Assisting in Microsurgery: Operative and Technical Considerations.

Microsurgery is technically challenging, typically requiring a primary surgeon and an assistant to complete several key operative steps. These may include manipulation of fine structures, such as nerves or vessels in preparation for anastomosis; stabilization of the structures; and needle driving. Even seemingly mundane tasks of suture cutting and knot tying require fine coordination between the primary surgeon and assistant in the microsurgical environment. Although prior literature discusses the implementation of microsurgical training centers at academic institutions and residency programs, there is a paucity of work describing the role of the assistant surgeon in a microsurgery operation. In this surgical technique article, the authors discuss the role of the assisting surgeon in microsurgery, with recommendations for trainees and attendings alike.

Novel Strategies for Evaluating and Improving Plastic Surgery Applicant Selection.

SUMMARY: Residency applicant evaluation and selection is a critical part of developing and maintaining a high-quality plastic surgery residency program. Currently, many programs rely on objective measures such as the United States Medical Licensing Exam scores, number of research publications, grade point average, Alpha Omega Alpha Honor Medical Society status, or a combination of these objective metrics. However, there is a growing body of literature suggesting that the current means of residency applicant evaluation and selection may not be the best predictive factors of future resident success. The aim of this study was to identify nontraditional means of evaluating plastic surgery residency candidates and discuss how these means have been implemented at the authors' institution. After reviewing industry hiring practices, the authors propose that standardized interviewing and personality testing can help evaluate some of the previously intangible parts of an applicant that may play a role in teamwork, commitment, and dedication to patient care.

Prepectoral implant reconstruction in the setting of post-mastectomy radiation.

Prepectoral breast reconstruction after mastectomy is a more commonly performed technique in recent years due to its numerous advantages over subpectoral breast reconstruction. This study reviews the current state of clinical outcomes for patients undergoing postmastectomy radiation therapy (PMRT) after prepectoral breast reconstruction. A comprehensive search of the literature was performed using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify all relevant studies. Outcome measures included demographics, mean follow-up, and complication measures. Three studies for a total of 175 breasts were identified. Average age was 49.3 years and BMI was 27.7 kg/m2. Mean follow up was 18.1 months. A total of 3 (1.7%) hematomas and 4 (2%) seromas were reported. Surgical site infection was the most common complication reported with an overall reported 32 breasts with infections (18%). A total of 9 (5.1%) cases of wound dehiscence were reported. Mastectomy flap necrosis was found in 10 (5.7%) breasts. A total of 22 (12.6%) tissue expanders or implants required explantation. The review of the literature suggests that prepectoral breast reconstruction with acellular dermal matrices in the setting of post mastectomy radiation therapy is a safe and successful surgical option resulting in excellent clinical outcomes. Furthermore, there may be a reduction of capsular contracture and implant migration in this setting, relative to traditional submuscular techniques with PMRT.

Complications after Perforated versus Nonperforated Acellular Dermal Matrix Use in Direct-to-Implant Breast Reconstruction: A Propensity Score Analysis.

Acellular dermal matrices (ADMs) were first incorporated into direct-to-implant (DTI) breast reconstruction by the senior author in 2001 and have since become foundational to implant-based reconstruction. ADM composition has evolved recently and now includes perforated types, which some speculate decrease the likelihood of seroma. The authors performed a retrospective review of perforated (P-ADM) and nonperforated (NP-ADM) ADM-assisted direct-to-implant breast reconstruction patients to evaluate differences in complication rates. METHODS: Retrospective review of direct-to-implant breast reconstruction patients operated on by a single surgeon (CAS) from 2011 to 2018 was conducted. Patient and operative characteristics, including ADM type, were recorded. A propensity score matching algorithm accounting for potentially confounding variables was developed, followed by univariate analysis to evaluate the association between ADM perforation and postoperative complications. RESULTS: The review began with 409 patients (761 breasts). Following exclusion of patients with missing demographic information, lack of ADM in their reconstruction, and follow-up times of less than 4 weeks, 364 patients (680 breasts) were included for analysis. A total of 530 (77.94%) and 150 (22.06%) breasts received NP-ADM and P-ADM, respectively. After propensity score matching, there were 294 breasts, composed of equal numbers of P-ADM and NP-ADM recipients. Univariate analysis showed no association between ADM type and any postoperative complication. CONCLUSIONS: The complication profile of direct-to-implant breast reconstruction appears to be unaffected by the use of P-ADM or NP-ADM. Current understanding of the association between ADM type and clinical outcomes would benefit from multi-institution, prospective, randomized trials.

Surgical delay of anterior chest wall prior to open coronary arterial bypass grafting surgery may decrease postoperative sternal complications.

Open coronary arterial bypass grafting (CABG) procedures are inherently risky in regards to the healing capacity of the subsequent sternal wound. Patients often have underlying risk factors for poor healing and the procedure itself often reduces vascularity to the anterior chest with internal mammary artery (IMA) dissection. Currently unrelated is the surgical delay procedure. It is a well-established technique for augmenting vascularity and ultimatelytissue survival. It involves partial disruption of the blood supply to a flap for a period of time prior to fully elevating the flap (usually between 3 and 21 days). Recently, endoscopic robotic IMA dissection has become possible as a part of totally endoscopic CABGs for left-sided vessel disease. We are proposing a new technique, using surgical delay for patients who require open sternotomies for CABGS to reduce the rate of postoperative sternal wound complications. To delay the CABG, the majority of a robotic internal IMA dissectionwould be performed prior to an open CABG via a midline sternotomy. We hypothesize that this may decrease sternal wound complication rates. Potential pitfalls include consequences of disrupting the normal anatomic location of the IMAs and causing inflammation before the open CABG. Animal models will be the next step, as they will evaluate the feasibility of the delay as well as help to determine the optimal timing for the procedure.

Autologous reconstruction following nipple sparing mastectomy: a comprehensive review of the current literature.

As surgical methods continue to evolve and patients become more educated consumers of their medical care, both oncologic breast surgeons and reconstructive plastic surgeons should understand the current options for surgical management of breast cancer. This review evaluates the current autologous breast reconstruction options following nipple sparing mastectomy (NSM). A comprehensive review of the current literature discussing autologous reconstruction after NSM was performed. Fat grafting alone has been used to reconstruct small to medium sized-breasts over multiple injection sessions. Goldilocks mastectomy-like reconstructions can be used for larger, more ptotic breasts. Pedicled latissimus dorsi (LD) flaps can be used, but usually need to be modified to ensure sufficient breast volume. While the lower abdominal tissue remains the most common donor site in free tissue transfer, other donor sites can be used if there is insufficient volume or inadequate perforators. Periareolar incisions are associated with the highest rates of overall complications and nipple areola complex necrosis. It has not been determined whether implant-based or autologous reconstructions have lower complication rates. Both prior radiation and large, ptotic breasts present unique challenges during reconstruction. Overall, there is a high rate of patient satisfaction with breast reconstruction following NSM. Autologous breast reconstruction after NSM is a safe method of breast cancer surgical management with aesthetically excellent results. Multiple techniques have been described along the reconstructive ladder. Special consideration should be given to choices of incision, previously irradiated breasts, and large, ptotic breasts.

Improved Techniques and Future Advances in Plastic Surgery in Global Health.

BACKGROUND: Plastic surgery has a long-standing history of being deeply interconnected with global health. This paper reviews the current state of global health as it relates to plastic surgery and makes forecasts for the future. METHODS: This study reviews the most current literature on global plastic surgery, as well as offers insights based on our 2 senior authors' experiences. For our literature search, the MEDLINE database was queried using relevant keywords through both PubMed and OVID user interfaces. FINDINGS: Early exposure to global plastic surgery often leads to a lifelong involvement. Formal integration of global surgery into residencies is becoming more common. Models of care for global plastic surgery range from small to large groups, spanning the full spectrum of reconstructive plastic surgery. The best of these groups have longitudinal relationships with their operative sites to allow for continuous care. Logistics and funding are crucial for successful care. Technological advances will make long-distance care more facile in the future. CONCLUSIONS: Global plastic surgery is rewarding to both patient and physician. Plastic surgery has been and will continue to be committed to providing high-quality global health care.

International Adoptees With Cleft Lip and/or Palate: Lessons Learned From a Growing Population.

BACKGROUND: International adoptees with cleft lip and palate (CLP) are a growing population in the United States. They represent a clinical challenge, presenting at various ages and stages of cleft repair. METHODS: A retrospective review of patients seen at the CLP Program at the Children's Hospital of Philadelphia (CHOP) between 1998 and 2012 with a history of international adoption was performed. Demographics, surgical histories, and long-term speech outcomes were reviewed. RESULTS: Seventy-four female and 77 male patients were evaluated. Patients were adopted at an average age of 2.3 years (range, 0.4-8.6 years); 80.8% (n = 122) of patients were adopted from China. The rate of international cleft adoption increased by approximately 1.5 patients per year (r = 0.7739, P < 0.001); 13.2% (n = 19) of all subjects with cleft palates had oronasal fistulas (ONFs) that required repair. The ONF rates for primary palatoplasties at CHOP were significantly lower compared to both preadoption repairs (P = 0.002) and postadoption repairs at outside hospitals (P = 0.01); 14.8% (n = 21) of all patients had secondary surgeries for velopharyngeal incompetence (VPI). Rates of secondary surgery for VPI were also significantly lower for primary palatoplasties at CHOP compared to both preadoption repairs (P = 0.0018) and postadoption repairs at outside hospitals (P = 0.0033). CONCLUSIONS: International adoptees with CLP are a growing population and are clinically challenging with high ONF rates and high secondary surgery rates for VPI. We recommend expedited repair of unoperated cleft palates in adoptees older than 18 months. Adopted patients with CLP should be rigorously evaluated for the need for speech therapy and secondary surgeries to correct for VPI.

A Comparative Cost Analysis of Cleft Lip Adhesion and Nasoalveolar Molding before Formal Cleft Lip Repair.

BACKGROUND: Patients with complete cleft lip and palate may benefit from cleft lip adhesion or nasoalveolar molding before formal cleft lip repair. The authors compared the relative costs to insurers of these two treatment modalities and the burden of care to families. METHODS: A retrospective analysis was performed of cleft lip and palate patients treated with nasoalveolar molding or cleft lip adhesion at The Children's Hospital of Philadelphia between January of 2007 and June of 2012. Demographic, appointment, and surgical data were reviewed; surgical, inpatient hospital, and orthodontic charges and costs were obtained. Multivariate linear regression and two-sample, two-tailed independent t tests were performed to compare cost and appointment data between groups. RESULTS: Forty-two cleft adhesion and 35 nasoalveolar molding patients met inclusion criteria. Mean costs for nasoalveolar molding were $3550.24 ± $667.27. Cleft adhesion costs, consisting of both hospital and surgical costs, were $9370.55 ± $1691.79. Analysis of log costs demonstrated a significant difference between the groups, with the mean total cost for nasoalveolar molding significantly lower than that for adhesion (p < 0.0001). Nasoalveolar molding patients had significantly more made, cancelled, no-show, and missed visits and a higher missed percentage than adhesion patients (p < 0.0001) for all except no-show appointments, (p = 0.0199), indicating a higher burden of care to families. CONCLUSIONS: Nasoalveolar molding may cost less before formal cleft lip repair treatment than cleft lip adhesion. Third-party payers who cover adhesion and not nasoalveolar molding may not be acting in their own best interest. Nasoalveolar molding places a higher burden of care on families, and this fact should be considered in planning treatment.

Chronic kidney disease (CKD) in disadvantaged populations.

Twelve March 2015 will mark the 10th anniversary of World Kidney Day (WKD), an initiative of the International Society of Nephrology and the International Federation of Kidney Foundations. Since its inception in 2006, WKD has become the most successful effort ever mounted to raise awareness among decision-makers and the general public about the importance of kidney disease. Each year WKD reminds us that kidney disease is common, harmful and treatable. The focus of WKD 2015 is on chronic kidney disease (CKD) in disadvantaged populations. This article reviews the key links between poverty and CKD and the consequent implications for the prevention of kidney disease and the care of kidney patients in these populations.

Long term speech outcomes following late cleft palate repair using the modified Furlow technique.

OBJECTIVES: Published reports and previous studies from our institution have reported worse overall speech results, including significantly higher rates of persistent articulation errors, in patients undergoing palatoplasty at age >18 months. This study further investigates the effects of late repair on long term speech outcomes. METHODS: A retrospective review was performed of non-syndromic patients undergoing primary palatoplasty at age >18 months between 1980 and 2006 at our institution. Longitudinal speech results were compared based on reason for late repair and age at repair. RESULTS: Forty-one patients were greater than 18 months of age at the time of palatoplasty, and 24 fit criteria for longitudinal data analysis. There was a statistically significant improvement in nasality scores at Time Point 1 for international adoptees compared to the non-adopted population (p=0.04). Patients with submucosal clefts were found to have significantly less severe nasal emission scores at Time Point 1 compared to those with overt clefts (p=0.04), but not at Time Point 2. There were no significant differences between scores if repair was performed between 18 and 36 months or >36 months, nor any difference in incidence of articulation errors between subgroups of patients with late repair at either Time Point. CONCLUSION: Our experience demonstrates that cleft palate repair after 18 months of age is associated with a significantly increased incidence of articulation errors associated with VPI, irrespective of reason for late repair, highlighting the persistence of learned compensatory behaviors in speech and the importance of proceeding with early repair.

The impact of a parent liaison at a major craniofacial center.

The psychosocial impact of craniofacial disfigurement affects both the developing child and his/her family. The Facial Reconstruction Center at the Children's Hospital of Philadelphia has employed a Parent Liaison (PL) to provide psychosocial support to families and has been an invaluable resource in this regard. We hypothesize that a PL impacts the overall outcome of the surgery by building trust between the parents and medical institution, and increasing satisfaction. An anonymous satisfaction survey was sent to families of craniofacial patients treated between January 1976 and June 2012. All patients who had undergone at least 1 craniofacial procedure had addresses on file and were included in this study. Statistical analyses were performed using the Mann-Whitney U test.During the study, 441 surveys were mailed to families meeting the inclusion criteria. A total of 151 families returned completed surveys (34.2%), and 121 surveys were included for analysis (27.4%). In rating overall satisfaction, families who met with the PL had statistically higher scores than those who had not (P = 0.0011). Parents who met with the PL preoperatively reported greater satisfaction in time spent answering questions (P = 0.0029) and the perception that questions were adequately answered (P = 0.0039). No statistical difference was observed in postoperative preparedness between families that did and did not meet the PL. The results demonstrate that the PL is beneficial in the education, experience, and satisfaction of families treated at a large Craniofacial Center. The PL complements the surgeon's treatment of the physical by adding psychosocial support.