Operating in an Opioid Crisis: A Temporal Analysis of Pain Medication Prescribing Practices in Plastic Surgery.

BACKGROUND: In response to the opioid epidemic, the United States declared a public health emergency in 2017. We evaluated pain medication prescribing practices among plastic and reconstructive surgeons, assessing pain medication prescription rates and opioid-related mortality both nationally and regionally within the United States. METHODS: A retrospective analysis of Medicare Part D prescriber data among plastic surgeons from 2013 through 2017 was conducted. Pain medications were categorized as opioid and nonopioid medications. Trends in surgeon prescribing habits were evaluated using the Cochrane-Armitage trend test. RESULTS: A total of 708,817 pain medication claims were identified: 612,123 claims (86%) were for opioid pain medications and 96,694 claims (14%) were for nonopioid pain medications. Total pain medication claims decreased from 44% of all medications in 2013 to 37% in 2017 (P < 0.001). Opioid medications decreased from 37% of total medication claims to 32% (P < 0.001). The overall opioid prescription rate fell from 1.53 claims per beneficiary in 2013 to 1.32 in 2017 (P < 0.001). Nonopioid pain medications decreased from 7% in 2013 to 6% in 2017 (P < 0.001); nonsteroidal anti-inflammatory drug claims increased by 44%. The prescription rate of nonopioid medications decreased from 2.40 claims per beneficiary in 2013 to 2.32 in 2017 (P < 0.001). An overall increase in opioid-related mortality was observed. Trends in pain medication prescriptions varied significantly among US regions and divisions. CONCLUSIONS: Plastic surgeons are prescribing less opioids and relying more on nonopioid pain medications. Increased adoption of multimodal pain treatment approaches among surgeons is a likely explanation for this trend in face of the current opioid crisis.

Trends in Medicare Reimbursement for the Top 20 Surgical Procedures in Craniofacial Trauma.

BACKGROUND: Research regarding financial trends in craniofacial trauma surgery is limited. Understanding these trends is important to the evolvement of suitable reimbursement models in craniofacial plastic surgery. The purpose of this study was to evaluate the trends in Medicare reimbursement rates for the top 20 most utilized surgical procedures for facial trauma. METHODS: The 20 most commonly utilized Current Procedural Terminology (CPT) codes for facial trauma repairs in 2018 were queried from The National Summary Data File from the Centers for Medicare & Medicaid Services (CMS). Reimbursement data for each procedure was then extracted from The Physician Fee Schedule Lookup Tool. Changes to the United States consumer price index (CPI) were used to adjust all gathered data for inflation to 2021 US dollars (USD). The average annual and the total percent change in reimbursement were calculated for the included procedures based on the adjusted trends from the years 2000 to 2021. RESULTS: From 2000 to 2021, the average reimbursement for all procedures decreased by 16.6% after adjusting for inflation. Closed treatment of temporomandibular joint dislocation and closed treatment of nasal bone fractures without manipulation demonstrated the greatest decrease in mean adjusted reimbursement at -48.7% and -48.3%, respectively, while closed treatment of nasal bone fractures without stabilization demonstrated the smallest mean decrease at -1.4% during the study period. Open treatment of nasal septal fractures with or without stabilization demonstrated the greatest increase in mean adjusted reimbursement at 18.9%, while closed treatment of nasal septal fractures with or without stabilization demonstrated the smallest increase at 1.2%. The average reimbursement for all closed procedures in the top 20 decreased by 19.3%, while that for all open procedures decreased by 15.5%. The adjusted reimbursement rate for all top 20 procedures decreased by an average of 0.8% each year. CONCLUSIONS: To the best of our knowledge, this is the first study to comprehensively evaluate trends in Medicare reimbursement for facial trauma surgical repairs. Adjusting for inflation, Medicare reimbursement for the top 20 most commonly utilized procedures has largely decreased from 2000 to 2021. Consideration of these trends by surgeons, hospital systems, and policymakers will be important to assure continued access to meaningful surgical facial trauma care in the United States.

Outcomes and Perioperative Risk Factors after Oncologic Free-Flap Scalp Reconstruction.

BACKGROUND: Little is known about the risk factors associated with complications after free flap scalp reconstruction. The purpose of this study was to identify patient, scalp defect, and flap characteristics associated with increased risk of surgical complications. METHODS: A retrospective study was performed of free-flap scalp reconstruction in oncologic patients at Memorial Sloan Kettering Cancer Center from 2002 to 2017. Data collection included patient, defect, flap, and complication characteristics. Complications were classified into major, defined as complications requiring surgical intervention, and minor, defined as complications requiring conservative treatment. Risk factors and outcome variables were compared using chi-square with Fisher's exact test. RESULTS: A total of 63 free flaps to the scalp in 58 patients were performed; average follow-up was 3.5 years. Most flaps were muscle-only or musculocutaneous. One-third of patients with free flaps experienced complications (n = 21, 15 major and 6 minor). Examining risk factors for complications, patients with cardiovascular disease were nearly three times more likely to have suffered a major complication than patients without cardiovascular disease (36.7 vs. 12.1%, p = 0.04). This was the only significant risk factor noted. Perioperative radiotherapy, prior scalp surgery, flap type, and recipient vessel selection were found to be nonsignificant risk factors. CONCLUSION: Cardiovascular disease may be a significant marker of risk for major complications in patients undergoing free-flap reconstruction of the scalp. This information should be used to help guide perioperative counseling and decision making in this challenging patient population.

Ethics Education in U.S. Allopathic Medical Schools: A National Survey of Medical School Deans and Ethics Course Directors.

AbstractPurpose: to characterize ethics course content, structure, resources, pedagogic methods, and opinions among academic administrators and course directors at U.S. medical schools. METHOD: An online questionnaire addressed to academic deans and ethics course directors identified by medical school websites was emailed to 157 Association of American Medical Colleges member medical schools in two successive waves in early 2022. Descriptive statistics were utilized to summarize responses. RESULTS: Representatives from 61 (39%) schools responded. Thirty-two (52%) respondents were course directors; 26 (43%) were deans of academic affairs, medical education, or curriculum; and 3 with other roles also completed the survey (5%). All 61 schools reported some form of formal ethics education during the first year of medical school, with most (n = 54, 89%) reporting a formal mandatory introductory course during preclinical education. Schools primarily utilized lecture and small-group teaching methods. Knowledge-based examinations, attendance, and participation were most commonly used for assessment. A large majority regarded ethics as equally or more important than other foundational courses, but fewer (n = 37, 60%) provided faculty training for teaching ethics. CONCLUSIONS: Despite a response rate of 39 percent, the authors conclude that medical schools include ethics in their curricula in small-group and lecture formats with heterogeneity regarding content taught. Preclinical curricular redesigns must innovate and implement best practices for ensuring sound delivery of ethics content in future curricula. Additional large-scale research is necessary to determine said best practices.

The Effects of Website and Social Media Presence of Integrated Plastic Surgery Residency Programs on Prospective Applicants: An Analysis During the Coronavirus Disease 2019 Pandemic.

PURPOSE: Integrated plastic surgery residency programs have increased their social media presence to educate and recruit prospective residents. This study aims to understand the impact of integrated plastic surgery residency program social media on the 2020 to 2021 applicants' evaluation of prospective programs, particularly during the coronavirus disease 2019 pandemic. MATERIALS AND METHODS: An optional 20-item online survey was sent to integrated plastic surgery residency applicants applying to the authors' program. RESULTS: Surveys were sent to 300 integrated plastic surgery residency applicants with an average of 168 responses (56% response rate). Social media resources included official residency program website (87.1%), Instagram (70.2%), and Doximity (46.8%). The most frequently used resource by applicants was the official residency program website (43.9%); Instagram was the second most frequently used (40.2%) followed by Doximity (8.3%). Most respondents agreed that social media was an effective means to inform applicants (66.1%), and it positively impacted their perception of the program (64.8%). The cited benefits were helping the program exhibit its culture and comradery among residents, faculty, and staff (78.4%). Among applicants, 73.6% noted that it had a significant impact on their perceptions of programs. Most respondents truncated their planned plastic surgery subinternships, completing 1 instead of 3 planned subinternships because of coronavirus disease 2019 limitations. CONCLUSIONS: During the 2020 to 2021 plastic surgery application cycle, applicants used social media accounts of plastic surgery residency programs to inform and educate themselves about prospective programs. This study suggests that investing resources into a social media residency accounts is a meaningful pursuit for integrated plastic surgery programs and is an important aspect in today's recruitment.

Procedural Trends in Medicare Reimbursement and Utilization for Breast Reconstruction: 2000-2019.

PURPOSE: Development of appropriate reimbursement models for breast reconstruction in the United States requires an understanding of relevant economic trends. The purpose of this study is to evaluate longitudinal patterns in Medicare reimbursement for frequently performed breast reconstruction procedures between 2000 and 2019. METHODS: Reimbursement data for 15 commonly performed breast reconstruction procedures were analyzed using the Centers for Medicare & Medicaid Services Physician Fee Schedule Look-Up Tool for each Current Procedural Terminology code. By utilizing changes to the US consumer price index, monetary data were adjusted for inflation to 2019 US dollars. Inflation-adjusted trends were used to calculate average annual and total percentage changes in reimbursement over time. RESULTS: From 2000 to 2019, average adjusted reimbursement for all procedures fell by 13.32%. All procedures demonstrated a negative adjusted reimbursement rate other than immediate insertion of breast prosthesis, which increased by 55.37%. The largest mean decrease was observed in breast reconstruction with other technique (-28.63%), followed by single pedicle transverse rectus abdominis myocutaneous flap (-26.02%), single pedicle transverse rectus abdominis myocutaneous flap with microvascular anastomosis (-23.33%), latissimus dorsi flap (-19.65%), and free flap reconstruction (-19.36%). CONCLUSIONS: There has been a steady yet substantial decline in Medicare reimbursement for the majority of breast reconstruction procedures over the last 20 years. Given increasing medical costs and the financial uncertainty of the US health care system, an understanding of Medicare reimbursement trends is vital for policymakers, administrators, and physicians to develop agreeable reimbursement models that facilitate growth and economic vitality of breast reconstruction in the United States.

Outcomes in Pediatric Maxillofacial Reconstruction With Vascularized Fibular Flaps: A Systematic Review.

BACKGROUND: The purpose of this study was to examine the complications and outcomes after maxillofacial reconstruction using the free fibular flap in the pediatric population. METHODS: A systematic review and descriptive analysis were conducted using data variables, including study characteristics; patient characteristics; postoperative complications (major and minor); surgical revision; and dental rehabilitation. RESULTS: The systematic review resulted in 1622 articles, 55 of which met inclusion criteria for this study. The 55 articles consisted of 17 case series and 38 case reports with level III/IV and level V of evidence, respectively. Of the 155 identified pediatric patients, the rate of major complications was 13.5% and minor complications was 24.5%. The most common complication was mild growth distortion (n = 7) at the recipient site. Complications at the donor site were less common. During follow-up, 29 patients (18.7%) underwent or awaited surgical revision, and 43 patients (27.7%) underwent or awaited dental rehabilitation. CONCLUSIONS: Our study suggests that the free fibular flap for pediatric maxillofacial reconstruction is safe and reliable. Additionally, surgical revision to correct the functional impairments resulting from primary reconstruction using the free fibular flap is relatively common.

Ultradelayed Arterial Thrombosis: Critical Flap Ischemia After Phalloplasty.

BACKGROUND AND OBJECTIVES: Delayed arterial thrombus causing loss of a cutaneous free flap at or beyond 6 months is a rare phenomenon. The purpose of this report is to describe 2 cases of arterial compromise requiring medical and surgical intervention at or beyond 6 months after radial forearm free flap (RFFF) phalloplasty and to define the phenomenon of ultradelayed arterial thrombosis. METHODS: Patient 1 is a 44-year-old transmale who presented with pulselessness, pallor, and hypersensitivity of his neophallus 10 years status post-RFFF phalloplasty using a saphenous vein interposition graft (SVIG) between the superficial femoral artery (SFA) and radial artery (RA). Patient 2 is a 35-year-old transmale who presented with similar complaints 6 months status post-RFFF phalloplasty with the same vascular connections as above. RESULTS: Patient 1 was found to have an arterial thrombus distal to the SFA-SVIG anastomosis requiring catheter-directed thrombolysis with tissue plasminogen activator, resulting in partial loss limited to the distal three fourths of the shaft. Patient 2 was also found to have an arterial thrombus distal to the SFA-SVIG anastomosis requiring catheter-directed thrombolysis with tissue plasminogen activator and common femoral artery CFA-RA bypass, resulting in partial loss limited to the neoglans. CONCLUSIONS: Ultradelayed arterial thrombosis is a rare phenomenon requiring urgent intervention. The exact causes of this phenomenon, whether mechanical or physiological or both, have yet to be fully elucidated but it is hypothesized that the original anastomosis may continue to serve as the critical blood supply to its flap as far as 10 years after surgery.

Same-day Discharge Is Safe and Effective After Implant-Based Breast Reconstruction.

BACKGROUND: Same-day discharge after mastectomy is a recently described treatment approach. Limited data exist investigating whether same-day discharge can be successfully implemented in patients undergoing mastectomy with immediate implant-based breast reconstruction (IBR). METHODS: Patients having mastectomy with IBR from 2013 to 2019 were reviewed. Enhanced recovery with same-day discharge was implemented in 2017. Patient characteristics, oncologic treatments, surgical techniques, and 90-day postoperative complications and reoperations were analyzed comparing enhanced recovery patients with historical controls. RESULTS: A total of 363 patients underwent nipple-sparing (214, 59%) or skin-sparing (149, 41%) mastectomy with 1-stage (270, 74%) or tissue expander (93, 26%) IBR. Enhanced recovery was used for 151 patients, with 79 of these patients (52%) discharged same-day. Overall, enhanced recovery patients experienced a significantly lower rate of 90-day complications (21% vs 41%, P < 0.001), including hematoma (3% vs 11%, P = 0.002), mastectomy flap necrosis (7% vs 15%, P = 0.02), seroma (1% vs 9%, P < 0.001), and wound breakdown (3% vs 9%, P = 0.05). Postoperative complication rates did not significantly differ among enhanced recovery patients discharged same day. Postoperative admissions significantly decreased after enhanced recovery implementation (100% to 48%, P < 0.001), and admitted enhanced recovery patients experienced a lower length of stay (1.2 vs 1.8, P < 0.001). Enhanced recovery patients experienced a lower incidence of ≥1 unplanned reoperation (22% vs 33%, P = 0.01); overall average unplanned and total reoperations did not significantly differ between groups. CONCLUSIONS: In conjunction with enhanced recovery practices, same-day discharge after mastectomy with IBR is a safe and feasible treatment approach.

Does Prior Breast Augmentation Affect Outcomes After Mastectomy With Reconstruction? An Analysis of Postoperative Complications and Reoperations.

BACKGROUND: The purpose of this study is to evaluate how prior breast augmentation impacts rates of complications and risk for reoperation after mastectomy with concurrent breast reconstruction. METHODS: Patients undergoing nipple-sparing, skin-sparing, or simple mastectomy with implant-based reconstruction from 2008 to 2018 were identified in a prospective database. Postoperative complications and reoperations were then analyzed comparing patients with prior augmentation to patients without history of previous breast surgery. RESULTS: A total of 468 patients were identified with a median follow-up of 4 years. Of these, 72 had prior augmentation mammoplasty. These patients underwent nipple-sparing (52, 72%), skin-sparing (15, 21%), or simple (5, 7%) mastectomy with immediate direct-to-implant (46, 61%) or tissue expander (26, 35%) reconstruction. On univariate analysis, this cohort had a lower body mass index (23.3 vs 25.3, P = 0.003), a higher rate of nipple-sparing mastectomy (72% vs 54%, P = 0.01), and a higher prevalence of stage I disease (44% vs 33%, P = 0.04). Differences in age, comorbidities, reconstructive techniques, tumor size, and neoadjuvant/adjuvant therapies were not significant. Overall complication rate between patients with or without prior augmentation did not significantly differ (51% vs 50%, P = 0.83); no significant differences in rates of surgical site infection, hematoma, mastectomy skin flap/wound necrosis, nipple complications, implant loss, or capsular contracture were found. Analysis of reoperations between patients with and without prior augmentation revealed no significant differences in average number of subsequent planned, unplanned, or total reoperations. On multivariate analysis, prior breast augmentation was found to be associated with significantly increased risk for undergoing ≥1 unplanned reoperation (odds ratio, 2.28; 95% confidence interval, 1.28-4.05, P = 0.005). CONCLUSIONS: Prior augmentation mammoplasty does not significantly affect rates of postoperative complications after mastectomy with concurrent reconstruction. Although prior augmentation does not affect number of subsequent reoperations on average, it does increase the risk of experiencing 1 or more unplanned reoperation after mastectomy with reconstruction.

3D Nipple-Areolar Tattoo: It's Technique, Outcomes, and Utilization.

BACKGROUND: Three-dimensional (3D) nipple-areolar tattoo is a novel approach to nipple-areolar complex reconstruction for which little data exist. Our aim was to evaluate 3D nipple-areolar tattoo outcomes and investigate if patient factors, payer status, surgeries, or therapies affect tattoo utilization. METHODS: Patients pursuing skin-sparing (SSM) or attempted nipple-sparing mastectomy (NSM) with breast reconstruction from 2008 to 2019 were reviewed. Outcomes included frequency of 3D tattoo, post-procedure complications (infections, or other local adverse sequelae), and rates, indications, and timing of revisions. Patient factors, payer status, surgeries, and adjuvant therapies underwent univariate analysis comparing rates of 3D tattoo and revisions. RESULTS: A total of 191 patients were identified; median follow-up was 4 years. The majority of patients were white (165, 86%), married (146, 76%), and post-menopausal (97, 51%), with private insurance (156, 81%). Surgeries included SSM (172, 90%) or attempted NSM (19, 10%) with implant (154, 81%) or autologous reconstruction (37, 19%). Sixty-two patients (32%) underwent 3D nipple-areolar tattooing. No post-procedure complications occurred. After tattooing, 20 patients (32%) pursued revisions, the majority due to color fading (12, 60%). Average time from tattoo to completion of revisions was 5.6 months. Patients undergoing autologous reconstruction had a higher rate of 3D tattooing (p < 0.001). Adjuvant radiation led to a higher rate of revisions (p = 0.02). Patient factors, payer status, index mastectomy, and chemotherapy did not significantly affect rates of 3D tattooing or revisions. CONCLUSIONS: 3D nipple-areolar tattoo utilization is likely unaffected by age, marriage, menopause, or payer status. Radiotherapy and color fading can lead to more revisions. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Analysis of 20-Year Trends in Medicare Reimbursement for Reconstructive Microsurgery.

BACKGROUND: Microsurgery is being increasingly utilized across surgical specialties, including plastic surgery. Microsurgical techniques require greater time and financial investment compared with traditional methods. This study aimed to evaluate 20-year trends in Medicare reimbursement and utilization for commonly billed reconstructive microsurgery procedures from 2000 to 2019. METHODS: Microsurgical procedures commonly billed by plastic surgeons were identified. Reimbursement data were extracted from The Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services for each current procedural terminology (CPT) code. All monetary data were adjusted for inflation to 2019 U.S. dollars. The average annual and total percentage changes in reimbursement were calculated based on these adjusted trends. To assess utilization trends, CMS physician/supplier procedure summary files were queried for the number of procedures billed by plastic surgeons from 2010 to 2018. RESULTS: After adjusting for inflation, the average reimbursement for all procedures decreased by 26.92% from 2000 to 2019. The greatest mean decrease was observed in CPT 20969 free osteocutaneous flaps with microvascular anastomosis (-36.93%). The smallest mean decrease was observed in repair of blood vessels with vein graft (-9.28%). None of the included procedures saw an increase in reimbursement rate over the study period. From 2000 to 2019, the adjusted reimbursement rate for all procedures decreased by an average of 1.35% annually. Meanwhile, the number of services billed to Medicare by plastic surgeons across the included CPT codes increased by 42.17% from 2010 to 2018. CONCLUSION: This is the first study evaluating 20-year trends in inflation-adjusted Medicare reimbursement and utilization in reconstructive microsurgery. Reimbursement for all included procedures decreased over 20% during the study period, while number of services increased. Increased consideration of these trends will be important for U.S. policymakers, hospitals, and surgeons to assure continued access and reconstructive options for patients.

The Chimeric Gracilis and Profunda Artery Perforator Flap: Characterizing This Novel Flap Configuration with Angiography and a Cadaveric Model.

BACKGROUND: A chimerically configured gracilis and profunda artery perforator (PAP) flap is highly prevalent based on recent computed tomography (CT)-imaging data. The purpose of this study is to further characterize the vascular anatomy of this novel flap configuration and determine the feasibility of flap dissection. METHODS: To characterize flap arterial anatomy, lower extremity CT angiograms performed from 2011 to 2018 were retrospectively reviewed. To characterize venous anatomy and determine the feasibility of flap harvest, the lower extremities of cadavers were evaluated. RESULTS: A total of 974 lower extremity CT angiograms and 32 cadavers were included for the assessment. Of the 974 CT angiograms, majority (966, 99%) were bilateral studies, yielding a total of 1,940 lower extremities (right-lower-extremity = 970 and left-lower-extremity = 970) for radiographic evaluation. On CT angiography, a chimerically configured gracilis and PAP flap was found in 51% of patients (n = 494/974). By laterality, chimeric anatomy was present in 26% of right lower extremities (n = 254/970) and 25% of left lower extremities (n = 240/970); bilateral chimeric anatomy was found in 12% (n = 112/966) of patients. Average length of the common arterial pedicle feeding both gracilis and PAP flap perforasomes was 31.1 ± 16.5 mm (range = 2.0-95.0 mm) with an average diameter of 2.8 ± 0.7 mm (range = 1.3-8.8 mm).A total of 15 cadavers exhibited chimeric anatomy with intact, conjoined arteries and veins allowing for anatomical tracing from the profunda femoris to the distal branches within the tissues of the medial thigh. Dissection and isolation of the common pedicle and distal vessels was feasible with minimal disruption of adjacent tissues. Chimeric flap venous anatomy was favorable, with vena commitante adjacent to the common pedicle in all specimens. CONCLUSION: Dissection of a chimeric medial thigh flap consisting of both gracilis and PAP flap tissues is feasible in a cadaveric model. The vascular anatomy of this potential flap appears suitable for future utilization in a clinical setting.

Aesthetic Surgery Research Funding: Where Does It Come From and to Whom Does It Go?

BACKGROUND: Recent data show that aesthetic surgery research is lagging compared with reconstructive surgery: research funding and institutional disparities within aesthetic surgery are potential factors in this trend. OBJECTIVES: The authors sought to determine if disparities exist in aesthetic surgery research based on funding sources or practice settings. METHODS: The authors reviewed Aesthetic Surgery Journal articles from 2009 to 2019. Chi-square, t test, bivariate, and multivariate regression analyses were employed to evaluate research trends. RESULTS: A total of 2262 publications were identified, with 318 funded articles meeting inclusion criteria. The majority of studies (294, 92%) received external funding, with 281 (88%) being supported solely by external funds. Externally funded studies were financed by private industry (194, 66%), foundations/societies (53, 18%), government grants (23, 8%), or a combination of agencies (24, 8%). The majority of funded studies were at academic institutions (266, 84%), followed by private practice (46, 14%) and private industry (6, 2%). Analysis of annual publications revealed a rising percentage of academic-based research, which correlated with decreasing research from private practice (r = -0.95, r2 = 0.89, P < 0.001). Compared with academic institutions, private practice relied more heavily on industry funding (55% vs 87%, respectively, P = 0.001), exhibiting lower rates of foundational/societal (20% vs 2%), governmental (9% vs 0%), combined (8% vs 7%), and internal department funding (8% vs 4%). Article citations and level of evidence were unaffected by funding source, agency, or practice setting. CONCLUSIONS: Lack of diversity in research funding among private practice surgeons may explain the reported discrepancies that currently exist between aesthetic and reconstructive surgery research.

Latissimus dorsi flap with vascularized lymph node transfer for lymphedema treatment: Technique, outcomes, indications and review of literature.

BACKGROUND AND OBJECTIVES: One of the surgical treatment options for lymphedema is vascularized lymph node transfer (VLNT). We present our experience with latissimus dorsi (LD) flap based VLNT for lymphedema treatment. METHODS: We reviewed 14 consecutive patients treated with pedicled or free LD VLNT between 2014 and 2016 for recalcitrant upper or lower extremity lymphedema. Seven patients underwent lymphovenous bypass in addition to LD VLNT. Limb volume and quality of life scores using the Lymphedema Life Impact Scale (LLIS) were analyzed for quantitative and qualitative assessment. RESULTS: Mean duration of lymphedema was 69 months (range 24-124 months). Follow-up ranged from 3 to 12 months (mean 6.7 month). Major complications included one free flap loss and one reoperation for thrombosis. Mean preoperative volume differential between normal and affected limb was 35% (range 3-87%). Volume differential reduction was 48%, 28%, and 46% at 3, 6, and 12 months, respectively. The LLIS score improved from mean of 46.8 before surgery to a mean of 38.6 at 12 month, demonstrating improvement in quality of life. CONCLUSIONS: The LD VLNT provides a viable option for treatment of UE and LE lymphedema in selected patients. J. Surg. Oncol. 2017;115:72-77. © 2016 Wiley Periodicals, Inc.

The utility of the musculocutaneous anterolateral thigh flap in pharyngolaryngeal reconstruction in the high-risk patient.

BACKGROUND AND OBJECTIVES: Prior radiotherapy leads to increased wound complication rates for microsurgical reconstruction of pharyngolaryngeal (PL) defects. Incorporating vastus lateralis muscle together with anterolateral thigh flap (ALT) skin in defect reconstruction is useful in protecting vital structures and reinforcing irradiated neck skin and suture lines. This study shows the utility of the musculocutaneous ALT (MC ALT) in PL reconstruction in previously irradiated patients. METHODS: A single-surgeon, retrospective chart review of all patients with defects of the PL region where an MC ALT was used for reconstruction from February 2014 to May 2016. The harvest of the MC ALT is described. RESULTS: Thirteen consecutive patients underwent reconstruction with a MC ALT flap. All 13 patients had received previous radiotherapy. PL defects included five partial, five subtotal, and three total. There was a 100% flap survival rate with five early recipient site complications including three fistulas, one neck abscess, and one partial muscle necrosis. Three patients (23%) developed strictures requiring dilatation, two of whom had received post-reconstruction radiotherapy. CONCLUSIONS: The use of the MC ALT for reconstruction of PL defects should be considered to mitigate the negative effects of prior irradiation and provide a back-up plan in instances where complications occur.

Implantable Doppler monitoring of buried free flaps during vascularized lymph node transfer.

BACKGROUND AND OBJECTIVES: Reliable flap monitoring is crucial to the success of free tissue transfer, including vascularized lymph node transfer (VLNT). However, no large-scale study has examined implantable Doppler monitoring in VLNT. We aimed to determine whether an implantable Doppler system can reliably monitor flap perfusion during VLNT and also to calculate the sensitivity and specificity of this system for detecting compromise in the monitored vessel. METHODS: An analysis of prospectively collected data of patients who underwent buried VLNT with implantable Doppler monitoring between 2014 and 2015 was performed. RESULTS: A consecutive series of 100 patients underwent VLNT with implantable Doppler monitoring. Five cases required return to the operating room for flap exploration due to a change in Doppler signal quality. All compromised flaps were salvaged. The sensitivity of the implantable Doppler system for flap monitoring was 100%, the specificity was 97.9%, the positive predictive value was 60%, and the negative predictive value was 100%. The false-positive rate was 2%. CONCLUSIONS: This is the largest reported series of implantable Doppler monitoring of free flap perfusion during VLNT. Our experience suggests that this is a safe and effective technique for postoperative monitoring of VLNT.