Perception of Implants among Breast Reconstruction Patients in Montreal.

BACKGROUND: In light of the recent surge of media coverage and social media influence regarding breast implants, it is essential to understand patients' concerns and misconceptions so that we can better serve them. METHODS: The authors designed a survey study for assessing the awareness and perception of patients toward breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant illness (BII). In total, 130 patients presenting to the senior author's breast reconstruction clinic completed the survey. The survey assessed patients' knowledge on and their perception of BIA-ALCL and BII. RESULTS: "News article" and "Television" were most often selected as sources of information for BIA-ALCL (21% and 20%, respectively) and BII (20% and 25%, respectively). A total of 100 patients (77%) had previous knowledge of BIA-ALCL. Forty-seven percent (n = 47/100) responded that they were unsure of the fate of a person diagnosed with BIA-ALCL, and 25% (n = 25/100) were unaware of the association between BIA-ALCL and specific implant type. Patients who were unaware of BIA-ALCL prognosis reported being less likely to receive breast implants in the future (P = 0.012, χ2 = 19.48). Eighty-nine patients (68%) had previous knowledge of BII. A total of 60 symptoms were mentioned by patients, with "Fatigue" (12%, n = 26) being cited the most often. CONCLUSIONS: The present survey highlights the importance for plastic surgeons to frequently discuss these entities with their patients. This should be done despite the obscurity of BII, in an effort to offer the best available evidence to our patients.

Spontaneous Osteogenesis of a Traumatic Mandibular Defect in the Pediatric Population.

Spontaneous osteogenesis of traumatic mandibular defects in the pediatric population remains a relatively rare phenomenon with only 2 patients reported in the literature. In the adult population, a low threshold exists for bone graft placement in the presence of small mandibular gaps, with no role for spontaneous osteogenesis in significant mandibular defects. The approach to traumatic mandibular defects in the pediatric population is not clearly described in the literature and the risks and benefits associated with donor site morbidity of bone graft harvest must be tempered by the possibility for potential spontaneous osteogenesis. The present study reports 1 such patient in whom a significant mandibular defect healed by means of rigid fixation of the defect and spontaneous osteogenesis, with no functional or esthetic sequelae at long-term follow-up. A review of the pertinent literature was performed, and the authors' approach is discussed. The authors propose that traumatic mandibular defects of < 3 cm in patients under the age of 10 years should be considered for treatment with rigid internal fixation alone and spontaneous osteogenesis.

Preservation of lower extremity spare parts using the University of Wisconsin solution.

The management of a mangled limb is a challenging endeavor. With the advancement in microsurgery, spare parts surgery (fillet flaps) has gained recent interest. In the context of lower extremity amputation secondary to trauma, viable spare parts can provide stump soft tissue coverage, potentially preserving critical length and obviating above-knee amputations. Commonly, spare parts surgery is performed in the acute setting but tissue preservation is sometimes necessary. The authors report their experience preserving a fillet flap of a mangled lower extremity for 48 h using the University of Wisconsin solution. A sole fillet flap and a split-thickness skin graft were harvested and preserved from the amputated lower extremity (based on the posterior tibial artery and vein). Stump coverage was achieved by anastomosing the fillet flap to the proximal posterior tibial artery and vein. This solution has not been previously described for preservation of fillet flaps.

Vascularized Tissue Reconstruction in Previously Irradiated Sarcoma Defects.

INTRODUCTION: Radiation therapy (RT) is recommended for appropriately selected sarcoma patients to minimize the risk of local recurrence and to maximize outcomes of disease-free survival and function. The purpose of this study was to confirm the safety of vascularized tissue reconstruction in recently irradiated sarcoma defects. METHODS: A retrospective review of all patients treated by the senior author for sarcoma reconstruction from January 2005 to July 2017 was performed. Two independent reviewers collected data from both electronic and paper medical records. Patients were included if they underwent flap reconstruction (pedicled or free) following sarcoma resection. The safety of neoadjuvant RT was compared with a control group with no previous irradiation using χ(2) analysis. RESULTS: Fifty-seven patients were included in the study; 35 patients were included in the preoperative RT group, and 22 patients were included in the control group (no previous irradiation). There was no significant difference in wound complications between the 2 groups (infection, dehiscence, hematoma, and seroma). Microvascular complications (arterial thrombosis, venous thrombosis, partial/total flap loss) were also comparable in the free tissue transfer subgroup. CONCLUSIONS: The current study demonstrates the safety of both pedicled and free flap reconstruction in previously irradiated sarcoma defects. Judicious selection of reconstructive technique and recipient vessels is crucial in obtaining optimal outcomes given the devastating effects of RT on native tissues.

Surgical Fixation of Metacarpal Shaft Fractures Using Absorbable Implants: A Systematic Review of the Literature.

BACKGROUND: Despite the proven efficacy and advantages of absorbable implants, their use for metacarpal shaft fixation has been limited. This is likely due to the high reported complication rates in early studies with polyglycolic acid (PGA) implants, notably high rates of noninfectious inflammatory reaction (5%-25%), occurring up to 30 weeks after fixation. The objective of this study was to assess the clinical outcomes of newer absorbable plates and screws in the treatment of metacarpal shaft fractures. METHODS: The authors performed a systematic search of the PubMed, Ovid MEDLINE, and EMBASE databases dating from 1946 to 2017. Primary outcome measures were the development of noninfectious inflammatory reaction and implant failure. RESULTS: A total of 42 metacarpal shaft fractures in 35 patients were included. The average follow-up time was 20.4 months (n = 24; range: 3.6-61 months). Only 1 case (2.4%) of noninfectious inflammatory reaction was reported with polylactic acid (PLA) plates and PLA/PGA compounds. Noninfectious inflammatory reaction was observed in 4 out of the 9 patients (44.4%) with a trimethylene carbonate/PLA compound. Symptoms appeared after an average time of 15.8 months (range: 12-19 months) post-fixation. Painless prolonged inflammation that resolved spontaneously within 6 months was reported in 7.1% of cases (n = 3). Implant failure with loss of fracture reduction was reported in 9.5% of cases (n = 4). CONCLUSIONS: Newer absorbable materials appear to have significantly lower rates of noninfectious inflammatory reaction than previously reported. When compared with metallic fixation of the metacarpal shaft, absorbable fixation appears to have comparable complication rates and biomechanical properties.

A systematic review of the effectiveness and complications of fat grafting in the facial region.

INTRODUCTION: The objective of this study was to evaluate the safety and efficacy of fat grafting to the facial region for the reconstruction and aesthetic enhancement of facial contour. METHODS: A systematic literature review of the National Library of Medicine (PubMed), MEDLINE and Cochrane databases was performed. Studies involving the outcomes of autologous fat grafting to correct or enhance contour defects of the face were included. Extracted data included patient demographics, harvest and injection sites, graft harvesting and injection technique, mean injected volume, retained volume percentage and complications. RESULTS: Forty-three articles met the inclusion criteria, resulting in 4577 patients with various facial contour defects treated with autologous fat grafting. Injection sites were categorized by anatomic facial regions as upper (32.5%), middle (53%) and lower face (14.5%). The mean volume of injected fat was 16.9 ml. The mean weighted volume retention of non-enriched grafts was 41.63% at the time of follow up (mean 13.9 months). A total of 104 (2.27%) complications were reported including asymmetry (74), skin irregularities (14), prolonged edema (4), graft hypertrophy (4), fat necrosis (3), infection (2), erythema (1), telangiectasia (1), and activation of acne (1). CONCLUSION: The present study represents the first systematic review of fat grafting in the facial region, a widely-performed procedure within plastic surgery practice. Importantly, it presents pooled important data such as retained grafting volume and complication rates in this anatomical region, providing clinicians with more accurate information with which to guide their decision-making and patient education.

The Impact of Implant Location on Breast Cancer Characteristics in Previously Augmented Patients: A Systematic Literature Analysis.

BACKGROUND: There is a paucity of data comparing the oncologic properties of breast cancer among patients previously having undergone breast augmentation in either the subglandular or subpectoral planes. The objective of the present systematic review was to evaluate whether implant location influenced the characteristics of breast tumors in previously augmented women. METHODS: A systematic literature search was performed to identify relevant articles reporting tumor characteristics in augmented patients. The search included published articles in three electronic databases; Ovid MEDLINE, EMBASE, and PubMed. Comparative studies (subglandular vs. subpectoral) were included. RESULTS: Analysis of data pooled from the included studies showed that subglandular implants had a higher frequency of tumors between 2 to 5 cm (26.5% vs. 9.9%, P = 0.0130). Subglandular implants also had a higher frequency of stage 2 tumors (42.9% vs. 23.7%, P = 0.0308). There was no significant difference in lymphovascular invasion between the 2 groups. These results of this systematic review suggest that the prognosis of patients undergoing augmentation is unaffected by implant location (subpectoral vs. subglandular). CONCLUSIONS: With the absence of large randomized controlled trials, our study provides surgeons with an evidence-based reference to improve informed consent with regards to implant placement.

A Review of Objective Measurement of Flap Volume in Reconstructive Surgery.

BACKGROUND: The utility and efficacy of 3-dimensional representation have been proven in bony reconstruction; however, its role in soft-tissue reconstruction remains limited. There is currently no reliable gold standard to objectively measure flap volume. This systematic review aims to summarize the available techniques used to objectively measure flap volume in reconstructive surgery. METHODS: A systematic literature search was performed to identify all relevant articles describing objective techniques to quantify flap volume. The search included published articles in 3 electronic databases-Ovid MEDLINE, EMBASE, and PubMed. RESULTS: A total of 16 studies were included. Flap volume was calculated using the following techniques: magnetic resonance imaging, computed tomography, 3-dimensional imaging and modeling, material templates, ultrasound, and weighing scales. Techniques and results of the included studies are summarized. CONCLUSIONS: This systematic review provides a summary of various published techniques for objective pre- or intraoperative quantification of flap volume in reconstructive surgery. The preliminary results from this review are promising, and we believe that 3-dimensional representation and objective quantification is the future of reconstructive flap surgery. More studies are needed to study the clinical relevancy and impact of the various imaging modalities reviewed and to develop automated volumetric measurement technology with improved accuracy, efficacy, and reproducibility.

Resorbable Material for Pediatric Orbital Floor Reconstruction.

INTRODUCTION: The use of resorbable materials is becoming more popular for pediatric orbital floor reconstruction. The purpose of this systematic review is to evaluate the effectiveness and safety of the various materials used in pediatric orbital floor reconstruction. METHODS: A systematic literature search was performed to identify all relevant articles reporting complications following pediatric orbital floor reconstruction. The search included published articles in three electronic databases-Ovid MEDLINE, EMBASE, and PubMed starting from database establishment to July 2017. Primary endpoints were enophthalmos, diplopia, and infection. Resorbable material was compared to autologous grafts and nonresorbable material. RESULTS: A total of 14 studies containing 248 patients were included in this review. Fifty-four (21.8%) patients had reconstruction performed with autologous grafts, 72 (29.0%) patients with resorbable material, and 122 (49.2%) patients with nonresorbable material. Resorbable materials had the lowest rate of postoperative enophthalmos (3/52; 5.8%) and the highest rate of postoperative diplopia (19/72; 26.4%). In contrast, nonresorbable materials had the lowest rate of postoperative diplopia (5/122; 4.1%), the highest rate of postoperative enophthalmos (14/102; 13.7%). Autologous reconstruction was associated with an 11.1% (4/36) rate of postoperative enophthalmos and a 22.2% (12/54) rate of postoperative diplopia. Nine cases (8.8%) of postoperative infection were documented with nonresorbable materials. No cases of infection were reported with autologous grafts or resorbable materials. CONCLUSION: Newer resorbable implants are safe and have a similar complication profile as traditional autologous grafts in pediatric orbital floor reconstruction.

Orbital Subcutaneous Emphysema in a Child.

The authors present a rare case of nontraumatic medial orbital wall fracture in an 11-year-old girl. Fractures of the orbital wall secondary to nose blowing have not been previously described in the pediatric population. The patient reported a history of chronic forceful nose blowing, followed by periorbital swelling after an episode of vigorous nose blowing. Erroneous diagnoses of sinusitis and periorbital cellulitis lead to unnecessary antibiotic treatment. The authors hypothesize that repeated and aggressive nose blowing is analogous to stress fractures, leading to weakening and eventual fracture of the medial orbital wall.

Restoration of shoulder motion using single- versus dual-nerve repair in obstetrical brachial plexus injury.

OBJECTIVE The purpose of this study was to compare shoulder abduction and external rotation (ER) after single-nerve repair of the upper trunk alone versus dual-nerve repair of both the upper trunk and the suprascapular nerve. METHODS A retrospective chart review of a single surgeon's experience repairing obstetrical brachial plexus injuries between June 1995 and June 2015 was performed. Eight patients underwent repair of the upper trunk alone, and 10 patients underwent repair of the upper trunk and the suprascapular nerve. Shoulder abduction and ER ranges of motion (ROMs) (in degrees) were recorded preoperatively and postoperatively. Postoperative ROM and the difference in ROM gained after surgery were compared by independent t-test analysis. RESULTS The mean follow-up time was 161.4 weeks (range 62-514 weeks, SD 124.0 weeks). The mean patient age at the time of surgery was 31.3 weeks (range 19.9-47.0 weeks, SD 6.9 weeks). The mean postoperative shoulder abduction ROMs were 145.0° (range 85°-180°, SD 39.4°) after single-nerve repair and 134.0° (range 90°-180°, SD 30.3°) after dual-nerve repair (p = 0.51). The mean postoperative shoulder ER ROMs were 67.5° (range 10°-95°, SD 28.8°) after single-nerve repair and 72.0° (range 10°-95°, SD 31.3°) after dual-nerve repair (p = 0.76). CONCLUSIONS The authors found no difference in shoulder abduction and ER between patients who underwent single-nerve repair of the upper trunk alone and those who underwent dual-nerve repair of both the upper trunk and the suprascapular nerve.

Prompt Referral in the Nonoperative Treatment of Obstetrical Brachial Plexus Injuries.

BACKGROUND: Prompt physical and occupational therapy is crucial in managing nonsurgical candidates with obstetrical brachial plexus injuries (OBPI). The objective of our study was to identify newborns suffering from nonoperative OBPI in need of a "fast-track" evaluation by a multidisciplinary team. METHODS: This is a retrospective review of patients with OBPI from June 1995 to June 2015. All nonsurgical candidates (Narakas class 1) were included in the study. The Gilbert score and the Medical Research Council grading system were used to measure shoulder and elbow function, respectively. The relationship between shoulder and elbow functional outcomes and time delay to consultation was studied using analysis of variance and Welch's tests. Various subgroups were studied based on OBPI risk factors: maternal diabetes, birth weight >4 kg, use of forceps, asphyxia, multiple comorbidities, and Apgar score at 1 and 5 minutes. RESULTS: A total of 168 patients were included in this study. Mean follow-up time was 313.8 weeks (minimum: 52; maximum: 1072; SD: 228.1). A total of 19 patients had an Apgar scores <7 at 5 minutes. Time delay between birth and the first consult to our clinic had an impact on shoulder outcome in the subgroup of newborns with Apgar scores <7 at 5 minutes. CONCLUSIONS: The subgroup of newborns with an Apgar score <7 at 5 minutes shows improved long-term shoulder function when promptly examined by an OBPI clinic. We recommend a "fast-track" referral for this time-sensitive population.

Surgical team turnover and operative time: An evaluation of operating room efficiency during pulmonary resection.

OBJECTIVE: Health care resources are costly and should be used judiciously and efficiently. Predicting the duration of surgical procedures is key to optimizing operating room resources. Our objective was to identify factors influencing operative time, particularly surgical team turnover. METHODS: We performed a single-institution, retrospective review of lobectomy operations. Univariate and multivariate analyses were performed to evaluate the impact of different factors on surgical time (skin-to-skin) and total procedure time. Staff turnover within the nursing component of the surgical team was defined as the number of instances any nurse had to leave the operating room over the total number of nurses involved in the operation. RESULTS: A total of 235 lobectomies were performed by 5 surgeons, most commonly for lung cancer (95%). On multivariate analysis, percent forced expiratory volume in 1 second, surgical approach, and lesion size had a significant effect on surgical time. Nursing turnover was associated with a significant increase in surgical time (53.7 minutes; 95% confidence interval, 6.4-101; P = .026) and total procedure time (83.2 minutes; 95% confidence interval, 30.1-136.2; P = .002). CONCLUSIONS: Active management of surgical team turnover may be an opportunity to improve operating room efficiency when the surgical team is engaged in a major pulmonary resection.