Pediatric Microsurgery and Free-Tissue Transfer.

Advancements in microsurgery, along with increased microsurgical experience in pediatric patients, have made free-tissue transfer a reliable modality for pediatric bone and soft tissue reconstruction today. Free-tissue transfer is most commonly used in children for the coverage of large or complex defects resulting from traumatic, oncologic, or congenital etiologies. While flap success and complication rates between pediatric and adult populations are similar, special considerations must be taken into account within the pediatric population. In this article, we will describe common indications, technical nuances, and clinical considerations for the management of the pediatric free-tissue transfer patient.

Current Surgical Outcomes of Nasal Tip Grafts in Rhinoplasty: A Systematic Review.

BACKGROUND: Refinement of the nasal tip plays an important role in rhinoplasty surgery outcomes and may be considered the most technically challenging aspect of the procedure. Numerous techniques have been described for nasal tip augmentation utilizing grafts. The aim of this study was to systematically review the existing literature on nasal tip grafts and appraise it critically. METHODS: A PubMed search was performed to identify journal articles related to nasal tip grafts from the past decade. A total of 44 studies met inclusion criteria. The Newcastle-Ottawa Quality Assessment Scale and Jadad scale were used to appraise 38 observational studies and six randomized trials, respectively, to determine the quality of the studies. RESULTS: Critical assessment revealed that the studies were highly variable in focus and encompassed autologous, homologous, and alloplastic grafts. The quality of the data included an average Newcastle-Ottawa Quality Assessment Scale score of 6.5 (out of 9) and Jadad score of 2.5 (out of 5). A majority of studies (86.4%) included objective outcomes using anthropometric measurements and a portion of studies (27.3%) also included patient-reported outcomes. CONCLUSIONS: The results of this systematic review suggest that more than one type of nasal tip graft may result in satisfactory outcomes. This review provides an expansive collection of studies on nasal tip grafts, which can serve as an invaluable tool for the plastic surgeon engaging in rhinoplasty.

Correlation between Relative Value Units and Operative Time for Flap-Based Reconstruction Procedures.

BACKGROUND: Procedures performed by plastic surgeons tend to generate lower work relative value units (RVUs) compared to other surgical specialties despite their major contributions to hospital revenue. The authors aimed to compare work RVUs allocated to all free flap and pedicled flap reconstruction procedures based on their associated median operative times and discuss implications of these compensation disparities. METHODS: A retrospective analysis of deidentified patient data from the American College of Surgeons National Surgical Quality Improvement Program was performed, and relevant CPT codes for flap-based reconstruction were identified from 2011 to 2018. RVU data were assessed using the 2020 National Physician Fee Schedule Relative Value File. The work RVU per unit time was calculated using the median operative time for each procedure. RESULTS: A total of 3991 procedures were included in analysis. With increased operative time and surgical complexity, work RVU per minute trended downward. Free-fascial flaps with microvascular anastomosis generated the highest work RVUs per minute among all free flaps (0.114 work RVU/minute). Free-muscle/myocutaneous flap reconstruction generated the least work RVUs per minute (0.0877 work RVU/minute) among all flap reconstruction procedures. CONCLUSIONS: Longer operative procedures for flap-based reconstruction were designated with higher work RVU. Surgeons were reimbursed less per operative unit time for these surgical procedures, however. Specifically, free flaps resulted in reduced compensation in work RVUs per minute compared to pedicled flaps, except in breast reconstruction. More challenging operations have surprisingly resulted in lower compensation, demonstrating the inequalities in reimbursement within and between surgical specialties. Plastic surgeons should be aware of these discrepancies to appropriately advocate for themselves.

Clavicular reconstruction utilizing free fibula flap with periosteal extension.

Clavicular reconstruction is typically managed conservatively. Despite demonstrating improving outcomes, including range of motion and pain, there are currently no published reports of acute reconstruction with vascularized free fibula flaps (VFFF) or vascularized periosteal extensions in adult patients with clavicular defects. VFFFs have been utilized to correct critical bony defects of the clavicle and chronic nonunions; however, descriptions following acute trauma are rare. Bony union enhancement with periosteal extension has been described in both pediatric and adult populations, but never in the case of clavicular reconstruction. Herein, we seek to fill this gap in the literature by describing the acute reconstruction of a 6.5 cm bony gap in a 29-year-old male following a gunshot wound to the chest, utilizing a 6.5 cm VFFF with periosteal extension, and inset to the internal mammary vessels. The postoperative course was uncomplicated, with bony consolidation noted by 10 weeks, and full, pain-free range of motion at 8 months, showing this technique may be a viable option following acute trauma.

Open Reduction Internal Fixation of Distal Radius Fractures: Retrospective Cohort Analysis of the Geriatric Population Using the NSQIP Database.

Background: Distal radius fractures (DRFs) are the most common upper extremity fractures with more than 600 000 cases per year in the United States and account for up to 18% of fractures in the geriatric population. The purpose of our study was to identify the influence of age on 30-day postoperative outcomes while adjusting for patient demographics and comorbidities. Methods: The National Surgery Quality Improvement Program database was queried for patients having undergone open reduction internal fixation (ORIF) of DRFs. Current Procedural Terminology codes 25607, 25608, and 25609 between the years 2007 and 2016 were collected and analyzed. Patients were divided into 2 groups: group 1, 18 to 64 years; and group 2, 65 years and older. Patient demographics; preoperative, perioperative, and postoperative variables; and complications were recorded and analyzed. Results: In all, 5894 patients were identified; group 1 consisted of 4056 patients aged <64 years, and group 2 consisted of 1838 patients aged 65 years and older. The total complication rate was 2.7% for all patients, 2.2% for group 1, and 3.4% for group 2. The most common complications included surgical site infection for group 1 and urinary tract infection for group 2. Univariate analysis demonstrated association between age ≥65 years and complication (hazard ratio, 1.55; 95% confidence interval, 1.12-2.14; P = .009). However, after controlling for statistically significant factors, age was not an independent predictor of complications (P = .685). Admission status, American Society of Anesthesiologists classification, operative time, renal failure, and bleeding disorders were independent predictors of 30-day complications across all patients. Conclusion: Our data suggest that patients aged 65 years and older without high-risk comorbidities should be offered ORIF of DRFs as their complication risk remains low.

Updates in Diabetic Wound Healing, Inflammation, and Scarring.

Diabetic patients can sustain wounds either as a sequelae of their disease process or postoperatively. Wound healing is a complex process that proceeds through phases of inflammation, proliferation, and remodeling. Diabetes results in several pathological changes that impair almost all of these healing processes. Diabetic wounds are often characterized by excessive inflammation and reduced angiogenesis. Due to these changes, diabetic patients are at a higher risk for postoperative wound healing complications. There is significant evidence in the literature that diabetic patients are at a higher risk for increased wound infections, wound dehiscence, and pathological scarring. Factors such as nutritional status and glycemic control also significantly influence diabetic wound outcomes. There are a variety of treatments available for addressing diabetic wounds.

Revisional Techniques for Secondary Cleft Lip Deformities.

Secondary deformities of repaired cleft lips are an unfortunate complication despite the meticulous approach of modern primary procedures. Most of these surgeries take place in the patient's early life and must be strategically planned to provide optimal cosmesis with minimal interventions. Depending on the level of severity, treatment of the secondary deformities ranges from noninvasive or minimally invasive techniques to complete revision cheiloplasty. Many novel topical, injectable, and laser therapies have allotted physicians more technical flexibility in treating superficial distortions. Nonetheless, surgical techniques such as diamond excision and adjacent tissue transfer remain popular and useful reconstructive modalities. Deformities involving the orbicularis oris must be completely taken down to allow full access to the muscle. Complete revision cheiloplasty requires recreation of the cleft defect and reconstruction similar to the primary repair. Due to the myriad of presentations of these secondary deformities, familiarity with the various treatments available is imperative for any cleft surgeon.

Scar Revisions.

Scars pose a complex challenge to the reconstructive surgeon in the variability of their presentation and their effect on cosmesis and function. Numerous surgical and nonsurgical options exist for scar management, each with their respective advantages and disadvantages. Each treatment modality should be tailored to the patient to ensure enhanced outcomes. In this review, we discuss different scar presentations, scar management options, and the benefits and risks with undergoing these various treatment modalities.

Vascularized Bone Grafts in Spinal Reconstruction: An Overview of Nomenclature and Indications.

Several vascularized bone grafts (VBGs) have been introduced for reconstruction and augmenting fusion of the spine. The expanding use of VBGs in the field of spinoplastic reconstruction, however, has highlighted the need to clarify the nomenclature for bony reconstruction as well as establish the position of VBGs on the bony reconstructive algorithm. In the current literature, the terms "flap" and "graft" are often applied inconsistently when describing vascularized bone transfer. Such inconsistency creates barriers in communication between physicians, confusion in interpreting the existing studies, and difficulty in comparing surgical techniques. VBGs are defined as bone segments transferred on their corresponding muscular attachments without a named major feeding vessel. The bone is directly vascularized by the muscle attachments and unnamed periosteal feeding vessels. VBGs are best positioned as a separate entity in the bony reconstruction algorithm between nonvascularized bone grafts (N-VBGs) and bone flaps. VBGs offer numerous advantages as they supply fully vascularized bone to the recipient site without the microsurgical techniques or pedicle dissection required for raising bone flaps. Multiple VBGs have been introduced in recent years to optimize these benefits for spinoplastic reconstruction.

High Mitotic Rate Predicts Sentinel Lymph Node Involvement in Thin Melanomas.

BACKGROUND: Indications for sentinel lymph node (SLN) biopsy in the population with thin melanoma have frequently changed over time. The objective of our study was to evaluate T1 melanoma pathologic features predictive of SLN positivity with a primary focus on identifying a specific mitotic value that is most predictive of lymph node disease. Further detailed predictive features would help physicians select patients with thin melanoma for SLN biopsy. METHODS: The Surveillance, Epidemiology, and End Results database was queried for all patients diagnosed with trunk or extremity cutaneous melanoma with ≤1 mm depth who underwent SLN biopsy between the years of 2010 and 2013. Patient demographics and tumor characteristics including depth, mitotic rate (MR), ulceration, and tumor location were evaluated. MR was dichotomized at multiple cut points to identify the ideal number of mitosis for MR as a predictor of SLN status. Multivariable logistic regression analyses were performed to identify the factors affecting nodal positivity and the impact of MR threshold. Kaplan-Meir curves were used for overall survival (OS) analysis. RESULTS: Factors significantly associated with SLN positivity in the entire cohort included MR (P < 0.001, OR 1.24, 95% CI 1.18-1.31), tumor location (P = 0.017, OR 1.48, 95% CI 1.07-2.05), and ulceration (P < 0.001, OR 2.01, 95% CI 1.39-2.93,). An MR ≥ 4 was significant for SLN positivity (P = 0.049, OR 1.08, 95% CI 1.01-1.38). Mean OS was 46.7 mo for MR < 4 compared with 43.2 mo for MR ≥ 4 (P < 0.001). CONCLUSIONS: MR ≥ 4 was significant and associated with SLN positivity in thin melanomas and asulceration. Thus, MR ≥ 4 should be considered as an indication for SLN biopsy in thin melanoma.

Remote Injuries and Outcomes After Distal Radius Fracture Management.

BACKGROUND: Distal radius fracture (DRF) is a common fracture of the upper extremity. The role of concurrent injuries in patients treated for DRFs is poorly elucidated. The authors sought to determine whether remote injuries were associated with worse outcomes after management of DRFs. METHODS: A retrospective cohort study including all consecutively seen patients by a university hospital hand service between 2010 and 2015. Preoperative radiographs were analyzed, and patients were managed by surgeon preference and evaluated postoperatively using pain scores. Remote injury was defined as any other injury sustained at the time of fracture not localized to affected extremity. Univariate analysis was performed to identify factors associated with risk of complication. A multivariate logistic regression analysis was performed, controlling for confounding factors. RESULTS: A total of 181 DRFs in 176 patients were treated over the 5-year period of the study. Forty-eight (26.5%) of the fractures were managed nonoperatively with casting, 12 (6.6%) with closed reduction and pinning, and 119 (65.7%) with open reduction and plating. The mean follow-up was 5.2 months. The complication rate was 18.2%. The most common complication was persistent pain in 5 patients, followed by median neuropathy, loss of reduction, arthritis, and distal radioulnar joint instability. After controlling for age, body mass index, hand surgeon, and other confounders, remote injury was associated with a significantly increased risk of complications ( P = .04, odds ratio: 6.03, 95% confidence interval: 1.05-34.70). CONCLUSIONS: Patients with remote injuries have a 6-fold increased risk of complications after DRF treatment. The additional risk in these patients should be considered during patient/family counseling and clinical decision-making in DRF management.