Augmented Reality Microsurgery: Proof of Concept for a Novel Approach to Microsurgical Field Visualization in Plastic Surgery.

BACKGROUND: Microsurgery is conducted on tiny anatomical structures such as blood vessels and nerves. Over the past few decades, little has changed in the way plastic surgeons visualize and interact with the microsurgical field. New advances in augmented reality (AR) technology present a novel method for microsurgical field visualization. Voice- and gesture-based commands can be used in real time to adjust the size and position of a digital screen. Surgical decision support and/or navigation may also be used. The authors assess the use of AR in microsurgery. METHODS: The video feed from a Leica Microsystems OHX surgical microscope was streamed to a Microsoft HoloLens2 AR headset. A fellowship-trained microsurgeon and three plastic surgery residents then performed a series of four arterial anastomoses on a chicken thigh model using the AR headset, a surgical microscope, a video microscope (or "exoscope"), and surgical loupes. RESULTS: The AR headset provided an unhindered view of the microsurgical field and peripheral environment. The subjects remarked on the benefits of having the virtual screen track with head movements. The ability of participants to place the microsurgical field in a tailored comfortable, ergonomic position was also noted. Points of improvement were the low image quality compared with current monitors, image latency, and the lack of depth perception. CONCLUSIONS: AR is a useful tool that has the potential to improve microsurgical field visualization and the way surgeons interact with surgical monitors. Improvements in screen resolution, latency, and depth of field are needed.

Updates on Enhanced Recovery after Surgery protocols for plastic surgery of the breast and future directions.

Introduction: Perioperative pain control is an important component of any plastic surgery practice. Due to the incorporation of Enhanced Recovery after Surgery (ERAS) protocols, reported pain level, opioid consumption, and hospital length of stay numbers have decreased significantly. This article provides an up-to-date review of current ERAS protocols in use, reviews individual aspects of ERAS protocols, and discusses future directions for the continual improvement of ERAS protocols and control of postoperative pain. ERAS components: ERAS protocols have proven to be excellent methods of decreasing patient pain, opioid consumption, and postanesthesia care unit (PACU) and/or inpatient length of stay. ERAS protocols have three phases: preoperative education and pre-habilitation, intraoperative anesthetic blocks, and a postoperative multimodal analgesia regimen. Intraoperative blocks consist of local anesthetic field blocks and a variety of regional blocks, with lidocaine or lidocaine cocktails. Various studies throughout the surgical literature have demonstrated the efficacy of these aspects and their relevance to the overall goal of decreasing patient pain, both in plastic surgery and other surgical fields. In addition to the individual ERAS phases, ERAS protocols have shown promise in both the inpatient and outpatient sectors of plastic surgery of the breast. Conclusion: ERAS protocols have repeatedly been shown to provide improved patient pain control, decreased hospital or PACU length of stay, decreased opioid use, and cost savings. Although protocols have most commonly been utilized in inpatient plastic surgery procedures of the breast, emerging evidence points towards similar efficacy when used in outpatient procedures. Furthermore, this review demonstrates the efficacy of local anesthetic blocks in controlling patient pain.

Decreasing Opioids in Outpatient Breast Surgery with an Enhanced Recovery after Surgery Program and Preoperative Education.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs have been detailed in the literature predominantly in the inpatient setting. The purpose of this study was to determine the effect of an ERAS protocol with a preoperative educational class on opioid prescribing and patient outcomes for outpatient breast surgery. METHODS: An ERAS protocol was formulated focusing on preoperative education, multimodal pain control, and an intraoperative block. The study was conducted as an institutional review board-approved retrospective review. Women undergoing breast reconstruction revision, breast reduction, delayed insertion of prosthesis, tissue expander to implant exchange, and matching procedures were included. The patients were separated into pre-ERAS and ERAS cohorts. Data on demographic characteristics, postanesthesia care unit (PACU) length of stay, PACU oral morphine equivalent (OME) consumption, outpatient OME prescriptions, major and minor complications, and need for additional opioid prescriptions were collected. Analysis was performed with the Fisher exact test or chi-square test as appropriate. RESULTS: Group 1 (pre-ERAS) and group 2 (ERAS) each included 68 patients. The cohorts had similar age, body mass index, diabetes status, and tobacco use. Group 1 was prescribed an average of 216 OMEs, compared with 126.4 OMEs for group 2, a 41.5% decrease ( P < 0.0001). The pre-ERAS group consumed an average of 23.3 OMEs in the PACU versus 16.6 OMEs in the ERAS group ( P = 0.005). Fewer patients in the ERAS group required additional prescriptions for narcotic pain medication at postoperative follow-up ( P = 0.116). No differences were seen in major or minor complications. CONCLUSION: An ERAS protocol that uses a multimodal approach to pain control and preoperative patient education is useful in the outpatient setting and can help decrease opioid consumption. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Enhanced Recovery After Surgery: Standardized Postoperative Instructions in Hand Surgery.

Background: Enhanced Recovery After Surgery (ERAS) is a standardized approach to care of the surgical patient. Postoperative patient instructions, an aspect of ERAS protocols, are difficult to standardize in hand surgery because of the diversity of procedures. The aim of this study was to determine the effect of standardized hand surgery postoperative instructions on the number of unscheduled postoperative patient encounters. Methods: The study was an institutional review board-approved prospective cohort in which all hand surgery patients from 6 surgeons at a single, hospital-based academic institution were included. For a 6-month period, both before and after establishing a standardized postoperative instructional handout, data were collected on unscheduled postoperative encounters within 14 days of surgery. Results: There were 330 patients in the control group versus 282 who received standardized postoperative instructions. Trauma comprised 24.6% of cases in comparison to 75.4% elective. Individual surgeons did not significantly influence whether patients had an encounter. Overall, patients who received standardized instructions were just as likely as the control group to have unscheduled encounters (41.5% vs 43.9%, respectively). Notably, elective patients were significantly more likely to have encounters (46%) versus trauma patients (33.1%; P = .007); however, the standardized instructions did not influence the number of encounters for either group. Conclusions: This study did not demonstrate a difference in unscheduled postoperative encounters after initiation of standardized postoperative instructions for hand surgery patients. These findings may help providers save time and resources by tailoring the use of ERAS in this distinct patient population.

Comparison of Liposomal Bupivacaine to a Local Analgesic Cocktail for Transversus Abdominis Plane Blocks in Abdominally Based Microvascular Breast Reconstruction.

BACKGROUND: Transversus abdominis plane blocks can improve pain control and decrease opioid use within an enhanced recovery after surgery (ERAS) protocol in patients undergoing abdominally based autologous breast reconstruction. The authors have transitioned to using a local analgesic cocktail for transversus abdominis plane blocks. The purpose of this study was to compare postoperative opioid use in patients who received the blocks. METHODS: Patients who underwent abdominally based autologous breast reconstruction between November of 2015 and December of 2019 were retrospectively reviewed. The study group received bupivacaine, ketorolac, dexmedetomidine, and dexamethasone; the control group received liposomal bupivacaine with or without bupivacaine, ketorolac, or dexmedetomidine, as a transversus abdominis plane block. The primary outcome of interest was postoperative opioid use and pain scores. RESULTS: One hundred four women met inclusion criteria: 36 in group A (before ERAS, before transversus abdominis plane block), 38 in group B (ERAS, transversus abdominis plane block with liposomal bupivacaine), and 30 in group C (ERAS, transversus abdominis plane block with local anesthetic cocktail). Total daily oral morphine equivalent consumption (group A, 633; group B, 240; group C, 135; p < 0.0001) and average daily oral morphine equivalent consumption (group A, 137; group B, 56; group C, 29; p < 0.0001) were significantly less for group C in the inpatient phase. Patients in group C were prescribed significantly fewer outpatient oral morphine equivalents (group A, 79; group B, 74; group C, 52; p = 0.01). CONCLUSIONS: Transversus abdominis plane blocks are a significant component of an ERAS protocol for abdominally based breast reconstruction. Liposomal bupivacaine is a popular option for transversus abdominis plane blocks. The authors' results demonstrate that a local anesthetic cocktail, composed of economical and readily available medications, can provide excellent patient pain control and decrease postoperative opioid use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Ambidexterity in left-handed and right-handed individuals and implications for surgical training.

Surgical training has historically been geared toward right-handed individuals. This could cause mentors to perceive left-handed students and residents as being more difficult to train. This study examined whether differences in dexterity exist between left-handed and right-handed individuals and the implications this may have on surgical training. Recent literature suggests that surgical training may need to be updated to train left-handed students more effectively. In this prospective, crossover study, 50 right-handed and 50 left-handed individuals of varying ages and occupations were evaluated using the O'Conner Tweezer Dexterity Test. Participants were timed while they used flat-tipped forceps to pick up 1″ brass metal pins and sequentially place one pin each in 100 pinholes 1/16″ in diameter on a 21″ × 12″ board. Participants completed this exercise with their dominant hand followed by their nondominant hand. Nondominant hand dexterity was measured by dividing the nondominant hand completion time by the dominant hand completion time, with a higher percentage associated with higher ambidexterity. Using the Student's two-tailed t test, we found that left-handed individuals had an 97.2% congruence between dominant and nondominant hands while right-handed individuals had a 71.6% congruence (P < 0.001). In conclusion, our results show that left-handed individuals have a greater degree of ambidexterity than their right-handed counterparts. These results suggest that any perceived difference between left-handed and right-handed surgical residents may not be due to innate skill or dexterity, but rather a combination of external influences.

Opioid Prescribing Practices in Cleft Lip and Cleft Palate Reconstruction.

INTRODUCTION: Currently, there is no consensus regarding the role of opioids in the management of perioperative pain in children undergoing cleft lip/palate repair. METHOD: The present study evaluated opioid prescribing patterns of surgeon members within the American Cleft Palate-Craniofacial Association surgeons utilizing an anonymous survey. RESULTS: Respondents performing cleft lip repair typically operate on patients 3 to 6 months of age (86%), admit patients postoperatively (82%), and discharge them on the first postoperative day (72%). Comparatively, respondents performed palatoplasty between the ages of 10 and 12 months (62%), almost always admit the patients (99%), and typically discharge on the first postoperative day (78%). Narcotics were more frequently prescribed after palatoplasty than after cleft lip repair, both for inpatients (66%; 49%) and at discharge (38%; 22%). Oxycodone was the most prescribed narcotic (39.1%; 41.4%), typically for a duration of 1 to 3 days (81.5%; 81.2%). All surgeons who reported changing their narcotic regimen (34.4% dose, 32.8% duration) after cleft lip repair, decreased both parameters from earlier to later in their career. Similarly, surgeons who changed the dose (32.2%) and duration (42.5%) of narcotics after palatoplasty, mostly decreased both parameters (96%). Additionally, physicians with >15 years of practice were less likely to prescribe opioids in comparison with colleagues with ≤15 years of experience. Ninety-two percent of respondents endorsed prescribing nonopioid analgesics after prescribing cleft surgery, most commonly acetaminophen (85.7%; 85.4%). CONCLUSION: Cleft surgeons typically prescribe opioids to inpatients and rarely upon discharge. Changes to opioid-prescribing patterns typically involved a decreased dose and duration.

Early versus Delayed Implant Exchange after Periprosthetic Breast Infection: A Single Center Study.

BACKGROUND: Breast implant infections are challenging problems for both plastic surgeons and patients. They may require readmissions, re-operations, and have the potential to compromise the final result. Our goal was to determine whether early operative intervention (return to the operating room <72 h after diagnosis of infection) or intravenous antibiotics with later operative intervention increased long-term retention of a prosthesis. METHODS: A retrospective review was conducted of patients who were hospitalized or underwent reoperation for an infection from 2006 through 2016. The length of hospitalization, length of IV antibiotic use, and retention of the breast prosthesis at 3-months after reoperation were recorded for each patient. RESULTS: A total of 43 patients were included in our study. Of these, 33 patients underwent early intervention, and 10 patients underwent delayed intervention. The average length of stay was significantly shorter in the early versus delayed return to OR group (4.1 versus 6.4 days; P = 0.008). The average duration of antibiotics was shorter in the early intervention group than the delayed group (5.1 versus 6.4 days; P = 0.28). At 3-months postoperatively, a greater proportion of patients in the early intervention group compared with the delayed group retained their breast prostheses (87.5% versus 60%; P = 0.25). CONCLUSIONS: The results of this study demonstrate that breast implants may be salvaged after early (<72 hours) or delayed (>72 hours) operative intervention; however, early intervention is associated with a significantly shorter length of stay, and trends toward a shorter antibiotic course and higher rate of implant retention at 3 months.

Operative Management of Abdominal Wound Dehiscence: Outcomes and Factors Influencing Time to Healing in Patients Undergoing Surgical Debridement With Primary Closure.

INTRODUCTION: Plastic surgeons are often consulted by other surgical teams for management of wound dehiscence following abdominopelvic surgery. OBJECTIVE: The purpose of this study is to determine whether operative debridement and primary closure of abdominopelvic wounds are safe and expeditious for patients. MATERIALS AND METHODS: A retrospective analysis was conducted on a database of patients who underwent operative debridement and closure at a single institution between January 2011 and December 2015 for dehisced abdominal or pelvic wounds acquired from prior obstetric, gynecologic, transplant, plastic, or general surgery procedures. RESULTS: Of the 163 patient records identified, 43 patients met inclusion criteria. The median time from final debridement and primary surgical closure to complete wound healing was 27 days. Time to healing differed significantly by index procedure type (P = .004), with obstetric procedures requiring the shortest median time (12.0 days) and general surgery procedures requiring the longest (39.5 days). Wound healing took 3.6 times longer for patients with diabetes (P = .046) and 11.4 times longer for patients who experienced delayed superficial wound healing or redehiscence (P = .003). Nevertheless, with the exception of 4 patients who died of other causes, all wounds (39/39; 100%) achieved complete wound closure. CONCLUSIONS: Operative debridement and closure of abdominopelvic wound dehiscence through a multidisciplinary team approach with plastic surgery results in expeditious wound healing with minimal complications, and it may be safer and more cost effective than healing by secondary intention.

Assessment of Function after Free Tissue Transfer to the Lower Extremity for Chronic Wounds Using the Lower Extremity Functional Scale.

BACKGROUND: Free tissue transfer is one option for preservation of form and function in the native limb, in the setting of soft tissue paucity. However, the data on patient functionality after microvascular intervention is inconsistently reported. The Lower Extremity Function Scale (LEFS) measures patient-reported difficulty in carrying out 20 physical activities, on a Likert scale, the sum of which correlates with descriptive functional stages of 1-5. We assess limb functionality in this cohort of microvascular patients using the LEFS survey. METHODS: A retrospective chart review was conducted at a single academic medical center of 101 consecutive free flaps, from 2011 to 2016. Of the flaps that met inclusion criteria, 39 had completed LEFS surveys. Mean LEFS scores were calculated, and the effects of risk factors such as diabetes, age, and smoking status were analyzed. RESULTS: The mean LEFS score after free tissue transfer was 50.3 (SD ± 21.1), with a mean follow up survey time of 3.0 years (SD ± 1.3). The score correlated with Stage 4 function, or "independent community ambulation," and age was the only demographic factor associated with decreased functionality in this group. This is compared with mean LEFS score of 43.1 (SD ± 18.4) in cohort of 55 below knee amputations (BKAs), and 38.3 (SD ± 14.9) in 28 above knee amputations (AKAs), both correlating with Stage 3 function: "limited community ambulation." CONCLUSIONS: Functional outcomes scores such as the LEFS demonstrate that patients can obtain an adequate level of functionality for independent community activity after free tissue transfer, although functional improvement diminishes with age.

Optical coherence tomography and computer-aided diagnosis of a murine model of chronic kidney disease.

Chronic kidney disease (CKD) is characterized by a progressive loss of renal function over time. Histopathological analysis of the condition of glomeruli and the proximal convolutional tubules over time can provide valuable insights into the progression of CKD. Optical coherence tomography (OCT) is a technology that can analyze the microscopic structures of a kidney in a nondestructive manner. Recently, we have shown that OCT can provide real-time imaging of kidney microstructures in vivo without administering exogenous contrast agents. A murine model of CKD induced by intravenous Adriamycin (ADR) injection is evaluated by OCT. OCT images of the rat kidneys have been captured every week up to eight weeks. Tubular diameter and hypertrophic tubule population of the kidneys at multiple time points after ADR injection have been evaluated through a fully automated computer-vision system. Results revealed that mean tubular diameter and hypertrophic tubule population increase with time in post-ADR injection period. The results suggest that OCT images of the kidney contain abundant information about kidney histopathology. Fully automated computer-aided diagnosis based on OCT has the potential for clinical evaluation of CKD conditions.

Use of indocyanine green fluorescent angiography in a hyperbaric patient with soft tissue radiation necrosis: a case report.

INTRODUCTION: Indocyanine green fluorescent angiography (ICFA), commonly used to assess vascularity in patients with non-healing lower extremity wounds, is emerging as a useful adjunct for hyperbaric oxygen (HBO2)therapy patients. We describe the use of ICFA to measure vascularity and help tailor an appropriate HBO2 regimen in a patient with breast soft tissue radiation necrosis (STRN). CASE REPORT: 67-year-old female with a history of right breast cancer treated two years previously with lumpectomy and radiation therapy (6200 cGy), developed open wounds in the right breast. A diagnosis of STRN was established; the patient completed 20 HBO2 treatments, followed by surgical closure of the right breast wounds. Intraoperative ICFA demonstrated a focal area of hypovascularity at the medial margin of the incision. Due to a concern of suboptimal vascularity, the patient returned for additional HBO2 treatments. ICFA was performed after eight postoperative HBO2 treatments, and showed improved vascularity in the previously identified area of concern. DISCUSSION: Studies of patients previously irradiated for head and neck cancer suggest that HBO2-induced vascularity is apparent after approximately eight HBO2 treatments and peaks around 20 treatments. The results from this case indicate that the doses of HBO2 needed for adequate neovascularization in patients with STRN may be variable. CONCLUSION: The use of ICFA may provide additional insight regarding HBO2-induced angiogenesis. Additional studies are required to establish the correct number of HBO2 treatments required for angiogenesis in previously irradiated patients with STRN, and to explore the role of ICFA in patients treated with HBO2.

Potential Future Applications for Negative Pressure Wound Therapy and Installation Devices.

Negative-pressure wound therapy (NPWT) applies vacuum pressure to a wound bed sealed by an adhesive dressing to improve wound healing. A cleansing solution, often antibiotics or saline, may be instilled into the wound bed concurrently and removed via suction, thus enhancing the therapeutic effect. The therapeutic effect results from improved blood flow and removal of inflammatory factors. Since 1995, the FDA has approved NPWT for medical use. Since then, this technology has been applied to different types of wounds, including diabetic and decubitus ulcers and postsurgical incisional wounds. There are many applications for NPWT that remain to be explored. In this article, we postulate on novel and future uses for NPWT, including application in targeted drug delivery, stem cell therapy, and the prospect of combination with filtration devices, adaptable smart dressings, and remote monitoring.

What Heals Hidradenitis Suppurativa: Surgery, Immunosuppression, or Both?

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the skin that is a significant source of impaired quality-of-life for affected individuals. For patients with refractory disease, radical resection of all involved tissue may offer the only potential option for a cure. However, high rates of recurrence after wide local excision have led investigators to seek alternative therapeutic combinations. We present our experience and a literature review. METHODS: A comprehensive literature review (1982-2016) was performed on PubMed and Ovid MEDLINE, using key words relevant to HS. RESULTS: A total of 1842 publications were identified, and 15 publications were included in this review on: surgical intervention (n = 10), biologic therapy (n = 4), and joint surgical and biologic treatment (n = 1) of HS. The treatment type, level of evidence, and key findings are assessed and discussed. CONCLUSIONS: Recent trials demonstrating the safety and efficacy of biologic therapy alone in patients with moderate-to-severe HS have spurred questions regarding the potential utility of these agents as adjuncts to more traditional surgical interventions. The results of the literature search advocate a role for radical resection and biologic therapy in the setting of moderate-to-severe disease. Preliminary results from limited case series suggest a potential role for combined management in the setting of advanced, recalcitrant disease.

Optical Coherence Tomography of the Aging Kidney.

OBJECTIVES: The aging kidney exhibits a progressive decline in renal function with characteristic histopathologic changes and is a risk factor for renal transplant. However, the degree to which the kidney exhibits this decline depends on several factors that vary from one individual to the next. Optical coherence tomography is an evolving noninvasive imaging technology that has recently been used to evaluate acute tubular necrosis of living-human donor kidneys before their transplant. With the increasing use of kidneys from older individuals, it is important to determine whether optical coherence tomography also can distinguish the histopathology associated with aging. MATERIALS AND METHODS: In this investigation, we used Munich-Wistar rats to evaluate the ability of optical coherence tomography to detect histopathologic changes associated with aging. Optical coherence tomography observations were correlated with renal function and conventional light microscopic evaluation of these same kidneys. RESULTS: With the onset of severe proteinuria at 10 to 12 months of age, optical coherence tomography revealed tubular necrosis/atrophy, interstitial fibrosis, tubular dilation, and glomerulosclerosis. With a further deterioration in kidney function at 16 to 18 months of age (as indicated by rising creatinine levels), optical coherence tomography revealed more extensive interstitial fibrosis and tubular atrophy, increased tubular dilation with cyst formation and more sclerotic glomeruli. CONCLUSIONS: The foregoing observations suggest that optical coherence tomography can be used to detect the histopathology of progressive nephropathy associated with aging.

Donor-Site Morbidity Following Free Tissue Harvest from the Thigh: A Systematic Review and Pooled Analysis of Complications.

Background Donor-site morbidity significantly influences patient satisfaction and quality of life following reconstructive surgery. The relevant donor-site morbidities associated with more commonly utilized thigh-based flaps are reviewed. Methods A systematic search of the MEDLINE and Cochrane databases from 1994 to 2014 was conducted to identify all reports of "anterolateral thigh (ALT)," "vastus lateralis (VL)," "anteromedial thigh (AMT)," "transverse upper gracilis (TUG)," tensor fascia latae (TFL)," "gracilis," and "rectus femoris (RF)," flaps. Only studies that investigated donor-site outcomes related to pain, paresthesia, wound dehiscence, infection, hematoma, seroma, contour deformity, and/or objective functional performance were included. Case series or anecdotal reports with less than five flaps, non-English, and animal studies were excluded. Results A total of 116 articles representing 4,554 flaps were reviewed, including 2,922 ALT/VL, 148 AMT, 436 TUG, 278 TFL, 527 gracilis, and 243 RF flaps. The most frequently cited donor-site complication was paresthesia (range: 0-36.4%), followed by wound dehiscence (range: 0.9-8.3%), contour deformity (range: 0-5.2%), pain (range: 0-6.3%), and seroma (range: 0.4-2.0%). Despite mixed results regarding functional performance, pooled-analysis of dynamometric studies demonstrated a significant reduction in strength only after RF flap harvest (21%). Conclusions Donor-site morbidity for thigh-flaps is minimal and appears to be well-tolerated by the majority of patients. Nevertheless, the appropriate flap selection is highly individualized, and patients must be informed of potential complications and morbidities specific to each flap. We have established the most current review of donor-site morbidity for thigh-based flaps to aid the surgeon in this important discussion.

Fluorescence Technology for Point of Care Wound Management.

As the prevalence of chronic wounds continues to rise, the need for point of care wound assessment has also increased. While a variety of technologies have been developed to improve diagnostic abilities and monitoring of wounds, none have proven completely effective in all settings. Further, many of the stalwart wound management techniques remain costly, time consuming, and technically challenging. The two key pivotal events of ischemia and infection can lead to limb loss. A relatively new crop of fluorescence-based technologies, including devices that measure pathogenic auto-fluorescence, fluorescence angiography, or map cutaneous oxygenation, are increasingly being utilized for adjunct wound assessment-both clinical and operative settings can address these events. These technologies offer rapid, efficient, visual, and quantitative data that can aid the wound provider in evaluating the viability of tissues, ensuring adequate perfusion, and optimizing wound bed preparation. In the following review, pathogenic auto-fluorescence is compared to gross evaluation of wound infection and culture based diagnostics, indocyanine green fluorescence angiography is compared to various methods of visual and physical assessments of tissue perfusion by the practitioner, and cutaneous oxygenation is compared to clinical signs of ischemia. We focus on the current applications of fluorescence technologies in wound management, with emphasis placed on the evidence for clinical and operative implementation, a safety analyses, procedural limitations, and the future direction of this growing field of wound assessment.