Panniculectomy Performed in Conjunction With Gynecologic Surgery in Obese and Morbidly Obese Patients: A National Surgical Quality Improvement Program Analysis and Systematic Review of the Literature.

INTRODUCTION: Panniculectomy is a common procedure in plastic surgery, often performed after massive weight loss and in morbidly obese patients. It is also performed in combination with various gynecologic procedures based on the rational that it will reduce complication rates and benefit the patient (Am J Obstet Gynecol, 2000. 182, 1502-1505; J Gynecol Technol, 1997;3:9-16; J Am Coll Surg, 1995). These and other studies fail to provide proof of these claims for a number of reasons, including study design, lack of a control group and the inclusion of nonmorbidly obese patients (J Am Coll Surg, 1995; Gynecol Oncol, 1998, 70, 80-86; Int J Gynecol Cancer, 2015;25(8):1503-1512). Recent medical practice has focused increasingly on minimizing patient morbidity and trends in reimbursement are moving toward penalizing practices, which increase complications. The aim of this study was to evaluate the premise that the addition of panniculectomy to gynecologic surgery in the obese and morbidly obese patient population results in a statistically significant improvement in measureable outcomes. METHODS/RESULTS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed to assess the association of complications with panniculectomy combined with gynecologic surgery in the morbidly obese patient population. The query identified 296 patients with a body mass index greater than 30 who had panniculectomy concomitant with gynecologic surgery. The results demonstrated a statistically significant relationship (P < 0.05) of these concomitant procedures with superficial infection, wound infection, pulmonary embolism, systemic sepsis, return to operating room, length of operation and length of stay. A systematic review of the literature was then performed which identified only 5 studies that included comparative cohorts of those with gynecologic surgery, with and without panniculectomy. There was no significant benefit across the studies in measured paramters. CONCLUSIONS: This NSQIP study and systematic review of the existing literature does not support the premise that there is a statistically significant benefit associated with performing panniculectomy in conjunction with gynecologic surgery in the morbidly obese patient population. The NSQIP data demonstrate significant elevation of negative outcomes in morbidly obese patients undergoing combined procedures. In the light of the risks to patients and current direction of medical practice the addition of elective panniculectomy to gynecologic surgery should be reevaluated in the a patient population with a body mass index greater than 30.

The effects of delta-9-tetrahydrocannabinol (THC) on inflammation: A review.

THC is the main psychoactive compound found in marijuana. A number of studies over the past few decades, both in vitro and in vivo, have demonstrated that THC down-regulates the inflammatory process through various mechanisms. Similar findings have been demonstrated with CBD, the other major bioactive component of marijuana. Given the essential role that inflammation plays in early wound healing, it is possible that marijuana, or its individual constituents, may impact this process. Herein, we review the existing literature related to the effects of THC on inflammation and potentially wound healing, and discuss how this connection may be relevant from a surgical perspective.

Guidelines for the Ethical Publication of Facial Photographs and Review of the Literature.

Facial photography presents a unique ethical dilemma, as faces are difficult to deidentify for publication. We performed a review of the literature to examine current guidelines for the publication of facial photographs. We also reviewed societies' websites, journal requirements, and ethical and legal aspects of confidentiality. Most articles emphasized the importance of consent for photography and publication. Masking is not appropriate, but some journals continue to allow masking. Most legislation allows patients to restrict the uses of photographs. In the end, it is imperative to protect patient privacy by obtaining consent for photograph publication after full disclosure of risks, and specific recommendations are provided regarding a comprehensive consent process.

Pyoderma Gangrenosum After Breast Surgery: Diagnostic Pearls and Treatment Recommendations Based on a Systematic Literature Review.

BACKGROUND: Pyoderma gangrenosum (PG) is a rare cutaneous disorder that poses a diagnostic challenge in the postoperative period. A systematic literature review was performed to determine distinguishing characteristics of PG in the setting of breast surgery that can facilitate timely diagnosis and appropriate treatment. METHODS: PubMed, EMBASE, Scopus, and Web of Science databases were systematically searched for articles with cases of PG occurring after breast surgery. Forty-three relevant articles, including 49 case reports, were identified. RESULTS: PG manifested bilaterally in 30 of 34 cases (88%) in which bilateral surgery was performed. Abdominal wounds were present in 6 of 7 cases in which an abdominal donor site was used for breast reconstruction. Nipples were spared from wound involvement in 33 of 37 cases (89%) in which nipples were present after surgery. Presence of fever was noted in 27 cases (55%) and leukocytosis in 21 cases (43%). A total of 33 patients (67%) underwent wound debridement. Successful medical treatment most commonly involved steroids (41 cases, 84%) and cyclosporine (10 cases, 20%). CONCLUSIONS: Pertinent clinical features were identified that may aid in timely diagnosis and treatment of PG after breast surgery. Appearance of discrete wounds involving multiple surgical sites that surround but spare the nipples should raise suspicion for PG rather than infection or ischemia, even with concomitant fever and leukocytosis. Wound debridement should be minimized and skin grafting considered only after medical therapy is initiated. Cognizance of these features may enable prompt therapeutic intervention that minimizes morbidity and improves outcomes.

Assessment of Nursing Deficiencies in the Postoperative Care of Microsurgical Patients.

Background Close monitoring is crucial following successful flap surgery. Ideally, all patients undergoing microvascular reconstruction should be evaluated in a dedicated unit with specialized nurses; however, this is not always possible and there is often a varied skill mix of nursing staff. The purpose of this study was to identify deficiencies in microsurgical education among nursing staff in an effort to target future educational efforts. Methods A 22-question electronic survey was sent out to all nursing staff at three sampled hospitals that manage microsurgical patients. Statistical analysis was performed to identify factors that predicted aptitude, comfort, and deficiencies in the treatment of microsurgical patients. Results Of the 160 registered nurses sampled, 106 completed the survey completely (66%). A total of 59 nurses worked at a tertiary care academic institution (55%) and the remaining 47 nurses worked at one of two community hospitals (45%).Regardless of whether the provider self-identified as a critical care or floor nurse, nurses from an academic medical center were significantly more comfortable with their ability to care for microsurgical patients when compared with their community medical center counterparts (p < 0.05). Furthermore, regardless of whether the provider self-identified as a critical care or the hospital setting where they worked, nurses with greater than 5 years of experience were significantly more comfortable with their ability to care for microsurgical patients when compared with nurses who had less than 5 years of experience (p < 0.05).There was no correlation with comfort level and the ability to interpret various postoperative flap-monitoring technologies between intensive care unit nurses and floor nurses. Conclusions We have identified that nurses with less than 5 years of experience or nurses in a community setting may be less comfortable with the care of postoperative microsurgical patients, especially if newer flap monitoring technologies are employed.

Effects of Neoadjuvant Chemotherapy on Autologous and Implant-Based Breast Reconstruction: A Systematic Review and Meta-Analysis of the Literature.

Neoadjuvant chemotherapy (NAC) is a standard modality of treatment for breast cancer. The exposure of patients to drugs that effect the cells and processes involved in healing prior to reconstructive surgical procedures is a source of concern for reconstructive surgeons. The reported effects of NAC on autologous and tissue expander to implant-based breast reconstruction vary from study to study and have not been comprehensively reviewed on a large scale. There is also significant variation from study to study regarding which outcomes are evaluated. The primary aim of this systematic review and meta-analysis is to evaluate the effect of neoadjuvant chemotherapy (NAC) on common and significant outcomes including total complication, reconstruction loss, and SSI (Surgical Site Infection) rates in breast reconstruction. The second aim of this study is to evaluate whether NAC has differing effects on implant-based reconstruction compared with autologous flap reconstruction. A systematic review of the literature published from 1991 to 2019 in the PubMed and Scopus library database was performed to identify studies reporting outcomes of breast reconstruction in patients receiving NAC. A meta-analysis was then performed. Primary outcomes reviewed included overall complication rates, SSI rates, and total loss of reconstruction (flap necrosis or premature tissue expander or implant removal). Outcomes were analyzed using a random effects model and chi-square statistical test. Our literature search yielded 22 manuscripts with a total of 3680 patients that fit our inclusion criteria, of which 12 reported on reconstruction loss, 14 reported on SSI rates, and 10 reported on overall complication rates. There was no significant difference in overall breast reconstruction loss rate (OR 1.30, P = .35), complication rate (OR 1.21, P = .06), and rate of SSI (OR 1.28, P = .85) between NAC vs. non-NAC groups. In patients undergoing autologous flap reconstruction there were no significant differences in complication (23.4% vs. 17.7%, P = 0.076), loss of reconstruction (3.1% vs. 4.4%, P = .393), or SSI (5.3% vs. 3.4%, P = .108) rates in patients who were treated with NAC compared to those who were not. Likewise, in patients undergoing TE/implant-based reconstruction there were no significant differences in complication (19.6 vs. 24.2 P = .069), loss of reconstruction (17.4% vs. 13.3%, P = .072), or SSI (7.9% vs. 5.1%, P = .073) rates in patients who were treated with NAC compared to those who were not. NAC was not associated with any significant differences in overall complication, reconstruction loss, or SSI rates in patients receiving implant-based or autologous flap breast reconstruction. Additionally, the lack of effect of NAC on overall complication, reconstruction loss or SSI rates did not differ with or depend on the type of reconstruction.

Educational and Clinical Outcome Measures in an Integrated Hand Service.

Background: We recently sought to integrate our orthopaedic and plastic hand surgeons with the goal of improving education, patient care, and providing seamless, continuous coverage for our trauma center. Our hypothesis was that integration could serve both the orthopaedic and plastic surgery training programs well and provide more consistent care for the trauma patients. Materials and Methods: Program director approval was granted for blinded analysis of case logs from plastic and orthopaedic surgery programs from 2012 through 2019. Data on mean and total number of hand cases were analyzed and compared for both specialties. Institutional Review Board approval was granted for a retrospective review of patient outcomes. Results: For both orthopaedic and plastics resident trainees, the mean number of hand cases increased during this study period suggesting that the integration had a favorable impact on both programs. The mean number of hand cases for orthopaedic residents rose from 163 to 246. The mean number of hand cases for plastic surgery residents rose from 218 to 295. Patient outcomes as reflected in length of stay and time to consultation also improved. Conclusion: To improve hand surgical training and patient care, an integrated orthoplastics approach to hand surgery was implemented at our institution. Plastic surgery trainees are completing more hand surgery cases in an integrated model (p < 0.001), including fracture care (p < 0.047). Orthopaedic surgery trainees have doubled the percentage of integumentary and microsurgery cases in the integrated model (p < 0.001). The educational and clinical changes affected in an integrated model have changed the paradigm for educating future hand surgeons at our institution.

Successful replantation of an amputated midfacial segment: technical details and lessons learned.

Successful microvascular replantation of amputated facial tissues has been sporadically reported in the literature, although most of these reports have concerned the reattachment of relatively small and segmental portions of the nose or nasal tip. We report the successful replantation of a traumatically amputated composite piece of tissue comprising the entire nose, most of the upper and lower lips, and the nasal boney and cartilaginous complex based on microvascular repair of the labial arteries and glabellar veins and discuss the results and implications of this experience.

Overcoming cross-gender differences and challenges in Le Fort-based, craniomaxillofacial transplantation with enhanced computer-assisted technology.

BACKGROUND: Sex-specific anthropometrics, skin texture/adnexae mismatch, and social apprehension have prevented cross-gender facial transplantation from evolving. However, the scarce donor pool and extreme waitlist times are currently suboptimal. Our objective was to (1) perform and assess cadaveric facial transplantation for each sex-mismatched scenario using virtual planning with cutting guide fabrication and (2) review the advantages/disadvantages of cross-gender facial transplantation. METHODS: Cross-gender facial transplantation feasibility was evaluated through 2 mock, double-jaw, Le Fort-based cadaveric allotransplants, including female donor-to-male recipient and male donor-to-female recipient. Hybrid facial-skeletal relationships were investigated using cephalometric measurements, including sellion-nasion-A point and sellion-nasion-B point angles, and lower-anterior-facial-height to total-anterior-facial-height ratio. Donor and recipient cutting guides were designed with virtual planning based on our team's experience in swine dissections and used to optimize the results. RESULTS: Skeletal proportions and facial-aesthetic harmony of the transplants (n = 2) were found to be equivalent to all reported experimental/clinical sex-matched cases by using custom guides and Mimics technology. Cephalometric measurements relative to Eastman Normal Values are shown. CONCLUSIONS: On the basis of our results, we believe that cross-gender facial transplantation can offer equivalent, anatomical skeletal outcomes to those of sex-matched pairs using preoperative planning and custom guides for execution. Lack of literature discussion of cross-gender facial transplantation highlights the general stigmata encompassing the subject. We hypothesize that concerns over sex-specific anthropometrics, skin texture/adnexae disparity, and increased immunological resistance have prevented full acceptance thus far. Advantages include an increased donor pool with expedited reconstruction, as well as size-matched donors.

Management of exposure of cardiac pacemaker systems.

The erosion and exposure of pacemakers are relatively uncommon occurrences but, given the number of these devices inserted yearly, they are nevertheless occurrences that plastic surgeons are likely to encounter in practice. Although there is a general agreement that clinically infected devices are best removed, it has been established that exposed but noninfected devices can usually be managed conservatively with coverage procedures. Reports in the literature, to date, describe a number of different procedures for coverage, and these reports generally comprise small numbers of patients. This study describes 16 patients referred to a single surgeon over a 14-year period with exposure or suspected impending exposure of their cardiac pacemaker systems. Fourteen patients required surgical revision for coverage of either the generator or defunctionalized wires. Equivalent success was achieved with either subfascial or submuscular coverage in 11 patients with generators present. Three patients with exposure of defunctionalized wires achieved successful coverage with submuscular burial. There was no correlation of culture results with recurrence of exposure.

Robot-assisted oropharyngeal reconstruction with free tissue transfer.

The surgical robot has been demonstrated to have useful applications in urologic, gynecologic, cardiac, general, and endocrine surgery. The development of robotic surgery has enhanced the precision and control of the surgeon in minimally invasive surgical situations specific to these specialties and, more recently, has been applied to the treatment of oropharyngeal tumors in the form of transoral robotic surgery (TORS). The elimination of the need for lip- and mandible-splitting approaches has allowed a reassessment of surgical options for the treatment of tumors that have until recently been primarily addressed nonoperatively with chemoradiation. The TORS approach has created the need to adapt current reconstructive options to robotic technology to manage the resultant tissue defects and to assess and compare the effectiveness of these procedures. This report details our early experience with the use of robot-assisted free tissue transfer for management of soft tissue defects of the oropharynx.

Review of inbound medical tourism and legal details of obtaining a visa for treatment of head and neck cancer.

BACKGROUND: We aim to provide a review of inbound medical tourism and the legal process of obtaining a visa for medical/surgical treatment for the patients with head and neck cancer. METHODS: We reviewed current statistics and the medical and legal literature regarding inbound medical tourism and the process of obtaining a visa for patients traveling to the United States for medical treatment. To illustrate this process, we present a case of an advanced-staged and disfiguring facial polymorphous high-grade adenocarcinoma in a previously healthy 29-year-old woman from Liberia. RESULTS: This report provides a synopsis of available statistical data on inbound medical tourism and the legal aspects of obtaining a visa for patients seeking medical care from abroad. CONCLUSIONS: Medical tourists traveling to the United States for treatment of head and neck pathologies face considerable barriers in obtaining prompt care, leading to a possible increased disease burden and difficulty in rendering oncologic treatment.

Electronic Communication in Plastic Surgery: Guiding Principles from the American Society of Plastic Surgeons Health Policy Committee.

BACKGROUND: With the advancement of technology, electronic communication has become an important mode of communication within plastic and reconstructive surgery. This can take the form of e-mail, text messaging, video conferencing, and social media, among others. There are currently no defined American Society of Plastic Surgeons guidelines for appropriate professional use of these technologies. METHODS: A search was performed on PubMed and the Cochrane database; terms included "telemedicine," "text messaging," "HIPAA," "metadata," "video conferencing," "photo sharing," "social media," "Facebook," "Twitter," and "Instagram." Initial screening of all identified articles was performed; the level of evidence, limitations, and recommendations were evaluated and articles were reviewed. RESULTS: A total of 654 articles were identified in the level I screening process; after more comprehensive review, 41 articles fit inclusion criteria: social networking, 12; telemedicine, 11; text messaging, 10; metadata, four; video conferencing, three; and Health Insurance Portability and Accountability Act, one. General themes were identified from these articles and guidelines proposed. CONCLUSION: Electronic communication can provide an efficient method of information exchange for professional purposes within plastic surgery but should be used thoughtfully and with all professional, legal, and ethical considerations.

Postoperative Nausea and Vomiting with Plastic Surgery: A Practical Advisory to Etiology, Impact, and Treatment.

Ambulatory surgery is common in plastic surgery, where many aesthetic and reconstructive procedures can be performed in hospitals, ambulatory surgery centers, or office-based surgery facilities. Outpatient surgery offers advantages to both the patient and the surgeon by increasing accessibility, flexibility, and convenience; lowering cost; and maintaining high-quality care. To optimize a patient's experience and comfort, postoperative nausea and vomiting (PONV) should be prevented. However, in those patients who develop PONV, it must be appropriately managed and treated. The incidence of PONV is variable. It is often difficult to accurately predict those patients who will develop PONV or how they will manifest symptoms. There are a variety of recommended "cocktails" for PONV prophylaxis and treatments that are potentially effective. The decision regarding the type of treatment given is often more related to provider preference and determination of side-effect profile, rather than targeted to specific patient characteristics, because of the absence of large volumes of reliable data to support specific practices over others. Fortunately, there are several tenets for the successful prevention and treatment of PONV we have extracted from the literature and summarize here. The following is a summary for the practicing plastic surgeon of the current state of the literature regarding PONV cause, risk factors, prophylaxis, and treatment that may serve as a guide for further study and practice management.

Pyoderma gangrenosum following autologous breast reconstruction.

Pyoderma gangrenosum (PG) is an uncommon disorder characterized by the development of painful cutaneous ulceration, commonly precipitated by dermal injury at surgical sites. It is a diagnostic challenge as it manifests as necrotizing wounds which are commonly misdiagnosed as postoperative wound infection or ischemia. We discuss the clinical features and histopathological findings that allow for rapid identification of PG following autologous breast reconstruction and suggest an algorithm to aid diagnosis.

Transoral robotic surgery for pharyngeal stenosis.

BACKGROUND: Pharyngeal stenosis is a complication of head and neck cancer and sleep apnea treatment that results in functional impairment. Due to the location of the stenosis and tendency to recur, surgical management is challenging. Robotic surgery may allow these areas to be treated with surgical technique that would be difficult using traditional approaches. METHODS: A retrospective chart review was performed to identify patients who underwent transoral robotic surgery (TORS) for pharyngeal stenosis at a tertiary hospital system. RESULTS: Five patients were identified, ages 8-75 years. Length of follow-up ranged from 1-12 months. There was one failure, a 74 year old male with a history of chemoradiation to the area who has required additional procedures. CONCLUSION: TORS may offer improved surgical access to the pharynx in patients who require complex reconstruction that would otherwise be very difficult. Appropriate patient selection is necessary and long-term follow-up is warranted for the selected cases.

Establishing cephalometric landmarks for the translational study of Le Fort-based facial transplantation in Swine: enhanced applications using computer-assisted surgery and custom cutting guides.

BACKGROUND: Le Fort-based, maxillofacial allotransplantation is a reconstructive alternative gaining clinical acceptance. However, the vast majority of single-jaw transplant recipients demonstrate less-than-ideal skeletal and dental relationships, with suboptimal aesthetic harmony. The purpose of this study was to investigate reproducible cephalometric landmarks in a large-animal model, where refinement of computer-assisted planning, intraoperative navigational guidance, translational bone osteotomies, and comparative surgical techniques could be performed. METHODS: Cephalometric landmarks that could be translated into the human craniomaxillofacial skeleton, and that would remain reliable following maxillofacial osteotomies with midfacial alloflap inset, were sought on six miniature swine. Le Fort I- and Le Fort III-based alloflaps were harvested in swine with osteotomies, and all alloflaps were either autoreplanted or transplanted. Cephalometric analyses were performed on lateral cephalograms preoperatively and postoperatively. Critical cephalometric data sets were identified with the assistance of surgical planning and virtual prediction software and evaluated for reliability and translational predictability. RESULTS: Several pertinent landmarks and human analogues were identified, including pronasale, zygion, parietale, gonion, gnathion, lower incisor base, and alveolare. Parietale-pronasale-alveolare and parietale-pronasale-lower incisor base were found to be reliable correlates of sellion-nasion-A point angle and sellion-nasion-B point angle measurements in humans, respectively. CONCLUSIONS: There is a set of reliable cephalometric landmarks and measurement angles pertinent for use within a translational large-animal model. These craniomaxillofacial landmarks will enable development of novel navigational software technology, improve cutting guide designs, and facilitate exploration of new avenues for investigation and collaboration.

Robotic-assisted FAMM flap for soft palate reconstruction.

UNLABELLED: OBJECTIVES/HYPOTHOSES: TORS (Trans Oral Robotic Surgery) has been demonstrated to be an acceptable alternative to chemoradiation for the treatment of early stage malignant lesions of the oropharynx, with equivalent tumor control and enhanced functional outcomes. Surgical ablation of tumors of the oropharynx under conditions of limited access, however, creates the need to adapt the robotic platform to surgical reconstruction and to assess reconstructive outcomes. We present our experience with the Facial Artery Musculomucosal (FAMM) flap with robotic assistance for the reconstruction of defects of the soft palate. METHODS: We reviewed the records of five patients who underwent combined robot-assisted resection of malignant lesions of the oropharynx with immediate reconstruction. The reconstructions included four ispilateral and one bilateral FAMM flaps. Patients were assessed for complications and functional results. RESULTS: Successful closure of the defect was achieved in all five patients. There were no major complications; however, three patients developed minor wound dehiscence and two were revised at the time of planned subsequent lymphadenectomy. All five patients achieved a good functional outcome. CONCLUSIONS: The FAMM flap is reliable and easy to raise and transfer, with the surgical robot making it a good candidate for reconstruction of moderate-sized defects created by TORS applied to malignancies of the soft palate. Minor wound dehiscence is not infrequent, but reconstructive outcomes are nevertheless good. A unilateral FAMM flap will reach to the contralateral border of the uvula and is best limited to defects with a width of 2 cm or less.

Robotic-assisted oropharyngeal reconstruction.

The development of robotic surgery has brought new levels of precision and control to minimally invasive surgical techniques. Its effectiveness, well established in urologic and gynecologic surgery applications, has also been demonstrated in cardiac, endocrine and general surgery. Recently, trans-oral robotic approaches to oropharyngeal tumor resection have been reported and, by eliminating the need for morbid lip and mandible splitting approaches, trans-oral robotic surgery (TORS) has allowed a re-assessment of surgical options for early stage tumors which have until recently been treated primarily with chemoradiation. The application of the TORS approach to malignant and non-malignant conditions affecting the oropharynx has created the need to develop robotic-assisted methods of managing the resultant tissue defects and to assess and compare the effectiveness of these procedures. This report details our early experience with the use of robotic surgery for management of soft tissue defects of the oropharynx in 12 patients.

Plastic surgery and smoking: a prospective analysis of incidence, compliance, and complications.

BACKGROUND: Tobacco use remains a persistent risk factor in elective plastic surgery. Although nicotine is thought to increase complications, which procedures are affected and the reliability of patient-provided histories remain poorly defined. The authors sought to examine nicotine use and its impact on outcomes. METHODS: All patients in a single-surgeon practice undergoing surgery with general anesthesia during a 2-year period were enrolled. Preoperative evaluation included a thorough smoking history. All patients had urine samples taken on the day of surgery to assess for nicotine metabolites. Patients were followed for a minimum of 3 months after surgery and monitored for complications. RESULTS: Four hundred fifteen patients were enrolled. Of these, 139 (33.5 percent) stated that they had quit smoking and 39 (9.4 percent) were admitted active smokers. For the 362 patients with urine nicotine analysis available, 54 showed active smoking. Fifteen of these (4.1 percent) had denied current tobacco use. Patients stating that they had quit smoking were more likely to be deceitful than those stating they had never smoked (p < 0.001). Smokers had significantly higher overall complication rates (OR, 3.7; p < 0.001) and tissue necrosis rates (OR, 4.3; p = 0.02) and were likelier to require reoperation (OR, 3.7; p < 0.001). CONCLUSIONS: In a large cohort study examining the prevalence and impact of nicotine in the general plastic surgery population, substantial rates of deception regarding smoking status were found. Furthermore, active smoking was strongly correlated with complications. A methodologic approach to the detection and management of patients using tobacco products can help to optimize outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.