The Chimeric Scapulodorsal Vascularized Latissimus Dorsi Nerve Flap for Immediate Reconstruction of Total Parotidectomy Defects With Facial Nerve Sacrifice: Building a New Program and Preliminary Results From 25 Cases.

BACKGROUND: Total parotidectomy with facial nerve sacrifice creates 2 challenging reconstructive problems: restoration of facial contour and facial nerve rehabilitation. Strong evidence suggesting that vascularized nerve grafts are superior to nonvascularized nerve grafts motivated our team to develop a chimeric scapulodorsal flap combining the usual harvestable local tissues with the vascularized latissimus dorsi motor nerve (SD-LDVxN). We present our experiences developing a new program at University of California, San Diego, highlighting our first case here, and present preliminary retrospective results focusing on the functional outcomes of facial nerve reanimation. MATERIALS AND METHODS: The first case performed in the United States was a 57-year-old woman with stage IVA left parotid adenoid cystic carcinoma and House-Brackmann grade 6 facial palsy. She underwent total parotidectomy with facial nerve sacrifice and a free chimeric SD-LDVxN flap reconstruction. She had an unremarkable postoperative course, and 3- and 6-month follow-up functional results are reported. Preliminary functional results from our total series of 25 patients were reported. RESULTS: At her 3-month follow-up, she was a House-Brackmann 5 with a static eFACE score of 37, dynamic eFACE score of 31, and smile eFACE score of 48. At her 6-month follow-up, she was a House-Brackmann 5 with a static eFACE score of 50, dynamic eFACE score of 27, and smile eFACE score of 53. Preliminary results from our total series of 25 patients with an average of 5 years of follow-up were a House-Brackmann 2.5 and eFACE scores of 83.1 for static facial symmetry, 67.5 for dynamic facial symmetry, and 77.7 for smile score. Twenty of the 25 patients had postoperative radiotherapy. No local tumor recurrence had been reported. The average reinnervation time was 9 months and ranged from 3 to 15 months. CONCLUSIONS: The SD-LDVxN flap is a highly resourceful solution to reconstruct complex parotid defects, especially those that sacrifice the facial nerve. The vascularized nerve graft allows for primary facial reanimation. Nerve recovery may be superior to what could be expected with a conventional nerve graft.

Reconstruction of Extensive Composite Parotid Region Oncologic Defects with Immediate Facial Nerve Reconstruction Using a Chimeric Scapulodorsal Vascularized Nerve Free Flap.

BACKGROUND: Cancer involving the parotid gland region may originates from parotid parenchyma itself or from locoregional organs and in rare cases, the facial nerve (FN) has to be sacrificed during tumor resection. In these cases, cancer extension often goes beyond the parotid compartment and requires extensive local resection responsible for complex multitissular defects. The goals of reconstruction may be summarized in the following two components: (1) restoration of the volumetric tissue defect and (2) FN reconstruction. The aim of this study is to describe our surgical technique and our cosmetic results using the chimeric scapulodorsal vascularized nerve (SDVN) flap to reconstruct extensive maxillofacial defects associated with FN sacrifice. METHODS: All patients undergone an extensive maxillofacial resection with FN sacrifice and primarily reconstructed with a SDVN flap were included. We classified the maxillofacial defects into six groups based on the type of resection. Intraoperative data including flap composition, topography of FN injury, length of nerve gap, and number of nervous anastomosis were recorded. RESULTS: Twenty-nine patients were included. Mean follow-up was 38.7 months. The harvested flaps included the SDVN combined with different components according to the defect group. A satisfactory volumetric restoration was obtained in 93% of cases. The mean number of distal nervous anastomosis was 4.5. The length of the vascularized grafted nerve ranged from 7 to 10 cm. CONCLUSION: This is largest series presented in literature on primary FN reconstruction utilizing a vascularized nerve graft. We believe that the chimeric SDVN flap should be highly considered for these cases due to its versatility. The surgeon is able to use single donor site available soft and hard tissues components along with a vascular motor nerve graft, which offers a great length and number of distal branches, and easily matches with the extracranial FN trunk and its peripheral ramifications.

Process of Care in Breast Reconstruction and the Impact of a Dual-Trained Surgeon.

BACKGROUND: For postmastectomy reconstruction, the most common model in the United States is a two-team approach, consisting of breast and plastic surgeon. In other countries, a single-surgeon approach trained in both plastic and oncologic surgery is well described. We hypothesized that a dual-trained breast and plastic surgeon would decrease the postoperative care burden for the patient without compromising outcomes and serve as a model for team-centered breast reconstruction care. METHODS: A retrospective review was performed of patients undergoing mastectomy with immediate expander reconstruction from January 2013 to October 2014. Patient data up to 1 year postoperatively was recorded. Patients were stratified by treatment to "single-surgeon" or "two-surgeon" team. Demographic and operative data were recorded. Google Maps was used to calculate travel distance. A standard of mean cost of travel per mile and mean hourly wage for San Diego County was used. The primary outcome was the total number of postoperative clinic visits. In addition, factors predictive of postoperative clinic visits were evaluated. RESULTS: During the study period, 147 patients were included in analysis (69, single-surgeon; 78, two-surgeon). The mean cost of travel per mile was US $59.2 cents and mean hourly wage for San Diego County was US $25.49. For the 1-year follow-up period, patients with the single surgeon had a mean (SD) of 9.3 (3.72) postoperative visits compared with 15.6 (3.96) for patients in the two-surgeon team (P < 0.0001).There were no statistical differences between groups in the rate of complications. In the final model, treatment team, bilateral mastectomies, and complications (operative and nonoperative) were significant predictors of the total number of postoperative visits. Patients in the two-surgeon team spent an additional 11.13 hours and 216 miles commuting and in clinic. In total, the additional 6.3 clinic visits for patients in the two-surgeon team resulted in an average of US $695.33 additional dollars spent on travel and lost wages. CONCLUSIONS: Single-surgeon patients required fewer postoperative visits. Fewer postoperative clinic visits may have significant socioeconomic and psychological benefits to patients. Given these results, we believe that streamlining care into an integrated multidisciplinary model would be beneficial.

The Impact of Residents on Patient Satisfaction.

BACKGROUND: High-quality physician communication is the foundation for achieving high patient satisfaction. Increasing importance is placed on eliciting feedback from patients. However, there have been few studies looking at the impact of resident involvement on patient satisfaction. Our hospital system values the patient's likelihood to recommend the practice as the top marker for patient satisfaction. METHODS: Between May 2016 and December 2016 at University of California, San Diego, all outpatient appointments were randomly mailed Press-Ganey surveys or an eSurvey regarding their experience. The surveys were filtered based on resident participation, and an χ test was performed to assess the impact of residents. An additional aim was to determine the degree to which the impact of resident involvement differed between surgical specialties. Binomial probability was calculated for each specialty using the 'no resident' group as the reference percentage. RESULTS: A total of 73,834 surveys were mailed or sent electronically, and 17,653 surveys were returned (23.9% response rate). Overall, patients expressed high levels of satisfaction with the quality of physician communication. Patients who had residents involved in their care reported a decrease in satisfaction with physician communication and a decrease in the likelihood to recommend the practice (88.7% vs 90.4%, P < 0.001). In the analysis of resident impact by surgical specialty, 9 specialties qualified for analysis. Resident involvement was associated with lower physician communication scores in orthopedic surgery (P = 0.032), otolaryngology (P = 0.015), and vascular surgery (P = 0.01). In all other surgical subspecialties, there was no statistically significant difference between groups. CONCLUSIONS: Overall, patients expressed high levels of satisfaction with the quality of physician communication with and without resident involvement. Resident physician involvement in surgical clinic visits was associated with lower overall patient satisfaction and decreased likelihood of recommending the practice. In addition, we observed that resident involvement was not associated with lower communication scores in most surgical specialties, including Plastic Surgery.

Computer-Aided Surgical Simulation in Head and Neck Reconstruction: A Cost Comparison among Traditional, In-House, and Commercial Options.

BACKGROUND: Computer-aided surgical simulation (CASS) has redefined surgery, improved precision and reduced the reliance on intraoperative trial-and-error manipulations. CASS is provided by third-party services; however, it may be cost-effective for some hospitals to develop in-house programs. This study provides the first cost analysis comparison among traditional (no CASS), commercial CASS, and in-house CASS for head and neck reconstruction. METHODS: The costs of three-dimensional (3D) pre-operative planning for mandibular and maxillary reconstructions were obtained from an in-house CASS program at our large tertiary care hospital in Northern Virginia, as well as a commercial provider (Synthes, Paoli, PA). A cost comparison was performed among these modalities and extrapolated in-house CASS costs were derived. The calculations were based on estimated CASS use with cost structures similar to our institution and sunk costs were amortized over 10 years. RESULTS: Average operating room time was estimated at 10 hours, with an average of 2 hours saved with CASS. The hourly cost to the hospital for the operating room (including anesthesia and other ancillary costs) was estimated at $4,614/hour. Per case, traditional cases were $46,140, commercial CASS cases were $40,951, and in-house CASS cases were $38,212. Annual in-house CASS costs were $39,590. CONCLUSIONS: CASS reduced operating room time, likely due to improved efficiency and accuracy. Our data demonstrate that hospitals with similar cost structure as ours, performing greater than 27 cases of 3D head and neck reconstructions per year can see a financial benefit from developing an in-house CASS program.

The vastus lateralis free flap for lower extremity gustilo grade III reconstruction.

BACKGROUND: Orthopedic trauma patients with Gustilo grade III injuries to the distal third of lower extremity present challenges to optimum reconstructive management. There is no consensus on the ideal autologous tissue for transfer in large lower extremity defect reconstruction. We present a large case series utilizing the vastus lateralis (VL) free flap for lower extremity Gustilo grade III reconstruction. PATIENTS AND METHODS: This is a case series of patients who underwent VL free tissue transfer for Gustilo grade III injuries. A total of 38 free tissue transfers were performed for lower extremity reconstruction, 19 of which were VL flaps. Mean interval between injury and reconstruction was 46 days (range 7-240 days). RESULTS: The mean wound size was 11.37 cm x 11.42 cm and all cases underwent delayed reconstruction. Seven day flap viability was 100% and 30-day flap viability was 17/19 (89%). There were six complications: two hematomas requiring drainage, one flap dehiscence, one distal flap loss requiring a reverse saphenous vein graft extension, and two complete flap losses. Of the two failed flaps, one was attributed to heparin-induced thrombocytopenia and the other to venous congestion complicated by methicillin-resistant Staphylococcus aureus infection. CONCLUSIONS: The VL free flap is a reliable and versatile flap that can be tailored and tangentially thinned to match the shape and size of a defect, and the long pedicle allows the surgeon to stay away from the zone of injury. This flap should be strongly considered for lower extremity reconstruction, especially in salvage operations for large defects. © 2015 Wiley Periodicals, Inc. Microsurgery 37:212-217, 2017.

The "Y" Double Spiral Cord: An Anatomic Variant of Dupuytren Disease: A Report of 2 Cases.

CASE: We report 2 cases of a spiral nerve variant that has only 1 previously reported description in the literature. A pretendinous cord was found to branch into a "Y" configuration, extending distally on both the radial and ulnar sides of the same digit, with the radial and ulnar digital nerves spiraling around each limb of the "Y cord". CONCLUSION: Rare spiral nerve variants exist which place the digital neurovascular bundles (NVBs) at risk. Awareness of these variants and adherence to conservative surgical principles allow the surgeon to identify these scenarios intraoperatively and safely dissect the digital NVBs free of pathologic tissue.

Heterotopic ossification after local steroid injection.

Pachydermodactyly (PDD) is a rare, benign disease associated with progressive swelling of the periarticular soft tissue of phalangeal hand joints typically treated with local steroid injections. We present a case of a 37-year-old man with PDD treated with local steroid injections. He later developed heterotopic ossification and para-articular calcifications in the injection sites. Heterotopic ossification is not associated with PDD nor is it a recognised complication of local steroid injections. This is the first case in literature of heterotopic ossification occurring after local steroid injection and brings to attention a new potential complication of a widely performed procedure.