou de la participation au processus de jumelage en microchirurgie. CONCLUSION: Il y a peu d'information relative au recrutement et à la formation dans la plupart des SSM. Les établissements universitaires devraient maintenir le contenu de leur site à jour et complet afin de mieux aider les candidats dans le cadre de leur processus de candidature.

SIEA versus DIEP Arterial Complications: A Cohort Study.

BACKGROUND: The authors analyzed arterial complications in patients undergoing breast reconstruction with superficial inferior epigastric artery (SIEA) flaps compared with deep inferior epigastric artery perforator (DIEP) flaps. The variability, caliber, and angiosome of the SIEA are cited as limitations. Experts currently limit SIEA reconstruction to cases with favorable arterial anatomy on preoperative imaging. METHODS: In this retrospective cohort study, consecutive flaps for breast reconstruction from the initial 7 years of a single microsurgeon's practice (2007 to 2013) were reviewed. Preoperative imaging was not used. Consistent intraoperative criteria for SIEA flap selection were used. All complications were abstracted independently in duplicate using a standardized form and a priori criteria. RESULTS: One hundred sixty-nine free flaps (SIEA, n = 44; DIEP, n = 125) were performed on 112 patients for unilateral or bilateral breast reconstruction. Significantly more SIEA flaps required reexploration versus DIEP flaps (20 percent versus 7 percent; p = 0.03). Arterial insufficiency was significantly higher among SIEA flaps (14 percent versus 1 percent; p = 0.001). There was no difference in venous insufficiency (p = 0.92). Significantly more SIEA flaps had necrosis requiring intervention (p = 0.03). Ultimately, significantly more SIEA flaps failed completely (14 percent versus 2 percent; p < 0.01). All SIEA flap failures were attributable to arterial thrombosis. CONCLUSIONS: Compared with DIEP flaps, SIEA flaps had significantly higher proportions of reexploration, arterial complication, necrosis, and failure. No difference in venous complications was found. DIEP outcomes agree with existing literature from specialized centers. Complications and failures in SIEA flaps were attributed to arterial thrombosis. Given the authors' practice setting, SIEA flaps are no longer performed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A systematic review of the endoscopic management of orbital floor fractures.

OBJECTIVE: To determine the safety and efficacy of the endoscopic management of isolated orbital floor fractures. METHODS: A systematic review was performed using electronic databases. Studies investigating the reconstruction of isolated orbital floor fractures using an endoscopic approach were considered for inclusion. Two investigators independently reviewed all results. Study quality was assessed using the Methodological Index for Nonrandomized Studies scale. Primary outcomes were the resolution of diplopia and enophthalmos. Secondary outcomes were postoperative complications, including blindness, paresthesias, sinusitis, infection, conversion to external approach, and need for revision surgery. RESULTS: Nine studies capturing 172 patients met the inclusion criteria for systematic review. Two studies were comparative and 7 were case series. Study quality was poor, lacking prospective data and reliable assessment of outcomes. Strong reviewer agreement was observed (intraclass correlation, 84%; 95% CI, 35%-96%). Diplopia resolved in 102 of 118 patients (86%) and enophthalmos resolved in 41 of 43 (95%). No complications of blindness, sinusitis, or conversion to external approach were reported. Thirteen patients (8%) had transient cheek numbness. Two patients (1%) required revision surgery. CONCLUSIONS: Reconstruction of isolated orbital floor fractures through an endoscopic approach appears to be safe and effective. High-level evidence prospectively comparing endoscopic and external approaches, however, is lacking.