Automatic Detection of Perilunate and Lunate Dislocations on Wrist Radiographs Using Deep Learning.

SUMMARY: Delayed or missed diagnosis of perilunate or lunate dislocations can lead to significant morbidity. Advances in computer vision provide an opportunity to improve diagnostic performance. In this study, a deep learning algorithm was utilized for detection of perilunate and lunate dislocations on lateral wrist radiographs. A total of 435 lateral wrist radiographs were labeled as normal or pathologic (perilunate or lunate dislocation). The lunate in each radiograph was segmented with a rectangular bounding box. Images were partitioned into training and test sets. Two neural networks, consisting of an object detector followed by an image classifier, were applied in series. First, the object detection module was used to localize the lunate. Next, the image classifier performed a binary classification for normal or pathologic. The accuracy, sensitivity, and specificity of the overall system were evaluated. A receiver operating characteristic (ROC) curve and the associated area under the curve (AUC) were used to demonstrate the overall performance of the computer vision algorithm. The lunate object detector was 97.0% accurate at identifying the lunate. Accuracy was 98.7% among the sub-group of normal wrist radiographs, and 91.3% among the sub-group of wrist radiographs with perilunate/lunate dislocations. The perilunate/lunate dislocation classifier had a sensitivity (recall) of 93.8%, specificity of 93.3%, and accuracy of 93.4%. The AUC was 0.986. We have developed a proof-of-concept computer vision system for diagnosis of perilunate/lunate dislocations on lateral wrist radiographs. This novel deep learning algorithm has potential to improve clinical sensitivity to ultimately prevent delayed or missed diagnosis of these injuries.

Impact of Adding Carpal Tunnel Release or Trigger Finger Release to Carpometacarpal Arthroplasty on Postoperative Complications.

BACKGROUND: This study assessed whether adding trigger finger or carpal tunnel release at the time of thumb carpometacarpal (CMC) arthroplasty would increase postoperative opioid use, readmissions, complications, or development of complex regional pain syndrome (CRPS). METHODS: Using the IBM MarketScan Research Databases from 2012 through 2016, the authors identified two CMC arthroplasty groups. The CMC-only group only had a CMC arthroplasty on the day of operation; the multiple-procedures group had a CMC arthroplasty and concurrent carpal tunnel or trigger finger release. Between the two groups, the authors compared persistent opioid use, 30-day readmissions, 30-day complications, and diagnosis of CRPS. RESULTS: The CMC-only group consisted of 18,010 patients; the multiple-procedures group consisted of 4064 patients. The patients in the multiple-procedures group received a CMC arthroplasty and a carpal tunnel release (74%), a trigger finger release (20%), or both (6%). CMC-only patients had lower rates of persistent opioid use compared with patients who underwent multiple procedures (16% versus 18%). Readmission rates were also lower for CMC-only patients (3% versus 4%). CMC-only patients had decreased odds of persistent opioid use (OR, 0.85; 95% CI, 0.75 to 0.97; P = 0.013) and readmissions (OR, 0.80; 95% CI, 0.67 to 0.96; P = 0.016). The most common reason for readmission was pain (16%). CONCLUSIONS: Adding another procedure to a CMC arthroplasty slightly increases the odds of adverse outcomes such as persistent opioid use and readmission. Patients and providers should weigh the efficiency of performing these procedures concurrently against the risk of performing multiple procedures at once. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Expansion of Reconstructive Surgical Capacity in Vietnam: Experience from the ReSurge Global Training Program.

BACKGROUND: Building local surgical capacity in low-income and middle-income countries is critical to addressing the unmet global surgical need. Visiting educator programs can be utilized to train local surgeons, but the quantitative impact on surgical capacity has not yet been fully described. The authors' objective was to evaluate the effectiveness of training utilizing a visiting educator program on local reconstructive surgical capacity in Vietnam. METHODS: A reconstructive surgery visiting educator program was implemented in Vietnam. Topics of training were based on needs defined by local surgeons, including those specializing in hand surgery, microsurgery, and craniofacial surgery. A retrospective analysis of annual case numbers corresponding to covered topics between the years 2014 and 2019 at each hospital was conducted to determine reconstructive surgical volume and procedures per surgeon over time. Direct costs, indirect costs, and value of volunteer services for each trip were calculated. RESULTS: Over the course of 5 years, 12 visiting educator trips were conducted across three hospitals in Vietnam. Local surgeons subsequently independently performed a total of 2018 operations corresponding to topics covered during visiting educator trips, or a mean of 136 operations annually per surgeon. Within several years, the hospitals experienced an 81.5 percent increase in surgical volume for these reconstructive clinical conditions, and annual case volume continues to increase over time. Total costs were $191,290, for a mean cost per trip of $15,941. CONCLUSIONS: Surgical capacity can be successfully expanded by utilizing targeted visiting educator trips to train local reconstructive surgeons. Local providers ultimately independently perform an increased volume of complex procedures and provide further training to others.

Economic Evaluation of a Global Reconstructive Surgery Visiting Educator Program.

Objective: The objective of this study was to quantify the cost-effectiveness and economic value of a reconstructive surgery visiting educator trip program in a resource-constrained setting. Background: Reconstructive surgical capacity remains inadequate in low- and middle-income countries, resulting in chronic disability and a significant economic toll. Education and training of the local surgical workforce to sustainably expand capacity have been increasingly encouraged, but economic analyses of these interventions are lacking. Methods: Data were analyzed from 12 visiting educator trips and independently-performed surgical procedures at 3 Vietnamese hospitals between 2014 and 2019. A cost-effectiveness analysis was performed using standardized methodology and thresholds to determine cost-effectiveness. Sensitivity analyses were performed with disability weights, discounting, and costs from different perspectives. Economic benefit was estimated using both the human capital method and the value of a statistical life method, and a benefit-cost ratio was computed. Results: In the base case analysis, the visiting educator program was very cost-effective at $581 per disability-adjusted life year (DALY) averted. Economic benefit was between $21·6 million and $29·3 million, corresponding to a 12- to 16-fold return on investment. Furthermore, when considering only costs to the organization, the cost decreased to $61 per DALY averted, with a 113- to 153-fold return on investment for the organization. Conclusions: Visiting educator programs, which build local reconstructive surgical capacity in limited-resource environments, can be very cost-effective with significant economic benefit and return on investment. These findings may help guide organizations, donors, and policymakers in resource allocation in global surgery.

Are we curing by cutting? A call for long-term follow up and outcomes research in global surgery interventions - perspective.

Success in global surgery interventions cannot be claimed until consistent long-term follow up is achieved and corresponding outcomes are studied. However, post-operative outcomes remain inconsistently collected and analyzed in the setting of global surgery, with current efforts largely focused on the delivery of surgical care. Barriers in low- and middle-income countries include patient cost and distance, low surgical workforce capacity, poor patient health literacy, lack of affordable technology availability, inconsistent documentation, and structural deficiencies. Here, we suggest that future work can be focused on (1) enhancing systems to facilitate long-term follow up and care, (2) expanding availability and adoption of electronic medical record systems, and (3) collaboration with local surgeons in the development of international cross-organizational registries and standardized quality measures. Long-term collaborations between local healthcare administrators and providers, policymakers, international bodies, nonprofit organizations, patients, and the private sector are necessary to build and sustain processes to achieve reliable long-term follow up and rigorous data collection, with the goal of ultimately ensuring better patient outcomes.

Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for Lymphedema Prevention after Axillary Lymph Node Dissection-A Single Institution Experience and Feasibility of Technique.

While surgical options exist to treat lymphedema after axillary lymph node dissection (ALND), the lymphatic microsurgical preventive healing approach (LYMPHA) has been introduced as a preventive measure performed during the primary surgery, thus avoiding the morbidity associated with lymphedema. Here, we highlight details of our operative technique and review postoperative outcomes. For our patients, limb measurements and body composition analyses were performed pre- and postoperatively. Intraoperatively, axillary reverse lymphatic mapping was performed with indocyanine green (ICG) and lymphazurin. SPY-PHI imaging was used to visualize the ICG uptake into axillary lymphatics. Cut lymphatics from excised nodes were preserved for lymphaticovenous anastomosis (LVA). At the completion of the microanastomosis, ICG was visualized draining from the lymphatic through the recipient vein. A retrospective review identified nineteen patients who underwent complete or partial mastectomy with ALND and subsequent LYMPHA over 19 months. The number of LVAs performed per patient ranged between 1-4 per axilla. The operating time ranged from 32-95 min. There were no surgical complications, and thus far one patient developed mild lymphedema with an average follow up of 10 months. At the clinic follow up, ICG and SPY angiography were used to confirm intact lymphatic conduits with an uptake of ICG across the axilla. This study supports LYMPHA as a feasible and effective method for lymphedema prevention.

Single-Unit technique for the use of acellular dermal matrix in immediate expander-based breast reconstruction.

BACKGROUND: The use of acellular dermal matrices (ADMs) in immediate two-stage prosthetic breast reconstruction following mastectomy is now a common practice. The procedure confers several compelling benefits, including coverage of the inferior pole, enhanced definition of the inframammary fold, and reduction of capsular contracture. However, operative techniques used to create the ADM inferolateral sling can be unwieldy in practice, typically involving the placement of the ADM followed by positioning and anchoring of the prosthetic expander. At best, this may be a relatively minor nuisance, but may potentially influence outcomes, including discrepancies in symmetry. METHODS: We present a novel modification that aims to streamline this procedure. Perforations are made through the allograft, through which the tissue expander tabs are brought through and sutured together ex vivo to allow the ADM and expander to be placed into the inframammary fold position as a single unit. A retrospective chart review was then performed of patients who underwent breast reconstruction utilizing this technique between July 2015 and December 2018. Outcomes including postsurgical complications such as infection, malposition, and reoperation were analyzed. RESULTS: Sixty-two patients met the inclusion criteria, corresponding to 108 breasts. The average follow-up was 18 months. The overall complication rate was 29.6% of breasts. The most commonly observed complications were mastectomy skin necrosis (9.3%) and major infection (8.3%). There was a 7.4% rate of malposition. CONCLUSIONS: This simple but effective modification in ADM technique is associated with a comparable complication rate and allows for greater ease and consistency in tissue expander placement.

Assessing the Accuracy of a 3-Dimensional Surface Imaging System in Breast Volume Estimation.

BACKGROUND: Preoperative prediction of breast volume can guide patient expectations and aid surgical planning in breast reconstruction. Here, we evaluate the accuracy of a portable surface imager (Crisalix S.A., Lausanne, Switzerland) in predicting breast volume compared with anthropomorphic estimates and intraoperative specimen weights. METHODS: Twenty-five patients (41 breasts) undergoing mastectomy were scanned preoperatively with the Crisalix surface imager, and 1 of 3 attending plastic surgeons provided an anthropomorphic volume estimate. Intraoperative mastectomy weights were used as the gold standard. Volume conversions were performed assuming a density of 0.958 g/cm. RESULTS: The Pearson correlation coefficient between imager estimates and intraoperative volumes was 0.812. The corresponding value for anthropomorphic estimates and intraoperative volumes was 0.848. The mean difference between imager and intraoperative volumes was -233.5 cm, whereas the mean difference between anthropomorphic estimates and intraoperative volumes was -102.7 cm. Stratifying by breast volume, both surface imager and anthropomorphic estimates closely matched intraoperative volumes for breast volumes 600 cm and less, but the 2 techniques tended to underestimate true volumes for breasts larger than 600 cm. Stratification by plastic surgeon providing the estimate and breast surgeon performing the mastectomy did not eliminate this underestimation at larger breast volumes. CONCLUSIONS: For breast volumes 600 cm and less, the accuracy of the Crisalix surface imager closely matches anthropomorphic estimates given by experienced plastic surgeons and true volumes as measured from intraoperative specimen weights. Surface imaging may potentially be useful as an adjunct in surgical planning and guiding patient expectations for patients with smaller breast sizes.

Pathway Analysis of Gene Expression in Murine Fetal and Adult Wounds.

Objective: In early gestation, fetal wounds heal without fibrosis in a process resembling regeneration. Elucidating this remarkable mechanism can result in tremendous benefits to prevent scarring. Fetal mouse cutaneous wounds before embryonic day (E)18 heal without scar. Herein, we analyze expression profiles of fetal and postnatal wounds utilizing updated gene annotations and pathway analysis to further delineate between repair and regeneration. Approach: Dorsal wounds from time-dated pregnant BALB/c mouse fetuses and adult mice at various time points were collected. Total RNA was isolated and microarray analysis was performed using chips with 42,000 genes. Significance analysis of microarrays was utilized to select genes with >2-fold expression differences with a false discovery rate of <2. Enrichment analysis was performed on significant genes to identify differentially expressed pathways. Results: Our analysis identified 471 differentially expressed genes in fetal versus adult wounds following injury. Utilizing enrichment analysis of significant genes, we identified the top 20 signaling pathways that were upregulated and downregulated at 1 and 12 h after injury. At 24 h after injury, we discovered 18 signaling pathways upregulated in adult wounds and 11 pathways upregulated in fetal wounds. Innovation: These novel target genes and pathways may reveal repair mechanisms of the early fetus that promote regeneration over fibrosis. Conclusion: Our microarray analysis recognizes hundreds of possible genes as candidates for regulators of scarless versus scarring wound repair. Enrichment analysis reveals 109 signaling pathways related to fetal scarless wound healing.

Comparison of Outcomes of Total Esophageal Reconstruction With Supercharged Jejunal Flap, Colonic Interposition, and Gastric Pull-up.

BACKGROUND: Esophageal reconstruction following esophagectomy is a complex operation with significant morbidity. Gastric pull-up (GPU) has historically been the first-line operation followed by the colonic interposition (CI) graft, but recently, the use of a pedicled, supercharged jejunal flap (SJF) has reemerged as an alternative. However, comprehensive reports on outcomes of SJFs remain limited, with exceedingly few direct comparisons of outcomes. METHODS: A retrospective chart review was completed for patients who underwent thoracic or total esophageal reconstruction between 2004 and 2014 at a single institution. A comparison of patient characteristics and outcomes was performed for 15 patients reconstructed with an SJF, 4 with CI, and 85 with GPU. RESULTS: Ten patients in the SJF group and 3 in the CI group underwent prior GPU with complications resulting in esophageal discontinuity. The CI group had significantly longer intensive care and overall hospital stays than either other group. Forty percent (SJF), 100% (CI), and 56% (GPU) experienced at least 1 complication during their postoperative hospitalization, most frequently bowel obstruction after SJF, anastomotic leak (CI), and pulmonary complications and arrhythmias (GPU). Rates of anastomotic leakage were 13% (GPU), 75% (CI), and 13% (SJF). Reoperation was required in 27% following SJF compared with 75% following CI and 19% following GPU. There was 1 CI graft failure and no SJF failures. CONCLUSIONS: The SJF is a reasonable first-line option for esophageal reconstruction, with comparable recovery, complication rate, and functional outcomes compared with the traditional GPU. When the stomach is unavailable, the SJF is superior to CI.

Pathway Analysis of Gene Expression of E14 Versus E18 Fetal Fibroblasts.

Objective: Fetuses early in gestation heal skin wounds without forming scars. The biological mechanisms behind this process are largely unknown. Fibroblasts, however, are cells known to be intimately involved in wound healing and scar formation. We examined fibroblasts in different stages of development to characterize differences in gene expression that may result in the switch from regenerative wound repair to repair with scarring. Approach: Fibroblasts were isolated and cultured from the back skin of BALB/c wild-type mouse fetuses at embryonic day (E)14 and E18 (n = 10). The fibroblast total RNA was extracted, and microarray analysis was conducted using chips containing 42,000 genes. Significance analysis of microarrays was performed to identify genes with greater than twofold expression difference and a false discovery rate of less than two. Identified genes subsequently underwent enrichment analysis to detect differentially expressed pathways. Results: Two hundred seventy-five genes were differentially expressed between E14 and E18 in fetal fibroblasts. Thirty genes were significantly downregulated and 245 genes were significantly upregulated at E18 compared with E14. Ingenuity pathway analysis identified the top 20 signaling pathways differentially activated in fetal fibroblasts between the E18 and E14 time points. Innovation: To our knowledge, this work represents the first instance where differentially expressed genes and signaling pathways between fetal fibroblasts at E14 and E18 have been studied. Conclusion: The genes and pathways identified here potentially underlie the mechanism behind the transition from fetal wound healing via regeneration to wound healing by repair, and may prove to be key targets for future therapeutics.

Noncoding RNAs in Wound Healing: A New and Vast Frontier.

Significance: Wound healing requires a highly orchestrated coordination of processes that are not yet fully understood. Therefore, available clinical therapies are thus far limited in their efficacy in preventing and treating both chronic wounds and scars. Current gene-based therapeutics is largely based on our understanding of the protein-coding genome and proteins involved in known wound healing pathways. Recent Advances: Noncoding RNAs such as microRNAs and long noncoding RNAs have recently been found to be significant modulators of gene expression in diverse cellular pathways. Research has now implicated noncoding RNAs in nearly every stage of the wound healing process, suggesting that they may serve as clinical therapeutic targets. Noncoding RNAs are critical regulators in processes such as angiogenesis and cutaneous cell migration and proliferation, including classically described biological pathways previously attributed to mostly protein constituents. Critical Issues: The complexity and diversity of the interactions of noncoding RNAs with their targets and other binding partners require thorough characterization and understanding of their functions before they may be altered to modulate human wound healing pathways. Future Directions: Research in the area of noncoding RNAs continues to rapidly expand our understanding of their potential roles in physiological and pathological wound healing. Coupled with improving technologies to enhance or suppress target noncoding RNA in vivo, these advances hold great promise in the development of new therapies for wound healing.

Ultrasound-assisted liposuction provides a source for functional adipose-derived stromal cells.

BACKGROUND AIMS: Regenerative medicine employs human mesenchymal stromal cells (MSCs) for their multi-lineage plasticity and their pro-regenerative cytokine secretome. Adipose-derived mesenchymal stromal cells (ASCs) are concentrated in fat tissue, and the ease of harvest via liposuction makes them a particularly interesting cell source. However, there are various liposuction methods, and few have been assessed regarding their impact on ASC functionality. Here we study the impact of the two most popular ultrasound-assisted liposuction (UAL) devices currently in clinical use, VASER (Solta Medical) and Lysonix 3000 (Mentor) on ASCs. METHODS: After lipoaspirate harvest and processing, we sorted for ASCs using fluorescent-assisted cell sorting based on an established surface marker profile (CD34+CD31-CD45-). ASC yield, viability, osteogenic and adipogenic differentiation capacity and in vivo regenerative performance were assessed. RESULTS: Both UAL samples demonstrated equivalent ASC yield and viability. VASER UAL ASCs showed higher osteogenic and adipogenic marker expression, but a comparable differentiation capacity was observed. Soft tissue healing and neovascularization were significantly enhanced via both UAL-derived ASCs in vivo, and there was no significant difference between the cell therapy groups. CONCLUSIONS: Taken together, our data suggest that UAL allows safe and efficient harvesting of the mesenchymal stromal cellular fraction of adipose tissue and that cells harvested via this approach are suitable for cell therapy and tissue engineering applications.

Validation of a Cognitive Task Simulation and Rehearsal Tool for Open Carpal Tunnel Release.

BACKGROUND: Carpal tunnel release is one of the most common surgical procedures performed by hand surgeons. The authors created a surgical simulation of open carpal tunnel release utilizing a mobile and rehearsal platform app. This study was performed in order to validate the simulator as an effective training platform for carpal tunnel release. METHODS: The simulator was evaluated using a number of metrics: construct validity (the ability to identify variability in skill levels), face validity (the perceived ability of the simulator to teach the intended material), content validity (that the simulator was an accurate representation of the intended operation), and acceptability validity (willingness of the desired user group to adopt this method of training). Novices and experts were recruited. Each group was tested, and all participants were assigned an objective score, which served as construct validation. A Likert-scale questionnaire was administered to gauge face, content, and acceptability validity. RESULTS: Twenty novices and 10 experts were recruited for this study. The objective performance scores from the expert group were significantly higher than those of the novice group, with surgeons scoring a median of 74% and medical students scoring a median of 45%. The questionnaire responses indicated face, content, and acceptability validation. CONCLUSIONS: This mobile-based surgical simulation platform provides step-by-step instruction for a variety of surgical procedures. The findings of this study help to demonstrate its utility as a learning tool, as we confirmed construct, face, content, and acceptability validity for carpal tunnel release. This easy-to-use educational tool may help bring surgical education to a new-and highly mobile-level.

Dynamic Rheology for the Prediction of Surgical Outcomes in Autologous Fat Grafting.

BACKGROUND: Because of the abundance and biocompatibility of fat, lipotransfer has become an attractive method for treating soft-tissue deficits. However, it is limited by unpredictable graft survival and retention. Currently, little is known about the viscoelastic properties of fat after various injection methods. Here, the authors assess the effects of cannula diameter, length, and shape on the viscoelastic properties, structure, and retention of fat. METHODS: Human lipoaspirate was harvested using suction-assisted liposuction and prepared for grafting. A syringe pump was used to inject fat at a controlled flow rate through cannulas of varying gauges, lengths, and shapes. Processed samples were tested in triplicate on an oscillatory rheometer to measure their viscoelastic properties. Fat grafts from each group were placed into the scalps of immunocompromised mice. After 8 weeks, graft retention was measured using micro-computed tomography and grafts were explanted for histologic analysis. RESULTS: Lipoaspirate injected through narrower, longer, and bent cannulas exhibited more shear thinning with diminished quality. The storage modulus (G') of fat processed with 18-gauge cannulas was significantly lower than when processed with 14-gauge or larger cannulas, which also corresponded with inferior in vivo histologic structure. Similarly, the longer cannula group had a significantly lower storage modulus than the shorter cannula, and was associated with decreased graft retention. CONCLUSIONS: Discrete modifications in the methods used for fat placement can have a significant impact on immediate graft integrity, and ultimately on graft survival and quality. Respecting these biomechanical influences during the placement phase of lipotransfer may allow surgeons to optimize outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Magnetic Nanoparticle-Based Upregulation of B-Cell Lymphoma 2 Enhances Bone Regeneration.

Clinical translation of cell-based strategies for tissue regeneration remains challenging because survival of implanted cells within hostile, hypoxic wound environments is uncertain. Overexpression of B-cell lymphoma 2 (Bcl-2) has been shown to inhibit apoptosis in implanted cells. The present study describes an "off the shelf" prefabricated scaffold integrated with magnetic nanoparticles (MNPs) used to upregulate Bcl-2 expression in implanted adipose-derived stromal cells for bone regeneration. Iron oxide cores were sequentially coated with branched polyethyleneimine, minicircle plasmid encoding green fluorescent protein and Bcl-2, and poly-ß-amino ester. Through in vitro assays, increased osteogenic potential and biological resilience were demonstrated in the magnetofected group over control and nucleofected groups. Similarly, our in vivo calvarial defect study showed that magnetofection had an efficiency rate of 30%, which in turn resulted in significantly more healing compared with control group and nucleofected group. Our novel, prefabricated MNP-integrated scaffold allows for in situ postimplant temporospatial control of cell transfection to augment bone regeneration. Stem Cells Translational Medicine 2017;6:151-160.

Hospital Transfer of Open Tibial Fractures Requiring Microsurgical Reconstruction Negatively Impacts Clinical Outcomes.

INTRODUCTION: Open tibial fractures are orthopedic emergencies that may present with severe soft tissue damage. Free tissue transfer is often required when local tissues are insufficient and patients may require hospital transfer to tertiary care centers for this purpose. Although the negative impact of inter-facility transfer has been well demonstrated in trauma patients, less is known regarding transfers for lower extremity injury patients. This study investigates differences in outcomes based on transfer status after open tibial fracture. METHODS: Thirty-four consecutive open tibial fractures requiring free tissue transfer over a 13-year period (2001-2014) were retrospectively reviewed. Patients transferred from outside facilities were compared to non-transferred patients in regards to demographics, injury, surgical characteristics, and outcomes (mean follow-up of 2.5 years). Student t tests and chi square analysis were used to compare means and proportions, respectively. RESULTS: One-half of patients were transferred from an outside hospital. Transferred and nontransferred patients were not significantly different in regard to age, sex, comorbidities, mechanism of injury, and Gustilo grade. There was no significant difference in the method of bony fixation or free flap used for soft tissue coverage. The time to wound vacuum-assisted closure placement was longer in transferred patients, though this difference was not found to be significant (2.4 vs 3.3 days, P = 0.55). Time to definitive bony fixation was delayed in the transfer group by 9 days (5.2 vs 14.1 days, P = 0.05) and to tissue coverage by 7 days (14.2 vs 20.9 days, P = 0.13). Rates of flap loss and amputation did not differ between the groups. However, transferred patients were more likely to develop osteomyelitis (risk ratio [RR], 3.0; P = 0.03), nonunion (RR, 5.0; P = 0.09), and require hardware removal (RR, 3.3; P = 0.01). CONCLUSIONS: Transferred and nontransferred patients were not significantly different in their demographics or presentation. However, an analysis of clinical outcomes showed that transfer was associated with increased rates of osteomyelitis, nonunion, and hardware removal. Although likely multifactorial, this study suggests that a delay to definitive fixation and soft tissue coverage contributes to the increased rate of complications and poorer prognosis.

Transversus Abdominis Plane Block and Free Flap Abdominal Tissue Breast Reconstruction: Is There a True Reduction in Postoperative Narcotic Use?

INTRODUCTION: The use of the transversus abdominis plane (TAP) block is increasing in abdominally based autologous tissue breast reconstruction as a method to provide postoperative donor site analgesia. The purpose of this study was to evaluate the efficacy of the TAP block in the immediate postoperative period. METHODS: A retrospective analysis of all patients who underwent autologous microsurgical breast reconstruction over a 2-year period (2013-2015) was conducted. Only patients with an abdominal donor site were included. Patients were grouped based on the presence or absence of TAP blocks. Primary endpoints included patient-reported pain score, daily and total narcotic use during the hospitalization, antiemetic use, as well as complications. RESULTS: We identified 40 patients that had undergone abdominal-based free flap breast reconstruction and TAP block catheter placement for postoperative analgesia that met inclusion criteria. This group was then compared with a matched cohort of 40 patients without TAP blocks. There were no complications associated with using the TAP catheters. There was no statistically significant difference in postoperative pain scores, daily or total narcotic use during the hospitalization, or antiemetic use between the 2 groups. Although not statistically significant, linear regression analysis identified trends of improved donor site analgesia in select groups, such as unilateral immediate reconstructions, body mass index greater than 30 kg/m, and those without abdominal mesh placed at the time of donor site closure in the TAP block group. CONCLUSIONS: Constant delivery of local anesthetic through the TAP block appears to be safe; however, it did not reduce narcotic requirements or postoperative pain scores in patients undergoing abdominal-based free flap breast reconstruction.

Suction assisted liposuction does not impair the regenerative potential of adipose derived stem cells.

BACKGROUND: Adipose-derived stem cells (ASCs) have been identified as a population of multipotent cells with promising applications in tissue engineering and regenerative medicine. ASCs are abundant in fat tissue, which can be safely harvested through the minimally invasive procedure of liposuction. However, there exist a variety of different harvesting methods, with unclear impact on ASC regenerative potential. The aim of this study was thus to compare the functionality of ASCs derived from the common technique of suction-assisted lipoaspiration (SAL) versus resection. METHODS: Human adipose tissue was obtained from paired abdominoplasty and SAL samples from three female donors, and was processed to isolate the stromal vascular fraction. Fluorescence-activated cell sorting was used to determine ASC yield, and cell viability was assayed. Adipogenic and osteogenic differentiation capacity were assessed in vitro using phenotypic staining and quantification of gene expression. Finally, ASCs were applied in an in vivo model of tissue repair to evaluate their regenerative potential. RESULTS: SAL specimens provided significantly fewer ASCs when compared to excised fat tissue, however, with equivalent viability. SAL-derived ASCs demonstrated greater expression of the adipogenic markers FABP-4 and LPL, although this did not result in a difference in adipogenic differentiation. There were no differences detected in osteogenic differentiation capacity as measured by alkaline phosphatase, mineralization or osteogenic gene expression. Both SAL- and resection-derived ASCs enhanced significantly cutaneous healing and vascularization in vivo, with no significant difference between the two groups. CONCLUSION: SAL provides viable ASCs with full capacity for multi-lineage differentiation and tissue regeneration, and is an effective method of obtaining ASCs for cell-based therapies.

Effects of A Novel Decision Aid for Breast Reconstruction: A Randomized Prospective Trial.

INTRODUCTION: The choice to undergo mastectomy and breast reconstruction is a highly personal decision with profound psychosocial effects, and ultimately, the decision between implant- and autologous tissue-based reconstruction should be made based on a combination of factual information and the patient's personal values and preferences. Unfortunately, patients undergoing breast reconstruction surgery may experience decision regret. Decision aids promote patient involvement in decision making by not only providing standard information about options, but also emphasizing comparative risks, benefits, and alternatives, and most importantly by providing clarification exercises regarding personal values to guide patients toward an individualized decision. METHODS: We developed a novel decision aid to provide decision support and structured guidance for prosthetic, autologous, and combined prosthetic-autologous breast reconstruction surgery. New breast reconstruction patients of one surgeon at our institution were randomized by week to either receive the decision aid or standard preconsultation material. Immediately preceding their new patient consultation clinic visit, patients were asked to complete the validated Decisional Conflict Scale and the BREAST-Q Preoperative survey. After 3 to 5 months following breast mound reconstruction, patients were asked to complete the Decision Regret Scale, BREAST-Q Postoperative survey, and the Hospital Anxiety and Depression Scale. RESULTS: Patients who received the decision aid demonstrated a trend toward decreased preoperative decisional conflict (mean of 13.3 ± 5.5, compared to 26.2 ± 4.2; n = 8 per group, P = 0.069), with similar preoperative BREAST-Q scores. Most patients desired to know "everything" regarding their reconstruction surgery (75%), and to be "very involved" in the decisions in their care (81%), with remaining patients wanting to know "as much as I need to be prepared" and to be "somewhat involved." Postoperatively, patients who received the decision aid demonstrated significantly less decision regret (P < 0.001), although there was no significant difference in anxiety, depression, or quality of life-related outcomes as measured by the BREAST-Q. CONCLUSIONS: The use of decision aids in breast reconstruction surgery may help decrease decisional conflict and regret through promoting improved information sharing and shared decision making, which are highly important in this particular setting, patient population, and in our move toward greater patient-centered care.