Superiorly Based Posterior Pharyngeal Flaps: Using A Care Pathway to Optimize Speech and Airway Outcomes.

BACKGROUND: Pharyngeal flap (PF) surgery is effective at improving velopharyngeal sufficiency, but historical literature shows a concerning prevalence rate of obstructive sleep apnea (OSA), reported as high as 20%. Our institution has developed a protocol to minimize risk of postoperative obstructive complications and increase safety of PF surgery. We hypothesize that (1) preoperative staged removal of significant adenotonsillar tissue along with (2) multiview videofluoroscopy to guide patient-specific surgical approach via appropriately sized PFs can result in excellent speech outcomes while limiting occurrence of OSA. METHODS: This was a retrospective chart review of all patients with velopharyngeal insufficiency (VPI) (aged 2-20 years) seen at the University of Rochester from 2015 to 2022 undergoing PF surgery to correct VPI. Nasopharyngoscopy was used for surgical planning and airway evaluation. Patients with tonsillar and adenoid hypertrophy underwent staged adenotonsillectomy at least 2 months before PF. Multiview videofluoroscopy was used to identify anatomic causes of VPI and to determine PF width. Patients underwent polysomnography and speech evaluation before and at least 6 months after PF surgery. RESULTS: Forty-one children aged 8.5 ± 4.1 years (range, 4 to 18 years) who underwent posterior PF surgery for VPI were identified. This included 10 patients with 22q11.2 deletion and 4 patients with Pierre Robin sequence. Thirty-nine patients had both pre- and postoperative speech data and underwent both a pre- and postoperative sleep study. Polysomnography showed no significant difference in obstructive apnea-hypopnea index after posterior PF surgery (obstructive apnea-hypopnea index preop, 1.3 ± 1.2 events per hour; postop, 1.7 ± 2.1 events per hour; P = 0.111). Significant improvements in speech outcome were seen in patients who underwent PF (modified Pittsburgh score preop, 11.52 ± 1.37; postop, 1.09 ± 2.35; P < 0.05). CONCLUSIONS: Use of preoperative staged adenotonsillectomy as well as patient-specific PF dimensions results in effective resolution of VPI and a low risk of OSA.

Hernia Recurrence and Complications After Abdominal Reconstruction With Reinforced Versus Nonreinforced Biologic Mesh.

INTRODUCTION: Both biologic and permanent (synthetic) meshes are used for abdominal wall reconstruction. Biologic mesh has the advantage of eventual incorporation, which makes it generally preferred in contaminated patients compared with synthetic mesh (Ann Surg. 2013;257:991-996). However, synthetic mesh has been shown to have decreased long-term hernia recurrence despite increased complications (JAMA Surg. 2022;157:293-301). Ovitex (TelaBio, Ltd, Auckland, New Zealand) is a combined reinforced biologic mesh with a permanent Prolene suture weave that theoretically combines incorporation with a long-term strength component. We hypothesize that a reinforced biologic will have a similar complication profile but decreased long-term hernia recurrence. METHODS: A single-center retrospective review was performed from January 2013 to January 2022. Baseline patient characteristics and outcomes including 90-day complications and recurrence were compared. Categorical and continuous variables were analyzed with χ2 and Wilcoxon rank sum tests, respectively. Predictors of postoperative complications and hernia recurrence were analyzed via univariate logistic regression and multivariate logistic regression with backward stepwise selection with a threshold of P < 0.2. RESULTS: Two hundred fifty-four patients underwent abdominal wall reconstruction biologic mesh (Strattice, Allergan; FlexHD, MTF Biologics; Alloderm, Allergan; Surgisis Gold, Cook Biotech; Ovitex, Telabio) with retrorectus (66.5%) or intraperitoneal (33.5%) mesh placement. Sixty-six of these used reinforced biologic mesh (Ovitex, TelaBio). Baseline characteristics were comparable including preoperative hernia size measured on CT. The mean follow-up time was 343 days. The majority of patients underwent component separation (80.3% bilateral, 11.4% unilateral, 8.3% none). On univariate analysis, reinforced biologic mesh did not impact 90-day complication rates (P = 0.391) or hernia recurrence rates (P = 0.349). On multivariate analysis, reinforced mesh had no impact on complication or recurrence rates (P > 0.2). A previous history of infected mesh was an independent risk factor for hernia recurrence (P = 0.019). Nonreinforced biologics were more likely to be used in instances of previous mesh infection (P = 0.025), bowel resection (P = 0.026), and concomitantly at the time of stoma takedown (P = 0.04). Reinforced biologics were more likely to be used with a history of previous hernia repair with recurrence not due to infection (P = 0.001). Body mass index >35 was an independent risk factor across both groups for 90-day complications (P = 0.028). CONCLUSIONS: Reinforced versus nonreinforced biologics have similar risk profile and recurrence rate when placed primary fascial repair achieved. In abdominal walls with history of infection, or abdominal wall reconstruction performed concomitantly at the time of stoma takedown or bowel resection/anastomosis, nonreinforced biologics were used more commonly with no difference in negative outcomes. This implies that they may have a role for use in contaminated surgical cases. Reinforced biologics were more commonly used as a mesh choice in the setting of previous hernia repair with recurrence with no difference in outcomes. This implies that the reinforced nature may be useful in situations where extra reinforcement of already traumatized abdominal wall tissue is needed. Retrorectus or intraperitoneal placement of any biologic mesh is acceptable and should be chosen based off surgeon comfort and anticipated cost saving of individual mesh brands. There may be a role for reinforced mesh in the setting of previous failed hernia repair with weakened fascia, as well as nonreinforced in contaminated cases.

Plastic Surgery Involvement With Surgical Management of Infected Ventricular Assist Devices Decreased Lifetime Return to Operating Room and 90-Day Infectious Complications.

BACKGROUND: The use of left ventricular assist devices (LVADs) for patients with end-stage cardiac failure awaiting heart transplantation has become increasingly common. However, ventricular assist device-related infections remain a major problem complicating their long-term use. Retrospective review has previously shown a decrease in lifetime return to operating room (RTOR) with no change in 90-day complications when a muscle or omental flap is used for coverage after washout for infection. We wished to determine if early plastic surgery intervention led to a decreased length of stay for these patients. METHODS: Patients with LVAD readmitted for LVAD infection at a single institution from 2008 to 2021 were identified using a preexisting database. Patients were followed retrospectively for an average of 3.2 years. Patient demographics, preoperative diagnosis/disease state, type of ventricular assist device inserted, postoperative day of ventricular assist device infection onset, definitive device coverage, timing of coverage procedure after the initial washout for infection, type of flap used for coverage, 90-day complications after definitive coverage, and lifetime return to operating room for infection were reviewed. Comparison analysis with χ2 and analysis of variance testing was used to analyze outcomes. RESULTS: Of 568 patients admitted with an LVAD infection, 104 underwent operative debridement and closure by plastic and reconstructive surgery (PRS) or cardiothoracic surgery (CTS). Fifty-three underwent PRS closure, and 51 underwent CTS closure. There was an increased incidence of diabetes among the PRS group (P < 0.001); otherwise, there was no difference in baseline characteristics. There was increased RTOR over a lifetime with CTS closure compared with PRS (P = 0.03) and increased 90-day risk of infection (P = 0.007). Patients with PRS closure had an increased risk of postoperative hematoma (P = 046). Plastic and reconstructive surgery was typically consulted on hospital day 10. Both PRS and CTS closure patients were discharged on postoperative day 7, on average (P = 0.542). CONCLUSIONS: Plastic surgery involvement with surgical decision making and closure of infected LVAD devices has a decrease in lifetime RTOR and decreased 90-day complications related to infections. There may be a benefit to earlier PRS consultation for coverage assessment.

Comparing Graduating Plastic Surgery Residents' Case Logs With Accreditation Council for Graduate Medical Education Requirements, Content at National Meetings, and In-Service Examination Test Items.

BACKGROUND: The importance of adaptable and up-to-date plastic surgery graduate medical education (GME) has taken on new meaning amidst accelerating surgical innovation and increasing calls for competency-based training standards. We aimed to examine the extent to which the procedures plastic surgery residents perform, as represented in case log data, align with 2 core standardized components of plastic surgery GME: ACGME (Accreditation Council for Graduate Medical Education) minimum procedure count requirements and the PSITE (Plastic Surgery In-Service Training Examination). We also examined their alignment with procedural representation at 2 major plastic surgery meetings. METHODS: Nine categories of reconstructive and aesthetic procedures were identified. Three-year averages for the number of procedures completed in each category by residents graduating in 2019-2021 were calculated from ACGME national case log data reports. The ACGME procedure count minimum requirements were also ascertained. The titles and durations of medical programming sessions scheduled for Plastic Surgery The Meeting (PSTM) 2022 and the Plastic Surgery Research Council (PSRC) Annual Meeting 2022 were retrieved from online data. Finally, test items from the 2020 to 2022 administrations of the PSITE were retrieved. Conference sessions and test items were assigned to a single procedure category when possible. Percent differences were calculated for comparison. RESULTS: The distribution of procedures on plastic surgery resident case logs differs from those of the major mechanisms of standardization in plastic surgery GME, in-service examination content more so than ACGME requirements. Meeting content at PSTM and PSRC had the largest percent differences with case log data, with PSTM being skewed toward aesthetics and PSRC toward reconstructive head and neck surgery. DISCUSSION: The criteria and standards by which plastic surgery residents are evaluated and content at national meetings differ from the procedures they actually complete during their training. Although largely reflecting heterogeneity of the specialty, following these comparisons will likely prove useful in the continual evaluation of plastic surgery residency training, especially in the preparation of residents for the variety of training and practice settings they pursue.

Needles, Herbs and Electricity: A Meta-Analysis of Traditional Eastern Medicine in the Management of Facial Paralysis.

In Eastern nations, interventions like acupuncture and herbal medicine are often first-line for patients presenting with facial paralysis. Despite the rising popularity of Eastern medicine in Western nations, literature assessing whether Eastern medicine interventions should be recommended for patients with facial paralysis is lacking. This meta-analysis aims to define what Eastern medicine interventions exist for the management of facial paralysis and assess whether current research supports these approaches as safe and effective. The Pubmed and Cochrane databases were reviewed in accordance with PRISMA guidelines. Inclusion criteria consisted of peer-reviewed studies published between 2000 and 2023 that reported on Eastern medicine, i.e. "complementary" or "alternative" interventions for facial paralysis. Effective and cured rates were the primary outcomes extracted from the literature. Interventions within these studies were categorized into 6 groups: 1. Standard acupuncture, 2. Special needle therapies, 3. Needle therapy + other alternative treatments, 4. Herbal medicine, 5. Alternative treatments + Western medicine, and 6. Western medicine alone. A multiple treatment meta-analysis was performed to assess differences in effective and cured rates. Fifteen studies involving Eastern medicine for the treatment of facial paralysis met inclusion criteria. No significant differences were found in effective and cured rates across groups. Multiple quality concerns were noted, such as the lack of control groups, blinding, and randomization noted in several studies. Many studies failed to report complications, preventing conclusions from being drawn on the safety of these Eastern medicine interventions. This meta-analysis was unable to support the recommendation of Eastern medicine approaches for patients with facial paralysis. No Eastern medicine treatments, combination of Eastern medicine treatments, or Eastern medicine treatments given with Western medicine were seen to be more effective than Western medicine alone.

Racial, Ethnic, and Socioeconomic Disparities in Burn Care Access: A Single-Center Retrospective Study.

While racial, ethnic, and socioeconomic disparities in burn care have been identified in the literature, there is a paucity of research into specific underlying causes of these disparities. Here, we sought to characterize whether time to initial burn consult might contribute to racial, ethnic, and socioeconomic differences in burn care outcomes. We performed a retrospective review of all patients evaluated by the burn surgery service at a single regional ABA-verified burn center between June 2020 and April 2022. Patients without data for the time of onset of burn injury were excluded. Time to burn consult was defined as the time from onset of burn injury to the time of first burn consult. Three hundred and sixty-five patients met the inclusion criteria. Average age was 33.3 years, and 65.8% of patients were male. Average time to burn consult for all patients was 17 hours and 07 minutes. There were no significant differences in this variable among our cohort when stratified by race, ethnicity, or insurance status. Rates of surgical management (Chi-squared P = 0.05) and length of stay (ANOVA P < 0.0001) significantly differed by insurance status, but not among racial or ethnic groups. Medicare patients had the highest rates of surgical intervention and longer hospital stays; patients without insurance had the lowest rates of surgical intervention and shorter hospital stays. These results indicate that time from burn onset to burn consult is unlikely to contribute meaningfully to racial, ethnic, and socioeconomic disparities in burn care. Further studies are needed to better understand other aspects of burn care that may contribute to the noted disparities.

Simultaneous Furlow Palatoplasty and Tonsillectomy for the Treatment of Velopharyngeal Insufficiency and Tonsillar Hypertrophy.

OBJECTIVE: To determine whether performing tonsillectomy at the time of Furlow palatoplasty for the treatment of cleft palate related velopharyngeal insufficiency (VPI) incurs increased surgical complications or compromises speech outcomes. DESIGN: A retrospective review of patients who had Furlow palatoplasty and the outcomes of surgery in the treatment of cleft palate related VPI. SETTING: A single academic center between January 2015 and January 2022. PARTICIPANTS: Patients with submucous cleft (SMC) palate or patients with prior straight line primary palatoplasty presenting with VPI. INTERVENTIONS: Simultaneous conversion Furlow palatoplasty and tonsillectomy. MAIN OUTCOME MEASURE(S): Primary outcome measures include preoperative and postoperative Modified Pittsburgh Weighted Speech Scale (mPWSS), and postoperative surgical complications. RESULTS: Eight patients (25%) underwent Furlow palatoplasty and concomitant tonsillectomy, while 24 patients (75%) underwent Furlow palatoplasty alone. A significantly lower median postoperative mPWSS score, corresponding to better velopharyngeal function, was reported for patients in the Furlow-tonsillectomy group (0, IQR 0-0) compared to the Furlow only group (1, IQR 0-9, p = 0.046). No surgical complications were encountered in either group. Five patients (20.8%) in the Furlow only group required subsequent surgery for persistent VPI. No patients in the Furlow-tonsillectomy group required additional surgical treatment for VPI (0%, p = 0.16). CONCLUSIONS: Tonsillectomy at time of Furlow palatoplasty is utilized in patients with both VPI and baseline tonsillar hypertrophy to lessen the risk of postoperative obstructive breathing. Tonsillectomy performed concurrently with Furlow palatoplasty is safe, without increased risk of surgical complications, and does not compromise post-Furlow palatoplasty speech outcomes.

Flap Coverage of Infected Ventricular Assist Devices Influences Patient Outcomes.

BACKGROUND: The use of left ventricular assist devices (LVADs) for patients with end-stage cardiac failure awaiting heart transplantation has become increasingly common. However, ventricular assist device-related infections remain a major problem complicating their long-term use. Poor data exist to determine how to manage these infections after operative debridement. METHODS: Patients who underwent insertion of a ventricular assist device and had a subsequent readmission for LVAD infection at the University of Rochester Medical Center from 2012 to 2022 were identified through accessing the medical records archives of the hospital. Patients were followed retrospectively for an average of 3.2 years. Patient demographics, preoperative diagnosis/disease state, type of ventricular assist device inserted, postoperative day of ventricular assist device infection onset, infectious organism identified at initial washout, infectious organism identified at time of definitive device coverage, timing of coverage procedure after the initial washout for infection, type of flap used for coverage, 90-day complications after definitive coverage, and lifetime return to operating room for infection were reviewed. Comparison analysis with a χ 2 test was used to analyze outcomes. RESULTS: Of 568 patients admitted with an LVAD-related infection 117 underwent operative debridement. Of these, 34 underwent primary closure, 31 underwent closure with secondary intention (negative pressure wound therapy with split thickness skin grafting), and 52 were closed with a flap (pectoralis, omental, latissimus, or vertical rectus abdominus musculocutaneous flap). There was a statistically significant higher incidence of return to the operating room (RTOR) for infection over a lifetime with primary closure compared with secondary intention and flap reconstruction ( P = 0.01, 0.02), but no difference in 90-day complications ( P = 0.76, P = 0.58). Eighty-three patients had a positive culture upon definitive coverage with 24 having a postsurgical complication, 15 of which required lifetime RTOR for infection. Thirty four were closed with negative cultures with 9 having a complication and 4 requiring RTOR for infection. This was not statistically significant for complications or RTOR ( P = 0.79, 0.40). Culture data were further substratified into bacterial cultures (n = 73) versus fungal cultures (n = 10), and there was no statistically significant difference between these compared with complications or RTOR ( P = 0.40, 0.39). CONCLUSIONS: Coverage of infected LVADs with locoregional flaps or allowing to granulate using wound vac therapy has a decreased lifetime RTOR for future infections for these patients without increase in 90-day complications. Timing of RTOR should not be impacted by positive cultures provided there is healthy granulation tissue in the wound.

Subpectoral versus prepectoral two-stage breast reconstruction: A propensity score-matched analysis of 30-day morbidity and long-term outcomes.

BACKGROUND: Approximately 80% of patients undergoing total mastectomy in the US opt for implant-based breast reconstruction (IBBR). A two-stage reconstruction with tissue expander (TE) remains the most common technique. Since the implementation of ADMs, a prepectoral approach has gained popularity and is becoming the standard of care. Herein, we compared the surgical and postoperative outcomes of prepectoral versus subpectoral two-stage IBBR. METHODS: A retrospective chart review was performed between January 2011 and December 2020. We included female patients undergoing immediate two-stage IBBR. The primary outcomes of this study were to compare the 30-day morbidity and the overall rate of complications during the first and second stages of reconstruction, and to compare the time to initiate postmastectomy radiotherapy (PMRT). Propensity score matching was implemented. RESULTS: After matching, 154 reconstructions were analyzed, 77 in each group. The two matched groups exhibited comparable (p > 0.05) characteristics for all analyzed demographic and intraoperative independent variables. Reconstructions in the prepectoral group had a shortened median time for drain removal (13-days vs. 15-days, p = 0.001). The intraoperative expansion volumes were higher in the prepectoral group (300 ml versus 200 ml, p = 0.025). The 30-day morbidity and first- and second-stage complication rates were not significantly different between groups. The time to start postmastectomy radiation therapy (PMRT) was not significantly different between groups (134-days versus 126.5-days, p = 0.58). CONCLUSION: Prepectoral and subpectoral TE placement had comparable complication rates during the first and second stages of IBBR. Timing for TE-to-Implant exchange and initiation of PMRT were comparable between the two approaches.

Outcomes Following Use of Negative-Pressure Wound Therapy Over Autologous Meshed and Non-Meshed Skin Grafts.

Negative-pressure wound therapy (NPWT) over split thickness skin grafts can control exudate, decrease infection rates, and improve revascularization. However, no study specifically addresses differences in outcomes between meshed/perforated and non-meshed autologous skin grafts dressed with NPWT. Through retrospective chart review, patients undergoing autologous split thickness skin grafting with a NPWT dressing for any burn injury over a 10-month period were identified. Data on etiology, graft take, meshed/perforated or non-meshed graft, graft size, and seroma/hematoma incidence were collected. Our study included 123 patients who had STSG with NPWT and consisted of 57% males, 57% Caucasian, and an average age of 41. Burn injury etiologies consisted of scald (55%), chemical (25%), flame (15%), and contact (5%). Average 2nd degree TBSA in our cohort was 2.34%, 3rd degree TBSA 4.50%, and total TBSA 5.35%. 66.7% of patients received non-meshed grafts, and these patients had an average graft area of 76.5 cm2. 33.3% of patients received meshed grafts, with an average graft area of 163.5 cm2. Non-meshed burn grafts were significantly smaller than meshed grafts (P = .04). There was 100% graft take and 0% seroma/hematoma formation in all patients. Data was analyzed using an unpaired student's T test and ANOVA testing. There were no statistically significant differences in patient demographics, or burn etiology. There exist many options for dressings after repair of burn injuries, each with its own unique advantages. There were, however, no differences in graft take or incidence of seroma/hematoma formation using a NPWT dressing over autologous meshed grafts vs non-meshed grafts. Our data shows that NPWT use as a bolster dressing is safe and efficacious overlying meshed skin grafts and non-meshed grafts.

Calf augmentation and volumetric restoration: A systematic review and meta-analysis.

BACKGROUND: Because of the recent attention focused on the aesthetics of the leg, outcomes in the literature are under-reported and require further investigation. We summarized the available evidence on the surgical techniques to augment the volume and dimension of the calf based on clinical outcomes and satisfaction rates. METHODS: An electronic search was conducted across PubMed MEDLINE, Web of Science, Scopus, and Ovid MEDLINER(R) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Data collection included the patients' characteristics, surgical techniques, and postoperative outcomes. Pooled estimates were calculated with a random-effect meta-analysis using the DerSimonian-Laird model. RESULTS: This review included 48 articles reporting outcomes of 2455 patients. The average age and follow-up were 33.15 years and 33.58 months, respectively. The most common indications for calf augmentation were esthetic concerns (48.7%). Most patients underwent subfascial implant placement (70.2%) followed by fat transfer (17.6%), submuscular implant placement (10.1%). Overall, the pooled satisfaction rate following calf augmentation was 95.4% (95% CI: 93.7%-97%). The pooled satisfaction rate for implant placement and fat transfer was 96.7% (95% CI: 94.4%-97.9%) and 87.2% (95% CI: 78.5%-96%), respectively. The pooled incidence of implant removal was 1.3% (95% CI: 0.7%-2%). The pooled estimate for additional fat grafting procedures following initial fat transfer was 54.1% (95% CI: 38.3%-70%). CONCLUSIONS: While fat transfer has an exceptional safety profile, additional procedures to achieve satisfactory outcomes are usually necessary. Subfascial implant placement provides the best volumetric expansion with a lower implant removal rate and optimal safety profile.

Unique presentation of Merkel cell tumour affecting the hand.

Merkel cell carcinoma (MCC) is a rare and highly aggressive skin cancer which most commonly occurs on the head and neck. A limited number of cases of MCC of the hand have been reported in the English literature. We describe a case of MCC of the hand in a man in his late 60s. The lesion presented on the dorsum of the left fifth digit, with metastasis to the left axillary lymph nodes. The primary lesion grew rapidly over a span of 3 months. The patient was treated with two courses of neoadjuvant nivolumab, amputation of the digit and left axillary lymph node resection followed by radiotherapy to the left hand and left axilla. He continues to follow-up for radiotherapy treatment 3 months postoperatively.

The Biomechanical Properties of Meshed versus Perforated Acellular Dermal Matrices (ADMs).

Acellular dermal matrices (ADMs) are used for soft tissue augmentation across surgical specialties. Since allograft incorporation depends on direct opposition between the ADM and a vascular bed, seroma formation can be detrimental to incorporation. Since most ADM products are available in many meshed and perforated forms, there is a lack of consistency between manufacture designs. We set out to determine the fluid egress properties and increase in surface area resulting from common cut patterns. METHODS: Three ADM cut patterns were studied: 1 meshed and 2 perforated. We calculated the surface area of these modified ADM samples. Fluid was passed through each ADM, and time required for fluid passage was recorded. An ANOVA (P < 0.05) was used to determine if there was a significant difference in egress properties across the 3 patterns. RESULTS: Meshing in a 1:1 pattern resulted in a 97.50% increase in surface area compared with the uncut product. In comparison, only a 0.30% increase resulted from Perforation Pattern #1 and a 0.59% increase resulted from Perforation Pattern #2. There was a significant difference in egress properties across the three cut patterns (P = 0.000). The average egress time of Mesh Pattern #1 was 1.974 seconds. The average egress time of Perforation Pattern #2 was 6.504 seconds, and of Perforation Pattern #1 was 10.369 seconds. CONCLUSIONS: Quantitative comparison revealed that meshing ADM significantly improves fluid egress and increases the surface area. Therefore, the use of meshed ADM tissue could improve the incorporation of ADM with the recipient, with improved patient outcomes.