Left Internal Mammary Vein Size and Its Impact on Microsurgical Breast Reconstruction.

The internal mammary vessels are the preferred recipient during free-flap breast reconstruction (FFBR). Previous studies have demonstrated that the left internal mammary vein (IMV) is consistently smaller than the right, but with unclear clinical implications. This study explores the impact of IMV size difference on FFBR complication rates. Methods: Abdominal-based FFBRs were retrospectively reviewed. Venous coupler size was considered a proxy for IMV diameter. Outcomes of three patient cohorts (all, unilateral, and bilateral reconstructions) were analyzed with univariate and multivariate analysis. Results: Our cohort consisted of 582 patients who underwent 874 abdominal-based FFBR, with a similar number of unilateral (n = 290) and bilateral (n = 292), and right (n = 424) and left (n = 450) reconstructions. Mean follow-up was over 4-years. For all reconstructions, the left IMV (2.7 ± 0.4 mm) was smaller than the right (3.0 ± 0.4 mm) (P < 0.0001). Complication rates between left- and right-sided FFBR were similar, but with a trend toward increased fat necrosis on the left (n = 17, 3.8% versus n = 8, 1.9%). Further subgroup analysis showed significantly higher fat necrosis in unilateral left-sided FFBR (n = 12 versus n = 2, P = 0.02), with left-sided FFBR being an independent risk factor for fat necrosis on multivariate analysis. Conclusions: The left-side IMV is significantly smaller than the right IMV. In bilateral reconstructions, the smaller size of the left IMV did not result in a greater risk of complications; however, in unilateral FFBR, fat necrosis was significantly higher on the left side.

Meta-analysis and Systematic Review of Skin Graft Donor-site Dressings with Future Guidelines.

BACKGROUND: Many types of split-thickness skin graft (STSG) donor-site dressings are available with little consensus from the literature on the optimal dressing type. The purpose of this systematic review was to analyze the most recent outcomes regarding moist and nonmoist dressings for STSG donor sites. METHODS: A comprehensive systematic review was conducted across PubMed/MEDLINE, EMBASE, and Cochrane Library databases to search for comparative studies evaluating different STSG donor-site dressings in adult subjects published between 2008 and 2017. The quality of randomized controlled trials was assessed using the Jadad scale. Data were collected on donor-site pain, rate of epithelialization, infection rate, cosmetic appearance, and cost. Meta-analysis was performed for reported pain scores. RESULTS: A total of 41 articles were included comparing 44 dressings. Selected studies included analysis of donor-site pain (36 of 41 articles), rate of epithelialization (38 of 41), infection rate (25 of 41), cosmetic appearance (20 of 41), and cost (10 of 41). Meta-analysis revealed moist dressings result in lower pain (pooled effect size = 1.44). A majority of articles (73%) reported better reepithelialization rates with moist dressings. CONCLUSION: The literature on STSG donor-site dressings has not yet identified an ideal dressing. Although moist dressings provide superior outcomes with regard to pain control and wound healing, there continues to be a lack of standardization. The increasing commercial availability and marketing of novel dressings necessitates the development of standardized research protocols to design better comparison studies and assess true efficacy.

Use of a novel chitosan-based dressing on split-thickness skin graft donor sites: a pilot study.

OBJECTIVE: Split-thickness skin graft (STSG) donor site dressings can play an integral role in reducing donor site morbidity. This study tested a novel, chitosan-based wound dressing, Opticell Ag, as an STSG donor site dressing for wounds <10% total body surface area (TBSA). METHOD: Between January and December 2016, the chitosan-based dressing was placed on participating patients' donor sites immediately following graft harvest and covered with a transparent occlusive dressing. Pain was evaluated on postoperative day one, before dressing change between days 5-7, and before and after dressing removal between days 10-14 using the Visual Analog Scale (VAS). The extent of re-epithelialisation was determined between day 10-14 and at one month, and healing quality was also evaluated at one month post-operatively using the Vancouver Scar Scale (VSS). RESULTS: A total of 19 patients were recruited, of which 16 completed the study. Patients experienced mild-to-moderate pain in their donor sites when the chitosan-based dressing was used. Pain decreased significantly between postoperative day one and days 10-14, as well as between days 5-7 and 10-14. The mean percentage of re-epithelialisation on days 10-14 was 92% and by one month was 99%. The mean VSS at one month was 3.2±1.4. There were no statistically significant differences between patients' re-epithelialisation rates or VSS scores. There were unplanned dressing changes in four patients. No donor site infections or other adverse events were identified. CONCLUSION: The chitosan-based dressing tested in this study is safe, effective, and associated with reasonable pain control and acceptable healing quality. The results suggest that it is a promising STSG donor site dressing.

Microsurgical Burn Reconstruction.

The treatment of burn-related wounds requires consideration of several factors, including defect size, available donor sites, exposure of critical structures, and the ultimate functional and aesthetic result of reconstruction. Although skin grafts and locoregional flaps are workhorses in burn reconstruction, they have inherent limitations that can directly impact reconstructive outcomes. Microsurgical free tissue transfer represents a viable option for the reconstruction of burn-related wounds in certain patients. Each anatomic region of the body has unique challenges that must be addressed to achieve a successful reconstruction. Therefore, the choice of free flap must be individualized to the wound and patients.

Unilateral Internal Mammary Recipient Vessels for Bilateral DIEP Flap Breast Reconstruction.

The deep inferior epigastric perforator flap has become increasingly popular for breast reconstruction with the most common recipient vessels being the internal mammary artery and vein. In certain cases, however, these recipient vessels are inadequate due to an absent or diminutive vein. Moreover, patients at high risk for future coronary artery disease may sacrifice the best conduit for coronary revascularization if the internal mammary recipients are used. Alternative recipient vessels, including the thoracodorsal, thoracoacromial, external jugular, and cephalic vessels have significant limitations. In this report, we describe a novel technique using unilateral internal mammary recipient vessels for bilateral free flap breast reconstruction. Two cases are presented that represent distinct indications for this technique: (1) absence or inadequacy of unilateral recipient vessels and (2) preservation of the left internal mammary system for future bypass in patients at high risk for coronary artery disease.

Skin Substitutes and Bioscaffolds: Temporary and Permanent Coverage.

Advancements in surgical wound treatment have led to skin substitutes and bioscaffolds as temporary and permanent coverage for burn wounds. Skin substitutes are used to improve wound coverage and restore the functional and aesthetic qualities of skin, and help to prevent wound infection and maintain a moist wound healing environment. Although allografts are preferred when autografts are not possible, high costs and limited availability have led to the use of xenografts and the development of skin substitutes and bioscaffolds. Despite constant evolution in the development of these skin substitutes and bioscaffolds, no single product stands out as the gold standard.

Negative Pressure Wound Therapy for Burns.

Negative pressure wound therapy (NPWT) has become a widely used treatment for acute and chronic wounds. NPWT is indicated for a variety of complex wounds, and some studies validate its use for certain aspects of burn care. Although further research is needed to explore the benefits for burns, NPWT has proven beneficial in its use as a dressing that bolsters skin grafts, promotes integration of bilaminate dermal substitutes, promotes re-epithelialization of skin graft donor sites, and potentially reduces the zone of stasis. This article reviews the literature on NPWT in burns, based on indication/application, and describes our experience with the use of modified NPWT for large burns.

Topical Vasodilators in Microsurgery: What Is the Evidence?

Background Topical vasodilators are frequently used during free tissue transfer to prevent and treat vasospasm and microvascular thrombosis. A variety of agents have been studied and are available, yet most microsurgeons select an agent based on anecdotal evidence or personal training. Our aim was to review the literature on topical vasodilators so microsurgeons can make more informed decisions about which agent to use. Methods A systemic review of the literature was performed on PubMed, EMBASE, and Google Scholar using keywords "topical vasodilator," "antispasmodic," "vasospasm," "free flaps," and "microsurgery." Studies were included if they provided a comparative quantitative assessment of topical vasodilators and were written in English. In vitro, in vivo, and clinical studies were included. Results A total of 15 studies were identified and included in our analysis. The three most common classes of topical vasodilator include local anesthetics, phosphodiesterase inhibitors, and calcium channel blockers (CCBs). Of the most commonly used topical vasodilators, CCBs (nifedipine and verapamil) were most effective followed by papaverine and lidocaine. Conclusion The most effective topical vasodilators appear to be CCBs including nifedipine, nicardipine, and verapamil. Evidence suggests that these agents are more effective than papaverine and lidocaine solutions that are commonly used. Future research should directly compare individual CCBs to assess the most effective agent. Studies to date have focused on vessels other than those used by microsurgeons, and therefore further studies specific to these vessels are warranted.

Miniplates Versus Reconstruction Bars for Oncologic Free Fibula Flap Mandible Reconstruction.

PURPOSE: The free fibula is the flap of choice for reconstructing most segmental mandibular defects resulting from head and neck resections. The use of miniplates or reconstruction bars for fixation has been described in the literature. We wanted to compare outcomes between the 2 methods of fixation in head and neck cancer patients. PATIENTS AND METHODS: An IRB approved retrospective review of 25 consecutive patients undergoing free fibula flap reconstruction of the mandible for head and neck cancer over a period of 5 years was performed. Patient demographics, risk factors, number of fibula osteotomies, defect length, and clinical outcomes were noted. Fourteen patients were reconstructed with miniplates and 12 with reconstruction bars. The choice of plate fixation was determined by the individual reconstructive surgeon. Wound complications requiring surgery and hardware removal rate were recorded. RESULTS: Average follow-up was 27 months. There was no significant difference with regard to age (P = 0.67), sex (P = 0.77), smoking (P = 0.63), neoadjuvant radiation (P = 0.47), number of osteotomies (P = 0.99), or defect length (P = 0.95) between the 2 groups. Of the 4 patients requiring hardware removal for infection or persistent symptoms, all were in the miniplate group (P = 0.05). Other clinical outcomes, such as hematoma, wound dehiscence, infection, fistula formation, and osteoradionecrosis were comparable between the 2 groups without significant differences. The overall complication rate was similar as well (P = 0.25). DISCUSSION: Different from other reports in the literature, we show that miniplate use resulted in more hardware removal for infection or persistent symptoms, and this was statistically significant while controlling for patient demographics, risk factors, number of osteotomies, and defect length. Much like other reports in the literature, however, there is no statistically significant difference in overall complication rates, and all other specific complications, when using miniplates versus reconstruction bars. The decision to use miniplates versus reconstruction bars remains a clinical one. In our experience, for 0 to 1 osteotomy, a reconstruction bar suffices. For multiple osteotomies, however, miniplates allow for more customization.

A review of negative-pressure wound therapy in the management of burn wounds.

OBJECTIVE: Negative pressure has been employed in various aspects of burn care and the aim of this study was to evaluate the evidence for each of those uses. METHODS: The PubMed and Cochrane CENTRAL databases were queried for articles in the following areas: negative pressure as a dressing for acute burns, intermediate treatment prior to skin grafting, bolster for skin autografts, dressing for integration of dermal substitutes, dressing for skin graft donor sites, and integrated dressing in large burns. RESULTS: Fifteen studies met our inclusion criteria. One study showed negative pressure wound therapy improved perfusion in acute partial-thickness burns, 8 out of 9 studies showed benefits when used as a skin graft bolster dressing, 1 out of 2 studies showed improved rate of revascularization when used over dermal substitutes, and 1 study showed increased rate of re-epithelialization when used over skin graft donor sites. CONCLUSIONS: Negative pressure can improve autograft take when used as a bolster dressing. There is limited data to suggest that it may also improve the rate of revascularization of dermal substitutes and promote re-epithelialization of skin graft donor sites. Other uses suggested by studies that did not meet our inclusion criteria include improving vascularity in acute partial-thickness burns and as an integrated dressing for the management of large burns. Further studies are warranted for most clinical applications to establish negative pressure as an effective adjunct in burn wound care.

Antibiotic Prophylaxis following Implant-Based Breast Reconstruction: What Is the Evidence?

BACKGROUND: Although data from other surgical disciplines do not support the use of prolonged postoperative prophylactic antibiotics, implant-based breast reconstruction is one area of plastic surgery where this may be warranted. The purpose of this study was to review the literature on antibiotic prophylaxis in prosthetic breast reconstruction, summarize findings, and provide recommendations. METHODS: A literature review was performed to identify studies that compared different perioperative prophylactic antibiotic regimens with respect to infectious outcomes in prosthetic breast reconstruction. RESULTS: Five studies and five systematic reviews were identified. One prospective randomized trial showed that a single preoperative dose was better than placebo, and another showed no difference between 24 hours versus until drain removal. Three studies were retrospective, one showing no difference between a single preoperative dose and prolonged antibiotic use, and two showing significant reduction in infectious complications with prolonged antibiotic use. One systematic review suggested an increased rate of infection with prolonged antibiotic use, and the other showed no difference between less than 24 hours and greater than 24 hours, but showed a reduction in infections compared to no treatment. CONCLUSIONS: The literature contains conflicting data regarding the optimal duration for perioperative antibiotic prophylaxis following prosthetic breast reconstruction. The authors' opinion is that 24 hours of antibiotic prophylaxis is warranted. Further studies are needed. Patient-centered antibiotic prophylaxis based on a risk-assessment model may be a more effective alternative to the current indiscriminate model of surgical-site infection control.

Implementation and Analysis of a Lean Six Sigma Program in Microsurgery to Improve Operative Throughput in Perforator Flap Breast Reconstruction.

PURPOSE: Perforator flaps have become a preferred method of breast reconstruction but can consume considerable resources. We examined the impact of a Six Sigma program on microsurgical breast reconstruction at an academic medical center. METHODS: Using methods developed by Motorola and General Electric, we applied critical pathway planning, workflow analysis, lean manufacturing, continuous quality improvement, and defect reduction to microsurgical breast reconstruction. Primary goals were to decrease preoperative-to-cut time and total operative time, through reduced variability and improved efficiency. Secondary goals were to reduce length of stay, complications, and reoperation. The project was divided into 3 phases: (1) Pre-Six Sigma (24 months), (2) Six Sigma (10 months), (3) and Post-Six Sigma (24 months). These periods (baseline, intervention, control) were compared by Student t test and χ analysis. RESULTS: Over a 5-year period, 112 patients underwent 168 perforator flaps for breast reconstructions, by experienced microsurgeons. Total operative time decreased from 714 to 607 minutes (P < 0.01), across the study period, with the greatest drop occurring in unilateral cases, from 672 to 498 minutes (P < 0.01). Length of stay decreased from 6.3 to 5.2 days (P = 0.01). Overall complication rates (35.9% vs 30%, not significant) and take-back rates (20.5% vs 23.9%, not significant) remained similar over the 5-year period. Physician revenue/minute increased from US $6.28 to US $7.59, whereas hospital revenue/minute increased from US $21.84 to US $25.11. CONCLUSIONS: A Six Sigma program in microsurgical breast reconstruction was associated with better operational and financial outcomes. These incremental gains were maintained over the course of the study, suggesting that these benefits were due, in part, to process improvements. However, continued reductions in total operative time and length of stay, well after the intervention period, support the possibility that "learning curve" phenomenon may have contributed to the improvement in these outcomes.

Extra-large negative pressure wound therapy dressings for burns - Initial experience with technique, fluid management, and outcomes.

OBJECTIVE: The use of negative-pressure-wound-therapy (NPWT) is associated with improved outcomes in smaller burns. We report our experience using extra-large (XL) NPWT dressings to treat ≥15% total body surface area (TBSA) burned and describe our technique and early outcomes. We also provide NPWT exudate volume for predictive fluid resuscitation in these critically ill patients. METHODS: We retrospectively reviewed patients treated with XL-NPWT from 2012 to 2014. Following excision/grafting, graft and donor sites were sealed with a layered NPWT dressing. We documented wound size, dressing size, NPWT outputs, graft take, wound infections, and length of stay (LOS). Mean NPWT exudate volume per %TBSA per day was calculated. RESULTS: Twelve burn patients (mean TBSA burned 30%, range 15-60%) were treated with XL-NPWT (dressing TBSA burned and skin graft donor sites range 17-44%). Average graft take was 97%. No wound infections occurred. Two patients had burns ≥50% TBSA and their LOS was reduced compared to ABA averages. XL-NPWT outputs peaked at day 1 after grafting followed by a steady decline until dressings were removed. Average XL-NPWT dressing output during the first 5 days was 101±66mL/%BSA covered per day. 2 patients developed acute kidney injury. CONCLUSION: The use of XL-NPWT to treat extensive burns is feasible with attention to application technique. NPWT dressings appear to improve graft take, and to decrease risk of infection, LOS, and pain and anxiety associated with wound care. Measured fluid losses can improve patient care in future applications of NPWT to large burn wounds.

Status of Microsurgical Simulation Training in Plastic Surgery: A Survey of United States Program Directors.

PURPOSE: Various simulation models for microsurgery have been developed to overcome the limitations of Halstedian training on real patients. We wanted to assess the status of microsurgery simulation in plastic surgery residency programs in the United States. METHODS: Data were analyzed from responses to a survey sent to all plastic surgery program directors in the United States, asking for type of simulation, quality of facilities, utilization by trainees, evaluation of trainee sessions, and perception of the relevance of simulation. RESULTS: The survey response rate was 50%. Of all programs, 69% provide microsurgical simulation and 75% of these have a laboratory with microscope and 52% provide live animal models. Half share facilities with other departments. The quality of facilities is rated as good or great in 89%. Trainee utilization is once every 3 to 6 months in 82% of programs. Only in 11% is utilization monthly. Formal evaluation of simulation sessions is provided by 41% of programs. All program directors agree simulation is relevant to competence in microsurgery, 60% agree simulation should be mandatory, and 43% require trainees to complete a formal microsurgery course prior to live surgery. DISCUSSION: There seems to be consensus that microsurgical simulation improves competence, and the majority of program directors agree it should be mandatory. Developing and implementing standardized simulation modules and assessment tools for trainees across the nation as part of a comprehensive competency-based training program for microsurgery is an important patient safety initiative that should be considered. Organizing with other departments to share facilities may improve their quality and hence utilization.

Vascularized treatment options for reconstruction of the ascending mandible with introduction of the femoral medial epicondyle free flap.

Reconstruction of the ascending portion of the mandible, including the angle, ramus, and condyle, can be a challenging surgical problem. Many treatment options are available, but no single procedure has been able to restore long-term form and function in every case. Currently, autologous nonvascularized bone grafts are the most common treatment, with the costochondral graft as the historic leader. Nonvascularized grafts can often restore vertical height and normal function but may face the challenge of long-term durability secondary to bone resorption. Emerging techniques in microvascular surgery may offer an alternative approach with the benefits of resistance to resorption and infection by maintaining a viable blood supply to the graft. Vascularized grafts may thus be used to full advantage in cases where prior surgery, scarring, disrupted vasculature, or radiation damage may compromise the long-term surgical success of a nonvascularized graft. This article reviews the literature and summarizes key points regarding nonvascularized and vascularized treatment modalities for reconstruction of the ascending mandible. In addition, we present the use of the femoral medial epicondyle free flap based on the descending genicular vascular pedicle as a novel reconstruction of the ascending portion of the mandible with minimal donor-site morbidity. Knowledge of all available options will aid the surgeon in achieving the optimal reconstruction for their patient and improve long-term outcomes.

The oblique mastectomy incision: advantages and outcomes.

Mastectomy has traditionally been performed using a transverse elliptical incision. The disadvantages of this approach are a potentially visible scar medially and poor subincisional soft-tissue coverage of implants laterally. A more natural and aesthetic result is obtained with an oblique incision running parallel to the pectoralis major muscle fibers. This approach offers women more freedom of choice in clothing as well as the potential for complete subincisional muscle coverage in alloplastic breast reconstruction, in addition to other functional advantages.

Three-dimensional nipple-areola tattooing: a new technique with superior results.

Traditional coloring techniques for nipple-areola tattooing ignore the artistic principles of light and shadow to create depth on a two-dimensional surface. The method presented in this article is essentially the inverse of traditional technique and results in a more realistic and three-dimensional reconstruction that can appear better than surgical methods. The application of three-dimensional techniques or "realism" in tattoo artistry has significant potential to improve the aesthetic outcomes of reconstructive surgery.