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BACKGROUND: A comprehensive comparison of surgical, aesthetic, and quality of life outcomes by reduction mammaplasty technique does not exist. We sought to ascertain the effect of technique on clinical, aesthetic, and patient-reported outcomes. METHODS: Patients with symptomatic macromastia undergoing a superomedial or inferior pedicle reduction mammoplasty by a single surgeon were identified. BREAST-Q surveys were administered. Postoperative breast aesthetics were assessed in 50 matched-patients. Patient characteristics, complications, quality of life, and aesthetic scores were analyzed. RESULTS: Overall, 101 patients underwent reductions; 60.3% had a superomedial pedicle. Superomedial pedicle patients were more likely to have grade 3 ptosis (P < 0.01) and had significantly shorter procedure time (P < 0.01). Only the inferior pedicle technique resulted in wound dehiscence (P = 0.03) and reoperations from complications (P < 0.01). Those who underwent an inferior pedicle reduction were 4.3 times more likely to experience a postoperative complication (P = 0.03). No differences in quality of life existed between cohorts (P > 0.05). Superomedial pedicle patients received significantly better scarring scores (P = 0.03). CONCLUSIONS: The superomedial pedicle reduction mammoplasty technique provides clinical and aesthetic benefits compared with the inferior pedicle technique.
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Mamoplastia , Qualidade de Vida , Feminino , Humanos , Resultado do Tratamento , Estudos Retrospectivos , Retalhos Cirúrgicos/cirurgia , Mamoplastia/métodos , Mama/cirurgia , Hipertrofia/cirurgia , Complicações Pós-Operatórias/cirurgia , Estética , Medidas de Resultados Relatados pelo PacienteRESUMO
BACKGROUND: Despite advanced wound care techniques, open fractures in the setting of lower extremity trauma remain a challenging pathology, particularly when free tissue transfer is required for coverage. We aimed to evaluate factors associated with flap failure in this setting using a large, heterogeneous patient population. METHODS: Retrospective review of patients who underwent traumatic lower extremity free flap reconstruction (2002-2019). Demographics wound/vessel injury characteristics, pre and perioperative factors, and flap outcomes were analyzed. RESULTS: One hundred eighty-eight free flaps met inclusion criteria, with 23 partial (12.2%) and 13 total (6.9%) flap failures. Angiography was performed in 87 patients, with arterial injury suffered in 43.1% of those evaluated. Time to flap coverage varied within 3 days (4.5%), 10 days (17.3%), or 30 days of injury (42.7%). In all, 41 (21.8%) subjects suffered from major flap complications, including failure and takebacks. Multivariate regression demonstrated the presence of posterior tibial (PT) artery injury predictive of both flap-failure (Odds ratio [OR] = 11.4, p < .015) and major flap complications (OR = 12.1, p < .012). Immunocompromised status was also predictive of flap failure (OR = 12.6, p < .004) and major complications (OR = 11.6, p < .007), while achieving flap coverage within 30 days was protective against flap complications (OR = 0.413, p < .049). Defect size, infection, and injury location were not associated with failure. CONCLUSIONS: When examining a large, heterogeneous patient cohort, free flap outcomes in the setting of lower extremity open fractures can be influenced by multiple factors. This presence of PT artery injury, flap coverage beyond 30 days of injury, and immunocompromised status appear predictive of flap complications in this context.
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Fraturas Expostas , Retalhos de Tecido Biológico , Traumatismos da Perna , Procedimentos de Cirurgia Plástica , Humanos , Fraturas Expostas/cirurgia , Fraturas Expostas/complicações , Traumatismos da Perna/cirurgia , Procedimentos de Cirurgia Plástica/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Retalhos de Tecido Biológico/irrigação sanguínea , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The need for preoperative imaging as well as anastomotic technique (ie, end-to-side [ETS] vs end-to-end [ETE]) are areas of controversy in microsurgical lower-extremity reconstruction. The objective of this study was to (1) investigate whether preoperative imaging is mandatory and (2) to elicit if the type of anastomosis impacts clinical outcomes. METHODS: A retrospective review of all patients who underwent microvascular lower-extremity reconstruction between 2007 and 2015 by a single surgeon was performed. Patients were categorized into groups based on anastomotic technique, that is, ETE versus ETS anastomosis. Patients in the ETE group were further subclassified into those who had preoperative imaging (computed tomography angiography [CTA]+) versus those who did not (CTA-). Parameters of interest included flap type, thrombosis rate, flap loss, length of stay (LOS), return to ambulation, and rate of secondary amputation. Two-sided statistical analysis was performed using Kruskal-Wallis rank-sum test and Fisher exact test. RESULTS: One hundred twenty-eight patients were analyzed: ETE (n = 40) and ETS (n = 88). Mean follow-up for both groups was 20 ± 19 months. Anterolateral thigh flaps were most commonly performed (71%). Overall flap loss rate was 3.1% without any significant differences noted with respect to thrombosis (arterial, P = 0.09; venous, P = 0.56), flap loss (P = 0.33), LOS (P = 0.28), amputation (P = 1.00), or return to ambulation (P = 0.77). Furthermore, the availability of preoperative imaging (CTA+: N = 11 vs CTA-: N = 29) did not impact rates of thrombosis (arterial, P = 0.29; venous, P = 0.31), flap loss (P = 1.00), LOS (P = 0.26), or return to mobility (P = 0.62). CONCLUSIONS: In light of similar reconstructive outcomes, we prefer to preserve distal extremity perfusion via ETS anastomoses whenever possible. Furthermore, preoperative vascular imaging angiography might not be necessary in patients with palpable pedal pulses on preoperative examination. An actionable algorithm for determining ETS versus ETE anastomosis in lower-extremity reconstruction is presented.
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Retalhos de Tecido Biológico , Procedimentos de Cirurgia Plástica , Cirurgiões , Anastomose Cirúrgica , Sobrevivência de Enxerto , Humanos , Microcirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: Traumatic intercalary defects of the tibia may be effectively managed with the free fibula flap. However, any alteration of limb alignment with residual bony angular deformity of the tibia must be also addressed. We describe the use of the free fibula flap in conjunction with external fixation to allow residual deformity correction and patient mobilization ambulation during healing of the free flap. METHODS: Retrospective medical record review was conducted of patients with segmental tibial defects greater than 7 cm who underwent reconstruction with fibula free flap and simple pin-bar external fixation, followed by conversion to 6-axis computer-assisted multiplanar circular ring external fixation to correct residual bony deformity. Outcomes analyses included free flap complications, return to the operating room, complications associated with the external fixation, bony union, correction of residual deformity, amputation rate, visual analog pain scales, and patient satisfaction. RESULTS: Eight patients (8 tibiae) underwent reconstruction. Mean tibial bone defect was 10.2 cm; all limbs had soft-tissue defects (mean size, 138 cm). Free fibula grafts were harvested as osteocutaneous or osteomyocutaneous flaps (average length, 12 cm). Complications included 1 delayed union and 3 (37.5%) patients readmitted for graft fracture. Ultimately, 100% of patients achieved graft union with satisfactory correction of residual limb deformity. Limb salvage rate was 100%. DISCUSSION: Management of segmental tibial bone loss utilizing initial simple external fixation and microsurgical reconstruction followed by application of computer-assisted circular external fixator may provide a reliable reconstructive protocol for posttraumatic tibial defects with residual bone malalignment.
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Retalhos de Tecido Biológico , Procedimentos de Cirurgia Plástica , Fraturas da Tíbia , Fixadores Externos , Fíbula/cirurgia , Fixação de Fratura , Humanos , Estudos Retrospectivos , Tíbia/cirurgia , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Over 175,000 Americans underwent bariatric surgery in 2013 alone, resulting in rapid growth of the massive weight loss population. As obesity is a known risk factor for breast cancer, plastic surgeons are increasingly challenged to reconstruct the breasts of massive weight loss patients after oncologic resection. The goal of this study is to assess the outcomes of autologous breast reconstruction in postbariatric surgery patients at a single institution. METHODS: Patients who underwent autologous breast reconstruction between 2008 and 2014 were identified. Those with a history of bariatric surgery were compared to those without a history of bariatric surgery. Analysis included age, ethnicity, BMI, comorbidities, flap type, operative complications, and reoperation rates. Propensity matched analysis was also conducted to control for preoperative differences between the two cohorts. RESULTS: Fourteen women underwent breast reconstruction following bariatric surgery, compared to 1,012 controls. Outcomes analysis revealed significant differences in breast revisions (1.35 vs. 0.61, P = .0055), implant placements (0.42 vs. 0.08, P = .0003), and total OR visits (2.78 vs. 1.67, P = .0007). There was no significant difference noted in delayed healing of the breast (57.4% vs. 33.7%, P = .087) or donor site (14.3% vs. 15.8%, P = 1.00). CONCLUSIONS: As the rise in bariatric surgery mirrors that of obesity, an increasing amount of massive weight loss patients undergo treatment for breast cancer. We demonstrate profound differences in this patient population, particularly in regards to revision rates, which affects operative planning, patient counseling, and satisfaction.
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Cirurgia Bariátrica/métodos , Mamoplastia/métodos , Retalhos Cirúrgicos/transplante , Redução de Peso , Adulto , Cirurgia Bariátrica/efeitos adversos , Contorno Corporal/métodos , Índice de Massa Corporal , Bases de Dados Factuais , Artérias Epigástricas/cirurgia , Estética , Feminino , Humanos , Pessoa de Meia-Idade , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Medição de Risco , Estatísticas não Paramétricas , Retalhos Cirúrgicos/irrigação sanguínea , Transplante Autólogo , Resultado do TratamentoRESUMO
INTRODUCTION: Despite a national health care policy requiring payers to cover breast reconstruction, rates of postmastectomy reconstruction are low, particularly among minority populations. We conducted this study to determine if geographic access to a plastic surgeon impacts breast reconstruction rates. METHODS: Using 2010 inpatient and ambulatory surgery data from 10 states, we identified adult women who underwent mastectomy for breast cancer. Data were aggregated to the health service area (HSA) level and hierarchical generalized linear models were used to risk-standardize breast reconstruction rates (RSRR) across HSAs. The relationship between an HSA's RSRR and plastic surgeon density (surgeons/100,000 population) was quantified using correlation coefficients. RESULTS: The final cohort included 22,997 patients across 134 HSAs. There was substantial variation in plastic surgeon density (median, 1.4 surgeons/100,000; interquartile range, [0.0-2.6]/100,000) and the use of breast reconstruction (median RSRR, 43.0%; interquartile range, [29.9%-62.8%]) across HSAs. Higher plastic surgeon density was positively correlated with breast reconstruction rates (correlation coefficient = 0.66, P < 0.001) and inversely related to time between mastectomy and reconstruction (correlation coefficient = -0.19, P < 0.001). Non-white and publicly insured women were least likely to undergo breast reconstruction overall. Among privately insured patients, racial disparities were noted in high surgeon density areas (white = 79.0% vs. non-white = 63.3%; P < 0.001) but not in low surgeon density areas (34.4% vs 36.5%; P = 0.70). CONCLUSIONS: The lack of geographic access to a plastic surgeon serves as a barrier to breast reconstruction and may compound disparities in care associated with race and insurance status. Future efforts to improve equitable access should consider strategies to ensure access to appropriate clinical expertise.
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Neoplasias da Mama/cirurgia , Área Programática de Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Mamoplastia/estatística & dados numéricos , Cirurgiões/provisão & distribuição , Cirurgia Plástica , Adulto , Idoso , Feminino , Política de Saúde , Humanos , Mastectomia , Área Carente de Assistência Médica , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos , Recursos HumanosRESUMO
OBJECTIVES: Incisional hernia (IH) remains a common, highly morbid, and costly complication. Modest progress has been realized in surgical technique and mesh technology; however, few advances have been achieved toward understanding risk and prevention. In light of the increasing emphasis on prevention in today's health care environment and the billions in costs for surgically treated IH, greater focus on predictive risk models is needed. METHODS: All patients undergoing gastrointestinal or gynecologic procedures from January 1, 2005 to June 1, 2013, within the University of Pennsylvania Health System were identified. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated IH after index procedures. Patients with prior hernia, less than 1-year follow-up, or emergency surgical procedures were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted. RESULTS: A total of 12,373 patients with a 3.5% incidence of surgically treated IH (follow-up 32.2â±â26.6 months) were identified. The cost of surgical treatment of IH and management of associated complications exceeded $17.5 million. Notable independent risk factors for IH were ostomy reversal (HRâ=â2.76), recent chemotherapy (HRâ=â2.04), bariatric surgery (HRâ=â1.78), smoking history (HRâ=â1.74), liver disease (HRâ=â1.60), and obesity (HRâ=â1.96). High-risk patients (20.6%) developed IH compared with 0.5% of low-risk patients (C-statisticâ=â0.78). CONCLUSIONS: This study demonstrates an internally validated preoperative risk model of surgically treated IH after 12,000 elective, intra-abdominal procedures to provide more individualized risk counseling and to better inform evidence-based algorithms for the role of prophylactic mesh.
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Parede Abdominal/cirurgia , Procedimentos Cirúrgicos Eletivos , Hérnia Incisional/economia , Hérnia Incisional/prevenção & controle , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Comorbidade , Custos e Análise de Custo , Feminino , Humanos , Incidência , Hérnia Incisional/epidemiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Telas CirúrgicasRESUMO
INTRODUCTION: While recent studies project a national shortage of plastic surgeons, there may currently exist areas within the United States with few plastic surgeons. We conducted this study to describe the current geographic distribution of the plastic surgery workforce across the United States. METHODS: Using the 2013 to 2014 Area Health Resource File, we estimated the number of plastic surgeons at the health service area (HSA) level in 2010 and 2012. The density of plastic surgeons was calculated as a ratio per 100,000 population. The HSAs were grouped by plastic surgeon density, and population characteristics were compared across subgroups. Characteristics of HSAs with increases and decreases in plastic surgeon density were also compared. RESULTS: The final sample included 949 HSAs with a total population of 313,989,954 people. As of 2012, there were an estimated 7600 plastic surgeons, resulting in a national ratio of 2.42 plastic surgeons/100,000 population. However, over 25 million people lived in 468 HSAs (49.3%) without a plastic surgeon, whereas 106 million people lived in 82 HSAs (8.6%) with 3.0 or more/100,000 population. Plastic surgeons were more likely to be distributed in HSAs where a higher percentage of the population was younger than 65 years, female, and residing in urban areas. Between 2010 and 2012, 11 HSAs without a plastic surgeon increased density, whereas 15 HSAs lost all plastic surgeons. CONCLUSIONS: Plastic surgeons are asymmetrically distributed across the United States leaving over 25 million people without geographic access to the specialty. This distribution tends to adversely impact older and rural populations.
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Médicos/provisão & distribuição , Procedimentos de Cirurgia Plástica/estatística & dados numéricos , Área de Atuação Profissional/estatística & dados numéricos , Cirurgia Plástica/estatística & dados numéricos , Adulto , Idoso , Área Programática de Saúde/estatística & dados numéricos , Competência Clínica , Feminino , Humanos , Masculino , Área Carente de Assistência Médica , Pessoa de Meia-Idade , Padrões de Prática Médica/estatística & dados numéricos , Estados Unidos/epidemiologiaRESUMO
Background: Gunshot wounds (GSWs) create significant morbidity in the United States. Upper extremity (UE) GSWs are at high risk of combined injuries involving multiple organ systems and may require variable treatment strategies. This study details the epidemiology, management, and outcomes of civilian UE GSWs at an urban level 1 trauma center. Methods: Using the University of Pennsylvania Trauma Registry, all adult patients with UE GSWs from 2015 to 2020 who were at least 6-months postinjury were studied for demographics, injury pattern, operative details, and postoperative outcomes. Fisher exact and Wilcoxon rank sum tests were used to determine differences in treatment modalities and outcomes. Results: In 360 patients, the most common victim was young (xÌ = 29.5 y old), African American (89.4%), male (94.2%), and had multiple GSWs (70.3%). Soft tissue-only trauma (47.8%) and fractures (44.7%) predominated. Presence of fracture was independently predictive of neurologic, vascular, and tendinous injuries (P < 0.001). Most soft tissue-only injuries were managed nonoperatively (162/173), whereas fractures frequently required operative intervention (115 of 161, P < 0.001). Despite a prevalence of comminuted (84.6%) and open (43.6%) fractures, hardware complications (7.5%) and wound infection (1.1%) occurred infrequently. Conclusions: Civilian GSWs to the UE with only soft tissue involvement can often be managed conservatively with antibiotic administration, bedside washout, and local wound care. Even with combined injuries and open fractures, single-stage operative debridement and fracture care with primary or secondary closure often prevail. As civilian ballistic trauma becomes more frequent in the United States, these data help inform patient expectations and guide management.
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LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Have an in-depth understanding of the functional and aesthetic requirements of lower extremity reconstruction. 2. Describe the considerations for achieving an optimal aesthetic outcome in the primary reconstruction settings. 3. Describe modalities of secondary flap revision for achieving an optimal aesthetic outcome. SUMMARY: Significant advancements have been made in the management of lower extremity reconstruction since Dr. Taylor's seminal case in 1973. Improvements in our understanding of vascular anatomy and evolution of microsurgical techniques have allowed for an ever-increasing array of free tissue transfer options for lower extremity reconstruction. The resulting expertise has engendered a paradigm shift toward the reconstructive elevator approach, with increased emphasis on cosmetic results. In the primary setting, aesthetic considerations play an important role in precoverage wound preparation, flap selection, and harvest technique, with the goal of achieving excellent like-with-like reconstruction at the time of initial surgery. Flap selection should be made to best match the three-dimensional architecture of the wound, and take into account the defect thickness, flap thickness, flap composition, and pedicle length. Primary flap thinning and harvest in the superficial fascial plane has been shown to be an effective modality to address excess adiposity and improve contour. Despite these efforts, secondary procedures are often required to optimize the limb's final appearance and functional outcomes, particularly in the foot and ankle region. These include debulking, liposuction, and staged excisions. As the field of limb salvage keeps evolving, aesthetics will continue to play an important role in extremity reconstruction planning and execution.
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Retalhos de Tecido Biológico , Lipectomia , Procedimentos de Cirurgia Plástica , Humanos , Retalhos Cirúrgicos/irrigação sanguínea , Extremidade Inferior/cirurgia , Salvamento de Membro , Estética , Retalhos de Tecido Biológico/irrigação sanguíneaRESUMO
BACKGROUND: Previous failed reduction and certain radiographic indicators historically have been used to differentiate simple and complex metacarpophalangeal joint (MPJ) dislocations in children, the latter of which warrants open reduction. This investigation aimed to determine the necessity for open reduction with these indicators and establish a new treatment algorithm and educational focus for these rare injuries. METHODS: A 12-year retrospective study was conducted on all children with MPJ dislocations at a single pediatric hospital. The rates of successful closed reduction, number of reduction attempts, and radiographic findings were detailed. Operative details and postoperative outcomes were also gathered. RESULTS: Thirty-three patients with a mean age of 11.1 years were included. Most were male [ n = 27 (82%)] and had undergone two or more previous reduction attempts at an outside facility. Stable closed reduction was then achieved outside of the operating room in five patients and in the operating room under general anesthesia in another 14, for a total of 19 of 33 patients (57.6%). The thumb was injured most often [ n = 19 (57.6%)] and more likely to undergo successful closed reduction ( P = 0.04). There was no relationship between number of previous reduction attempts and ability to achieve closed reduction ( P = 0.72). Neither joint-space widening nor proximal phalanx bayonetting was correlated radiographically with failure of closed reduction ( P = 0.22 and P = 1, respectively). CONCLUSIONS: This study supports closed reduction of pediatric MPJ dislocations in the operating room under general anesthesia before conversion to open reduction, regardless of injury characteristics or previous reduction attempts. This strategy is likely to limit unnecessary open surgery and related risks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.
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Luxações Articulares , Humanos , Masculino , Criança , Feminino , Estudos Retrospectivos , Luxações Articulares/diagnóstico por imagem , Luxações Articulares/cirurgia , Redução Aberta , Articulação Metacarpofalângica/diagnóstico por imagem , Articulação Metacarpofalângica/cirurgia , Articulação Metacarpofalângica/lesões , ExtremidadesRESUMO
SUMMARY: Patients with significant loss of abdominal wall soft tissue represent a reconstructive challenge. The purpose of this study was to describe the authors' experience using microvascular free tissue transfer to repair complex abdominal wall defects with insufficient overlying soft tissue. In this report, the authors highlight their techniques and experiences in performing microvascular free tissue transfer to the abdominal wall for these massive, complex defects. In total, 14 patients who underwent 16 free-flap reconstructions were included in the series. The patients' mean age was 50 ± 14 years, and mean body mass index was 27 ± 5 kg/m2. The mean hernia defect size was 412 ± 149 cm2. Ten flaps were fasciocutaneous anterolateral thigh flaps, one myocutaneous anterolateral thigh flap, two subtotal thigh flaps, one myocutaneous latissimus dorsi flap, one parascapular/latissimus dorsi flap, and one free filet of the lower leg. Five cases (36 percent) developed hernia recurrence, and seven developed surgical site complications. All flaps survived, with no total flap loss. This report highlights that microsurgical free tissue transfer in combination with mesh repair is a safe and reliable method for restoring complex, large, full-thickness abdominal wall defects. This case series illustrates a number of techniques and considerations that are of importance to achieve a favorable outcome when faced with these complex defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Parede Abdominal/cirurgia , Retalhos de Tecido Biológico/transplante , Hérnia Abdominal/cirurgia , Herniorrafia/métodos , Microvasos/transplante , Adulto , Idoso , Feminino , Retalhos de Tecido Biológico/irrigação sanguínea , Herniorrafia/instrumentação , Humanos , Masculino , Pessoa de Meia-Idade , Telas Cirúrgicas , Resultado do TratamentoRESUMO
Gun violence reached a 20-year peak in 2020, with the first-line treatment of axillosubclavian vascular injuries (SAVIs) remaining unknown. Traditional open exposure is difficult and exposes patients to iatrogenic venous and brachial plexus injury. The practice of endovascular treatment has been increasing. We performed a retrospective analysis of SAVIs at a level I trauma center. Seven patients were identified. Endovascular repair was performed in five patients. Technical success was 100%. The early results suggest that endovascular treatment of trauma-related SAVIs can be performed safely and effectively. However, complications such as stent thrombosis or occlusion can occur, demonstrating the need for surveillance.
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BACKGROUND: Current hernia patient-reported outcome (PRO) measures were developed without patient input, greatly impairing their content validity. OBJECTIVE: The purpose of this study was to develop a conceptual model for PRO measures for ventral hernia (VH) patients. METHODS: Fifteen semi-structured, concept elicitation interviews and two focus groups employing nominal group technique were conducted with VH patients. Patients were recruited between November 2015 and July 2016 over the telephone from a five-surgeon patient cohort at our institution. Iterative thematic analysis identified domains. Reliability and validation were achieved using inter-rater reliability checks and triangulation. RESULTS: Seven framework domains were established: (1) expectations; (2) self and others; (3) surgeon and surgical team; (4) sensation; (5) function; (6) appearance; and (7) overall satisfaction. Overall patient satisfaction was associated with two themes: (1) provider-patient relationship; and (2) patient assessment of post-repair improvement. CONCLUSIONS: VH patients experience a profoundly broad range of reactions to VH repair. A patient-informed PRO instrument that addresses the spectrum of patient-identified outcomes can guide practice, optimizing care targeting VH patients' needs.
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Hérnia Ventral/cirurgia , Medidas de Resultados Relatados pelo Paciente , Satisfação do Paciente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Pesquisa Qualitativa , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Clinical indications are expanding for the use of fasciocutaneous free flaps in lower extremity traumatic reconstruction. The authors assessed the impact of muscle versus fasciocutaneous free flap coverage on reconstructive and functional outcomes. METHODS: A multicenter retrospective review was conducted on all lower extremity traumatic free flaps performed at Duke University (1997 to 2013) and the University of Pennsylvania (2002 to 2013). Muscle and fasciocutaneous flaps were compared in two subgroups (acute trauma and chronic traumatic sequelae), according to limb salvage, ambulation time, and flap outcomes. RESULTS: A total of 518 lower extremity free flaps were performed for acute traumatic injuries (n = 238) or chronic traumatic sequelae (n = 280). Muscle (n = 307) and fasciocutaneous (n = 211) flaps achieved similar cumulative limb salvage rates in acute trauma (90 percent versus 94 percent; p = 0.56) and chronic trauma subgroups (90 percent versus 88 percent; p = 0.51). Additionally, flap choice did not impact functional recovery (p = 0.83 for acute trauma; p = 0.49 for chronic trauma). Flap groups did not differ in the rates of flap thrombosis, flap salvage, flap loss, or tibial nonunion requiring bone grafting. Fasciocutaneous flaps were more commonly reelevated for subsequent orthopedic procedures (p < 0.01) and required fewer secondary skin-grafting procedures (p = 0.01). Reconstructive and functional outcomes remained heavily influenced by injury severity. CONCLUSIONS: Muscle and fasciocutaneous free flaps achieved comparable rates of limb salvage and functional recovery. Flap selection should be guided by defect characteristics and reconstructive needs. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
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Fraturas Expostas/cirurgia , Retalhos de Tecido Biológico/transplante , Traumatismos da Perna/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Lesões dos Tecidos Moles/cirurgia , Cicatrização/fisiologia , Doença Aguda , Adulto , Análise de Variância , Doença Crônica , Estudos de Coortes , Feminino , Seguimentos , Retalhos de Tecido Biológico/irrigação sanguínea , Sobrevivência de Enxerto , Humanos , Escala de Gravidade do Ferimento , Traumatismos da Perna/diagnóstico , Salvamento de Membro/métodos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Retalho Miocutâneo/irrigação sanguínea , Retalho Miocutâneo/transplante , Estudos Retrospectivos , Medição de Risco , Transplante de Pele/métodos , Lesões dos Tecidos Moles/diagnóstico , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Hypercoagulable conditions are often considered relative contraindications to free flap reconstruction. This paper presents and critically examines a novel anticoagulation regimen developed to address this disease state. METHODS: Hypercoagulable patients who underwent free tissue transfer between 2007 and 2015 were identified. From 2011, all such patients were subjected to a novel anticoagulation protocol involving an intravenous bolus of 2000 U of unfractionated heparin prior to microvascular pedicle anastomosis, followed by a heparin infusion at 500 U/h, which was postoperatively increased to therapeutic levels. Patients were discharged on full anticoagulation for 1 month. Patients prior to 2011 received only subcutaneous heparin. Outcomes in patients receiving this novel anticoagulation protocol were compared to those of patients receiving standard therapy (postoperative subcutaneous heparin). RESULTS: Twenty-three hypercoagulable patients underwent reconstruction with 32 flaps. Eleven patients were administered the novel protocol. No thromboses were noted in the novel protocol cohort, while three thrombotic events occurred in the control cohort (0% vs. 17.6%, p = 0.23). No flaps were salvaged after thrombosis. All losses occurred in the control cohort (0% vs. 17.6%, p = 0.23). The novel protocol cohort was more likely to have postoperative red blood cell transfusions (72.6% vs. 16.7%, p = 0.007), hematomas (26.7% vs. 0%, p = 0.04), and lower mean hemoglobin nadirs [6.9 (1.0) vs. 8.9 ± 1.8 g/dL, p = 0.01]. CONCLUSION: The key approach to hypercoagulable patients is likely prevention over treatment. Patients who received prophylactic heparin infusions had clinically lower rates of thrombotic events and flap loss. However, this encouraging finding must be balanced with the increased risk for postoperative bleeding complications.
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Anticoagulantes/administração & dosagem , Heparina/administração & dosagem , Microcirurgia/métodos , Trombofilia/complicações , Trombose/prevenção & controle , Esquema de Medicação , Feminino , Retalhos de Tecido Biológico , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Estudos RetrospectivosRESUMO
BACKGROUND: Thrombocytosis in patients undergoing lower extremity free tissue transfer may be associated with increased risk of microvascular complications. This study assessed whether preoperative platelet counts predict lower extremity free flap thrombosis. METHODS: All patients undergoing lower extremity free tissue transfer at Duke University from 1997 to 2013 and at the University of Pennsylvania from 2002 to 2013 were retrospectively identified. Logistic regression was used to assess whether preoperative platelet counts independently predict flap thrombosis, controlling for baseline and operative factors. RESULTS: A total of 565 patients underwent lower extremity free tissue transfer, with an overall flap thrombosis rate of 16 percent (n = 91). Elevated preoperative platelet counts were independently associated with both intraoperative thrombosis (500 ± 120 versus 316 ± 144 × 10/liter; p < 0.001) and postoperative thrombosis (410 ± 183 versus 320 ± 143 × 10/liter; p = 0.040) in 215 patients who sustained acute lower extremity trauma within 30 days before reconstruction. In acute trauma patients, preoperative platelet counts predicted a four-fold increased risk of intraoperative thrombosis (cutoff value, 403 × 10/liter; OR, 4.08; p < 0.001) and a two-fold increased risk of postoperative thrombosis (cutoff value, 361 × 10/liter; OR, 2.16; p = 0.005). In patients who did not sustain acute trauma, preoperative platelet counts predicted a four-fold increased risk of intraoperative thrombosis (cutoff value, 352 × 10/liter; OR, 3.82; p = 0.002). CONCLUSIONS: Acute trauma patients with elevated preoperative platelet counts are at increased risk for lower extremity free flap complications. Prospective evaluation is warranted for guiding risk stratification and targeted treatment strategies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
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Retalhos de Tecido Biológico/irrigação sanguínea , Extremidade Inferior/cirurgia , Procedimentos de Cirurgia Plástica , Contagem de Plaquetas , Complicações Pós-Operatórias/etiologia , Trombose/etiologia , Adulto , Idoso , Feminino , Seguimentos , Retalhos de Tecido Biológico/transplante , Humanos , Modelos Logísticos , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/lesões , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Período Pré-Operatório , Estudos Retrospectivos , Fatores de Risco , Trombose/diagnóstico , Resultado do TratamentoRESUMO
BACKGROUND: Preoperative surgical risk assessment continues to be a critical component of clinical decision-making. The ACS Universal Risk Calculator estimates risk for several outcomes based on individual risk profiles. Although this represents a tremendous step toward improving outcomes, studies have reported inaccuracies among certain patient populations. This study aimed to assess the predictive accuracy of the American College of Surgeons' (ACS) Risk Calculator in patients undergoing open ventral hernia repair (VHR). METHODS: A review of patients undergoing open, isolated VHR between 7/1/2007 and 7/1/2014 by a single surgeon was performed. Risk factors and outcomes were collected as defined by National Surgical Quality Improvement Project. Thirty-day outcomes included serious complication, venous thromboembolism, medical morbidity, surgical site infection (SSI), unplanned reoperation, mortality, and length of stay (LOS). Patient profiles were entered into the ACS Surgical Risk Calculator and outcome-specific risk predictions recorded. Prediction accuracy was assessed using the Brier score and receiver-operator area under the curve (AUC). RESULTS: One hundred forty-two patients undergoing open VHR were included. ACS predictions were accurate for cardiac complications (Brier = .02), venous thromboembolism (Brier = .08), reoperation (Brier = .10), and mortality (Brier = .01). Significantly, underestimated outcomes included SSI (Brier = .14), serious complication (Brier = .30), and any complication (Brier = .34). Discrimination ranged from highly accurate (mortality, AUC = .99) to indiscriminate (SSI, AUC = .57). Predicted LOS was 3-fold shorter than observed (2.4 vs 7.4 days, P <.001). CONCLUSIONS: The ACS Surgical Risk Calculator accurately predicted medical complications, reoperation, and 30-day mortality. However, SSIs, serious complications, and LOS were significantly underestimated. These findings suggest that additional considerations are needed to better estimate complications after open VHR.
Assuntos
Hérnia Ventral/cirurgia , Herniorrafia/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Estudos Retrospectivos , Medição de Risco , Fatores de RiscoRESUMO
BACKGROUND: The authors hypothesize that early posterior vault distraction osteogenesis safely confers considerable cranial vault remodeling, sufficient to enable fronto-orbital advancement to be delayed to a later age, with improved outcomes. METHODS: The authors conducted a retrospective cohort study of children with syndromic craniosynostosis treated before (2003 to 2008) or after (2009 to 2014) implementation of posterior vault distraction osteogenesis. RESULTS: Sixty children with syndromic craniosynostosis presented during the study period. Forty met inclusion criteria with care continuity and complete records: 22 before and 18 after implementation of posterior vault distraction osteogenesis. Only 11 patients (61 percent) who underwent initial posterior vault distraction osteogenesis required frontal advancement, at a mean follow-up of 4.0 years of age, compared with 22 patients (100 percent) before implementation of posterior vault distraction osteogenesis. Kaplan-Meier survival analysis indicated significant delay of first fronto-orbital advancement in the posterior vault distraction osteogenesis cohort compared with the pre-posterior vault distraction osteogenesis cohort (p = 0.011). Comparing treatment in the first 5 years of life among posterior vault distraction osteogenesis versus non-posterior vault distraction osteogenesis subcohorts of patients older than 5 years, there were significantly fewer fronto-orbital advancements performed (0.6 versus 1.5 per patient; p = 0.023). CONCLUSION: Using early posterior vault distraction osteogenesis for patients with syndromic craniosynostosis significantly reduces the average number of fronto-orbital advancement procedures in the first 5 years of life, delays initial fronto-orbital advancement, and is likely to reduce the total number of major craniofacial procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Assuntos
Algoritmos , Craniossinostoses/cirurgia , Osteogênese por Distração/métodos , Procedimentos de Cirurgia Plástica , Fatores Etários , Pré-Escolar , Intervenção Médica Precoce , Humanos , Lactente , Estimativa de Kaplan-Meier , Estudos Retrospectivos , Síndrome , Resultado do TratamentoRESUMO
BACKGROUND: Max Muenke included midface hypoplasia as part of the clinical syndrome caused by the Pro250Arg FGFR3 mutation that now bears his name. Murine models have demonstrated midface hypoplasia in homozygous recessive mice only, with heterozygotes having normal midfaces; as the majority of humans with the syndrome are heterozygotes, we investigated the incidence of midface hypoplasia in our institution's clinical cohort. METHODS: We retrospectively reviewed all patients with a genetic and clinical diagnosis of Muenke syndrome from 1990 to 2014. Review of clinical records and photographs included skeletal Angle Class, dental occlusion, and incidence of orthognathic intervention. Cephalometric evaluation of our patients was compared to the Eastman Standard Values. RESULTS: 18 patients met inclusion criteria - 7 females and 11 males, with average follow-up of 11.2 years (1.0-23.1). Cephalometric analysis revealed an average sella-nasion-A point angle (SNA) of 82.5 (67.8-88.8) and an average sella-nasion-B point angle (SNB) of 77.9 (59.6-84.1). The SNA of our cohort was found to be significantly different from the Eastman Standards (p = 0.017); subgroup analysis revealed that this was due to the mixed dentition group which had a higher than average SNA. 12 patients were noted to be in Class I occlusion, 4 in Class II malocclusion, and 2 in Class III malocclusion. Only one patient (6%) underwent orthognathic surgery for Class III malocclusion. CONCLUSIONS: While a part of the original description of Muenke syndrome, clinically significant midface hypoplasia is not a common feature. This data is important, as it allows more accurate counseling of patients and families. LEVEL OF EVIDENCE: III.