Aesthetic Surgery in Plastic Surgery Academia.

BACKGROUND: Aesthetic surgery is a critical component of academic plastic surgery. As institutions are placing increased focus on aesthetic surgery, there is an opportunity to identify factors that facilitate the creation and maintenance of successful aesthetic plastic surgery programs. OBJECTIVES: The aim of this study was to conduct a national survey to evaluate the current state of academic aesthetic surgery and to identify factors that contribute to success. METHODS: A REDCap 122-question survey was developed and validated by members of the Academic Aesthetic Surgery Roundtable (AASR). The national survey was distributed to department chairs and division chiefs with active ACGME-approved plastic surgery programs (n = 92). Responses underwent Pearson's chi-squared, Wilcoxon rank-sum, and postselection inference analyses. AASR members convened to interpret data and identify best practices. RESULTS: Responses were received from 64 of 92 queries (69.6%). The multivariate analysis concluded traits associated with successful academic aesthetic surgery practices included the presence of aesthetic surgery-focused, full-time faculty whose overall practice includes >50% aesthetic surgery (P = 0.040) and nonphysician aesthetic practitioners who provide injection services (P = 0.025). In the univariate analysis, factors associated with strong aesthetic surgery training programs included resident participation in faculty aesthetic clinics (P = 0.034), aesthetic research (P = 0.006), and discounted resident aesthetic clinics (P < 0.001). CONCLUSIONS: The growth of academic aesthetic surgery practices represents a significant opportunity for advancement of resident training, departmental financial success, and diversification of faculty practices. By identifying and sharing best practices and strategies, academic aesthetic surgery practices can be further enhanced.

Complications after thigh sarcoma resection.

BACKGROUND AND OBJECTIVES: Standard treatment for extremity sarcoma is limb-sparing surgery often with radiation, but complications occur frequently. We sought to determine factors predictive of wound complications after thigh sarcoma resection and reconstruction while analyzing trends over time. METHODS: We reviewed all thigh defects requiring plastic surgeon reconstruction following sarcoma resection at our institution from 1997 to 2014. Patient demographics, comorbidities, operative characteristics, multi-modality therapies, and complications were analyzed. Wound complications were: infection, dehiscence, seroma, hematoma, or partial/total flap loss. RESULTS: There were 159 thigh reconstructions followed for 30 months on average. Eighty-seven percent of patients underwent radiation and 42% had chemotherapy. Almost half (49.1%) had a complication. The most common wound complication was surgical site infection (23.3%) followed by dehiscence (19.5%), and seroma (10.7%). Less common were partial (2.5%) or total flap loss (0.6%). Reoperation was required in 21 patients (13.2%). Tobacco use, older patient age, cardiac disease, and higher body mass index were independently associated with wound complications. Complications trended towards decreasing over time, but this was not statistically significant. CONCLUSIONS: Tobacco use, cardiac disease, and higher body mass index, but not the timing of reconstruction, appear to increase the risk of wound complications after thigh soft tissue sarcomas resection and plastic surgery reconstruction.

Tardive dyskinesia is associated with altered putamen Akt/GSK-3ß signaling in nonhuman primates.

BACKGROUND: Tardive dyskinesia is a delayed and potentially irreversible motor complication arising from chronic exposure to antipsychotic drugs. Interaction of antipsychotic drugs with G protein-coupled receptors triggers multiple intracellular events. Nevertheless, signaling pathways that might be associated with chronic unwanted effects of antipsychotic drugs remain elusive. In this study, we aimed to better understand kinase signaling associated with the expression of tardive dyskinesia in nonhuman primates. METHODS: We exposed capuchin monkeys to prolonged haloperidol (n = 10) or clozapine (n = 6) treatments. Untreated animals were used as controls (n = 6). Half of haloperidol-treated animals (5) developed mild tardive dyskinesia similar to that found in humans. Using Western blots and immunochemistry, we measured putamen total and phosphorylated protein kinase levels associated with canonical and noncanonical signaling cascades of G protein-coupled receptors. RESULTS: Antipsychotic drugs enhanced pDARPP-32 and pERK1/2, but no difference ws observed in phosphoprotein kinase levels between dyskinetic and nondyskinetic monkeys. On the other hand, comparison of kinase levels between haloperidol-treated dyskinetic and nondyskinetic monkeys indicated that dyskinetic animals had lower GRK6 and ß-arrestin2 levels. Levels of pAkt and pGSK-3ß were also reduced, but only haloperidol-treated monkeys that developed tardive dyskinesia had reduced pGSK-3ß levels, whereas pAkt levels in dyskinetic animals positively correlated with dyskinetic scores. Interestingly, double immunofluorescence labeling showed that putamen dopamine D3 receptor levels were upregulated and that D3/pAkt colocalization was enriched in haloperidol-treated animals displaying tardive dyskinesia. CONCLUSIONS: Our results suggest that upregulation of putamen dopamine D3 receptor and alterations along the noncanonical GRK6/ß-arrestin2/Akt/GSK-3ß molecular cascade are associated with the development of tardive dyskinesia in nonhuman primates. © 2019 International Parkinson and Movement Disorder Society.

Study of the Impact of the Location of a Perforator in the Perfusion of a Perforator Flap: The Concept of "Angle of Perfusion".

Background Perforator flaps remain challenging in their design, especially as free flaps. We used a cadaveric model to help refine the design of perforator flaps by studying their vascular features. We define the angle of perfusion of a perforator as a tool to achieve safer flap designs. Methods A total of 83 flaps were designed from 20 fresh cadaveric anterolateral thigh flaps. The most dominant perforator larger than 0.5 mm was used as the reference point on the midline of the flap, and the tip of the flap was set at 5 cm (n = 10), 2 cm (n = 5), or 10 cm (n = 5) from this perforator. The perforator was injected with contrast agent, and the flap was scanned with computed tomography (CT) angiography. The vascular territory of the injected perforator was drawn twice by two different investigators. Perfused volumes were then obtained through a computerized algorithm on the CT workstation. Flaps were then flushed with heparinized saline and cut at decreasing angles (120, 90, 60, and 45 degrees) and rescanned with contrast for each perfusion angle. The perfused volumes were calculated for each angle. Results Volume and percentage of perfusion were significantly decreased with decreasing angles of perfusion, regardless of perforator location (2 cm, p = 0.002; 5 cm, p = 0.02; 10 cm, p < 0.001). Conclusions Acute angles of perfusion were associated with fewer incorporated linking vessels and lower flap perfusion. This phenomenon was less apparent in centrally located perforators. Perfusion angle and perforator location influence flap vascularity in a cadaveric model.

Comparative Study of Liposomal Bupivacaine Versus Paravertebral Block for Pain Control Following Mastectomy with Immediate Tissue Expander Reconstruction.

BACKGROUND: Several approaches to minimize postoperative pain, nausea, and enhance recovery are available for patients undergoing mastectomy with immediate tissue expander (TE) reconstruction. We compared the effectiveness of intraoperative local infiltration of liposomal bupivacaine (LB) to preoperative paravertebral block (PVB). METHODS: We retrospectively reviewed patients who underwent mastectomy with immediate TE reconstruction between May 2012 and October 2014 and compared patients with preoperative ultrasound-guided PVB to those with intraoperative LB infiltration. RESULTS: Fifty-three patients (54.6 %) received LB and 44 received PVB. LB was associated with less opioid use in the recovery room (p < 0.001), fewer patients requiring antiemetics (p = 0.03), and lower day of surgery pain scores (p = 0.008). LB also was associated with longer time to first opioid use (p = 0.04). On multivariable analysis controlling for expander placement location, year of surgery, and axillary lymph node dissection (ALND), the only variable that remained statistically significant was lower opioid use in the recovery room for patients with LB (p = 0.03) and day of surgery pain scores approached significance (p = 0.05). There was no difference in the proportion of patients discharged within 36 h of surgery between the groups. Focusing on first cases of the day (where PVBs are performed in the OR) showed average time to skin incision was 15 min shorter in the LB group (p = 0.004). CONCLUSIONS: Local infiltration of LB in patients undergoing mastectomy with immediate TE reconstruction decreases narcotic requirements in the recovery room, shortens preoperative anesthesiology time, and provides similar, if not better, perioperative pain control compared with PVB.

Free flaps for reconstruction of soft tissue defects in lower extremity: A meta-analysis on microsurgical outcome and safety.

BACKGROUND: Microsurgical free flaps for reconstruction of soft tissue defects in lower extremity have evolved into a reliable procedure over last decades; however, there lacked high level of evidence. METHODS: A systematic literature research was performed including studies between 2000 and 2014 in English, German, and Chinese (PubMed, EMBASE). Publications were selected applying inclusion/exclusion criteria. Postoperative complications were statistically analyzed with metaprop command of R GUI 3.0.1. RESULTS: Alltogether 30 articles overlooking 1,397 free flaps were included. The rate of total flap loss was 6.0% (95% confidence interval [CI] = 4.0%-8.0%, PQ (P values of Q statistics) = 0.03); the thrombosis rate was 6.0% (95% CI = 4.0%-9.0%, PQ = 0.01); the hematoma rate was 4.0% (95% CI = 3.0%-5.0%, PQ = 0.79); the partial necrosis rate was 6.0% (95% CI = 4.0%-10.0%, PQ < 0.01); the early infection rate was 4.0% (95% CI = 2.0%-6.0%, PQ = 0.03), and the dehiscence rate was 3.0% (95% CI = 2.0%-5.0%, PQ = 0.12). Reconstruction for diabetic foot may be not associated with a significant increase of procedural risk (Total flap loss rate = 6%, 95% CI = 3.0%-9.0%, PQ = 0.44). CONCLUSIONS: Microsurgical reconstruction of soft tissue defects in the lower extremity reconstruction could be regarded safe and reliable. A standardization of report of perioperative parameters and clinical outcomes is needed. © 2016 Wiley Periodicals, Inc. Microsurgery 36:511-524, 2016.

The Distally Based Dorsal Metatarsal Artery Perforator Flap: Vascular Study and Clinical Implications.

Background Intrinsic flaps based on the dorsal metacarpal arteries are useful for coverage of dorsal hand, finger, and thumb defects. The purpose of this study was to explore the anatomy of the dorsal metatarsal arteries (DMtAs) in the foot to help define their clinical utility. We observed the size and numbers of distal perforators from the DMtAs and quantified the vascular perfusion pattern of the DMtA perforator across the skin. Methods Ten fresh cadaver feet were injected with latex and dissected to assess the size and number of distal perforators from the DMtAs. Five DMtA perforator flaps were injected with methylene blue to visualize and quantify the vascular territory of the skin flap to understand the clinical possibilities. In addition, a clinical case is described and shown. Results Ten fresh cadaver feet were dissected. The first DMtA was absent in two specimens and the second, third, or fourth DMtA was absent in one specimen each. The available DMtAs had between two and five cutaneous perforators supplying the skin (average, 3.7 perforators per DMtA). The largest perforators to the skin were always seen in the distal half of the DMtA and ranged from 0.4 to 0.8 mm (average, 0.5 mm). Methylene blue injections showed an average flap surface of 21.6 × 47.6 mm. Conclusion This cadaveric study demonstrates the usefulness of the DMtA perforator flap. The flap is a valuable addition to the arsenal of flaps to cover the dorsum of the toe, webspace, or defects exposing tendons on the distal dorsum of the foot.

Maximizing the Volume of Latissimus Dorsi Flap in Autologous Breast Reconstruction with Simultaneous Multisite Fat Grafting.

BACKGROUND: The pedicled latissimus dorsi (LD) flap serves an important function in breast reconstruction, but its utility is limited by its inability to provide sufficient breast volume. OBJECTIVES: The purpose of this preliminary report was to review the techniques and outcomes of utilizing fat-grafted, volume-enhanced LD flap transfer with fat grafting recipient sites in autologous breast reconstruction. METHODS: A retrospective study was performed of 10 patients (14 breasts) who underwent autologous breast reconstruction utilizing the LD flap transfer technique and simultaneous fat grafting between August 2012 and September 2014. Multilayer, multisite fat grafting was performed to the LD muscle, LD skin paddle, mastectomy skin flaps, and the pectoralis major and serratus muscles simultaneously with the LD flap transfer. RESULTS: Three patients underwent an immediate breast reconstruction, four underwent a delayed breast reconstruction, and four underwent a tertiary breast reconstruction following previously failed breast reconstructions (one patient underwent each of the first two procedures, one on each breast). The average age of the patients was 55 years (range, 39-76 years), the average body mass index of the patients was 29.3 (range, 19.6-39.9), and the average fat grafting volume for the patients was 176 mL (range, 50-300 mL). There was 100% flap survival and complete wound healing. No seroma or fat grafting-related complications were clinically detected. Three patients required additional fat grafting. CONCLUSIONS: The fat-grafted, volume-enhanced LD flap procedure with fat grafting recipient sites offers a simple and safe technique for autologous breast reconstruction, with low morbidity and fast recovery. It can be a useful alternative to utilizing abdomen-based flaps in autologous breast reconstruction or could be performed to salvage both implant-based and free-flap breast reconstructions. LEVEL OF EVIDENCE 4: Therapeutic.

Local Infiltration of Liposomal Bupivacaine for Pain Control in Patients Undergoing Mastectomy with Immediate Tissue Expander Reconstruction.

Mastectomy with immediate tissue expander reconstruction is associated with postoperative pain, nausea, and vomiting. Various techniques of perioperative and postoperative pain control have been described. Our standard of care for postsurgical pain management in patients undergoing mastectomy with immediate tissue expander reconstruction has been preoperative ultrasound-guided paravertebral block. Recent literature demonstrating the opioid-sparing benefits of liposomal bupivacaine has directed two of our plastic surgeons to pilot its use in immediate tissue expander reconstruction. In the accompanying video, we present our technique of intraoperative local infiltration of liposomal bupivacaine into the base of mastectomy skin flaps, serratus fascia, and periaxillary tissue after completion of the mastectomy and before tissue expander placement into the reconstruction pocket.

Reconstruction of Large Perineal and Pelvic Wounds Using Gracilis Muscle Flaps.

BACKGROUND: The reconstruction of large defects after abdominoperineal resections and pelvic exenterations has traditionally been accomplished with vertical rectus myocutaneous flaps (VRAMs). For patients requiring two ostomies, robot-assisted abdominoperineal resections (APRs), and to avoid the morbidity of a VRAM harvest, the authors have used the gracilis muscle flap to reconstruct the large dead space in these patients. METHODS: A retrospective analysis of 16 consecutive APRs (10 with concomitant pelvic exenterations) reconstructed with gracilis flaps during a 2-year period was performed. Gracilis muscle flaps were used to obliterate the dead space after primary skin closure was ensured with adduction of the legs. RESULTS: All 16 patients had locally advanced cancers and had received neoadjuvant chemotherapy and radiation. Of these 16 patients, 10 had pelvic exenterations. All the patients had reconstruction with gracilis flaps (6 bilateral flaps). One major wound complication in the perineum occurred as a result of an anastomotic leak in the pelvis, but this was managed with conservative dressing changes. Three patients had skin separation in the perineum greater than 5 mm with intact subcutaneous closure. No patients required operative debridement or revision of their perineal reconstruction. No perineal hernias or gross dehiscence of the skin closure occurred. CONCLUSIONS: Large pelvic and perineal reconstructions can be safely accomplished with gracilis muscle flaps and should be considered as an alternative to abdominal-based flaps.

Combination of a fillet flap, free tissue transfer, and autologous tissue grafts in pelvic reconstruction following retroperitoneal sarcoma: a case report.

The resection of large pelvic tumors is challenging due to their infiltrative nature into multiple structures and organ systems. In this report, we describe the use of multiple vascularized and nonvascularized spare parts to reconstruct a pelvic defect in a patient with a uniquely large pelvic sarcoma invading the spinal canal. A 39-year-old Caucasian female who presented with a large retroperitoneal sarcoma where the tumor encased the left ureter, kidney, colon, and external iliac vessels and invaded the L3-S1 vertebral bodies. An extensive hemipelvectomy and reconstruction was performed over two days. A free thigh and leg fillet flap together with ipsilateral fibula flap, based on the superficial femoral artery and venae comitantes, was used for spinal reinforcement as well as abdominal and pelvic wall reconstruction. The postoperative course was uneventful without complications, no flap compromise or wound healing problems. After a follow-up period of 4 months, the patient had no complications and returned to activities of daily living with mild limitations. The success of this flap procedure shows the practicality and usefulness of using the full spectrum of tissue transfer for the purposes of a large pelvic reconstruction.

Randomized trial of drain antisepsis after mastectomy and immediate prosthetic breast reconstruction.

BACKGROUND: In this 2-site randomized trial, we investigated the effect of antiseptic drain care on bacterial colonization of surgical drains and infection after immediate prosthetic breast reconstruction. METHODS: With IRB approval, we randomized patients undergoing bilateral mastectomy and reconstruction to drain antisepsis (treatment) for one side, with standard drain care (control) for the other. Antisepsis care included both: chlorhexidine disc dressing at drain exit site(s) and irrigation of drain bulbs twice daily with dilute sodium hypochlorite solution. Cultures were obtained from bulb fluid at 1 week and at drain removal, and from the subcutaneous drain tubing at removal. Positive cultures were defined as ≥1+ growth for fluid and >50 CFU for tubing. RESULTS: Cultures of drain bulb fluid at 1 week (the primary endpoint) were positive in 9.9 % of treatment sides (10 of 101) versus 20.8 % (21 of 101) of control sides (p = 0.02). Drain tubing cultures were positive in 0 treated drains versus 6.2 % (6 of 97) of control drains (p = 0.03). Surgical site infection occurred within 30 days in 0 antisepsis sides versus 3.8 % (4 of 104) of control sides (p = 0.13), and within 1 year in three of 104 (2.9 %) of antisepsis sides versus 6 of 104 (5.8 %) of control sides (p = 0.45). Clinical infection occurred within 1 year in 9.7 % (6 of 62) of colonized sides (tubing or fluid) versus 1.5 % (2 of 136) of noncolonized sides (p = 0.03). CONCLUSIONS: Simple and inexpensive local antiseptic interventions with a chlorhexidine disc and hypochlorite solution reduce bacterial colonization of drains, and reduced drain colonization was associated with fewer infections.

Blockade of lysosomal acid ceramidase induces GluN2B-dependent Tau phosphorylation in rat hippocampal slices.

The lysosomal acid ceramidase, an enzyme known to limit intracellular ceramide accumulation, has been reported to be defective in neurodegenerative disorders. We show here that rat hippocampal slices, preincubated with the acid ceramidase inhibitor (ACI) d-NMAPPD, exhibit increased N-methyl-D-aspartate (NMDA) receptor-mediated field excitatory postsynaptic potentials (fEPSPs) in CA1 synapses. The ACI by itself did not interfere with either paired pulse facilitation or alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate (AMPA) receptor-mediated fEPSPs, indicating that its influence on synaptic transmission is postsynaptic in origin and specific to the NMDA subtype of glutamate receptors. From a biochemical perspective, we observed that Tau phosphorylation at the Ser262 epitope was highly increased in hippocampal slices preincubated with the ACI, an effect totally prevented by the global NMDA receptor antagonist D/L(-)-2-amino-5-phosphonovaleric acid (AP-5), the calcium chelator 1,2-bis(o-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid (BAPTA), and the GluN2B (but not the GluN2A) receptor antagonist RO25-6981. On the other hand, preincubation of hippocampal slices with the compound KN-62, an inhibitor known to interfere with calcium/calmodulin-dependent protein kinase II (CaMKII), totally abolished the effect of ACI on Tau phosphorylation at Ser262 epitopes. Collectively, these results provide experimental evidence that ceramides play an important role in regulating Tau phosphorylation in the hippocampus via a mechanism dependent on GluN2B receptor subunits and CaMKII activation.

Augmented Reality Microsurgery: Proof of Concept for a Novel Approach to Microsurgical Field Visualization in Plastic Surgery.

BACKGROUND: Microsurgery is conducted on tiny anatomical structures such as blood vessels and nerves. Over the past few decades, little has changed in the way plastic surgeons visualize and interact with the microsurgical field. New advances in augmented reality (AR) technology present a novel method for microsurgical field visualization. Voice- and gesture-based commands can be used in real time to adjust the size and position of a digital screen. Surgical decision support and/or navigation may also be used. The authors assess the use of AR in microsurgery. METHODS: The video feed from a Leica Microsystems OHX surgical microscope was streamed to a Microsoft HoloLens2 AR headset. A fellowship-trained microsurgeon and three plastic surgery residents then performed a series of four arterial anastomoses on a chicken thigh model using the AR headset, a surgical microscope, a video microscope (or "exoscope"), and surgical loupes. RESULTS: The AR headset provided an unhindered view of the microsurgical field and peripheral environment. The subjects remarked on the benefits of having the virtual screen track with head movements. The ability of participants to place the microsurgical field in a tailored comfortable, ergonomic position was also noted. Points of improvement were the low image quality compared with current monitors, image latency, and the lack of depth perception. CONCLUSIONS: AR is a useful tool that has the potential to improve microsurgical field visualization and the way surgeons interact with surgical monitors. Improvements in screen resolution, latency, and depth of field are needed.

Inferior dermal flap in immediate breast reconstruction.

BACKGROUND: The inferior dermal flap can be used in conjunction with implants or tissue expanders to avoid need for acellular dermal matrix in breast reconstruction and on occasion can serve as an alternative to an autologous flap by functioning as a reconstructed breast mound. Candidates for this procedure are women with high BMI or breast ptosis who desire a decrease in breast size at time of mastectomy with reconstruction. This procedure recruits the de-epithelialized excess skin inferiorly and laterally from a skin-sparing mastectomy and uses this to eliminate the need for acellular dermal matrix in a cost-conscious environment. METHODS: The skin-sparing mastectomy is performed, and the inferior skin flap is de-epithelialized to create the inferior dermal pedicle. A gel implant is placed retropectorally, and the inferior dermal flap is sutured to the inferior border of the pectoralis major muscle and laterally to a muscle-sparing serratus pedicle to provide support and coverage of the implant. RESULTS: We have performed this procedure in several patients and present a video outlining the technique of this procedure in a 54-year-old female diagnosed with left breast DCIS. Postoperative pictures taken at 6 weeks showed an excellent cosmetic result without complications. CONCLUSIONS: The inferior dermal flap is a simple and reproducible procedure that can reduce cost by eliminating the use of acellular dermal matrix. It provides an excellent cosmetic outcome in women undergoing mastectomy with large BMI and breast ptosis seeking reduction in breast size.

NMDA reduces Tau phosphorylation in rat hippocampal slices by targeting NR2A receptors, GSK3ß, and PKC activities.

The molecular mechanisms that regulate Tau phosphorylation are complex and currently incompletely understood. In the present study, pharmacological inhibitors were deployed to investigate potential processes by which the N-methyl-D-aspartate (NMDA) subtype of glutamate receptors modulates Tau phosphorylation in rat hippocampal slices. Our results demonstrated that Tau phosphorylation at Ser199-202 residues was decreased in NMDA-treated hippocampal slices, an effect that was not reproduced at Ser262 and Ser404 epitopes. NMDA-induced reduction of Tau phosphorylation at Ser199-202 was further promoted when NR2A-containing receptors were pharmacologically isolated and were completely abrogated by the NR2A receptor antagonist NVP-AAM077. Compared with nontreated slices, we observed that NMDA receptor activation was reflected in high Ser9 and low Tyr216 phosphorylation of glycogen synthase kinase-3 beta (GSK3ß), suggesting that NMDA receptor activation might diminish Tau phosphorylation via a pathway involving GSK3ß inhibition. Accordingly, we found that GSK3ß inactivation by a protein kinase C- (PKC-) dependent mechanism is involved in the NMDA-induced reduction of Tau phosphorylation at Ser199-202 epitopes. Taken together, these data indicate that NR2A receptor activation may be important in limiting Tau phosphorylation by a PKC/GSK3ß pathway and strengthen the idea that these receptors might act as an important molecular device counteracting neuronal cell death mechanisms in various pathological conditions.

Split and thinned pedicle deep inferior epigastric perforator (DIEP) flap for vulvar reconstruction.

Vulvar defects following tumor extirpation are most commonly closed primarily by the gynecologist but larger and/or radiated defects often require reconstruction with flaps for adequate coverage and wound healing. Recurrence of vulvar carcinomas remains a challenge, so secondary reconstruction becomes increasingly problematic where locoregional flaps (i.e., gracilis, rectus, anterolateral thigh, and gluteal flaps) may have already been utilized, radiated, or have resulted in unacceptable cosmetic or functional morbidity. We present two cases of recurrent vulvar carcinoma following radiation therapy requiring total vulvectomy and a novel approach for soft-tissue reconstruction. Previous authors have reported the use of thinned and split flaps, but we combine these techniques to split and thin a transversely oriented deep interior epigastric artery perforator (DIEP) flap to maximize aesthetic results and minimize donor-site morbidity. The DIEP flap is commonly performed by microsurgeons for autologous free-tissue transfer in breast reconstruction but also serves as a useful option for large vulvar or perineal defects, either in primary or secondary reconstruction.

Modern Approaches to Alternative Flap-Based Breast Reconstruction: Transverse Upper Gracilis Flap.

The transverse upper/myocutaneous gracilis is a medial thigh-based flap primarily reserved as a secondary choice for autologous reconstruction of small to moderate-sized breasts in women without a suitable abdominal donor site. Its consistent and reliable anatomy based on the medial circumflex femoral artery permits expedient flap harvest with relatively low donor site morbidity. The primary disadvantage is the limited achievable volume, often necessitating augmentation such as extended flap modifications, autologous fat grafting, flap stacking, or even implant placement.

Decreasing Opioids in Outpatient Breast Surgery with an Enhanced Recovery after Surgery Program and Preoperative Education.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs have been detailed in the literature predominantly in the inpatient setting. The purpose of this study was to determine the effect of an ERAS protocol with a preoperative educational class on opioid prescribing and patient outcomes for outpatient breast surgery. METHODS: An ERAS protocol was formulated focusing on preoperative education, multimodal pain control, and an intraoperative block. The study was conducted as an institutional review board-approved retrospective review. Women undergoing breast reconstruction revision, breast reduction, delayed insertion of prosthesis, tissue expander to implant exchange, and matching procedures were included. The patients were separated into pre-ERAS and ERAS cohorts. Data on demographic characteristics, postanesthesia care unit (PACU) length of stay, PACU oral morphine equivalent (OME) consumption, outpatient OME prescriptions, major and minor complications, and need for additional opioid prescriptions were collected. Analysis was performed with the Fisher exact test or chi-square test as appropriate. RESULTS: Group 1 (pre-ERAS) and group 2 (ERAS) each included 68 patients. The cohorts had similar age, body mass index, diabetes status, and tobacco use. Group 1 was prescribed an average of 216 OMEs, compared with 126.4 OMEs for group 2, a 41.5% decrease ( P < 0.0001). The pre-ERAS group consumed an average of 23.3 OMEs in the PACU versus 16.6 OMEs in the ERAS group ( P = 0.005). Fewer patients in the ERAS group required additional prescriptions for narcotic pain medication at postoperative follow-up ( P = 0.116). No differences were seen in major or minor complications. CONCLUSION: An ERAS protocol that uses a multimodal approach to pain control and preoperative patient education is useful in the outpatient setting and can help decrease opioid consumption. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Updates on Enhanced Recovery after Surgery protocols for plastic surgery of the breast and future directions.

Introduction: Perioperative pain control is an important component of any plastic surgery practice. Due to the incorporation of Enhanced Recovery after Surgery (ERAS) protocols, reported pain level, opioid consumption, and hospital length of stay numbers have decreased significantly. This article provides an up-to-date review of current ERAS protocols in use, reviews individual aspects of ERAS protocols, and discusses future directions for the continual improvement of ERAS protocols and control of postoperative pain. ERAS components: ERAS protocols have proven to be excellent methods of decreasing patient pain, opioid consumption, and postanesthesia care unit (PACU) and/or inpatient length of stay. ERAS protocols have three phases: preoperative education and pre-habilitation, intraoperative anesthetic blocks, and a postoperative multimodal analgesia regimen. Intraoperative blocks consist of local anesthetic field blocks and a variety of regional blocks, with lidocaine or lidocaine cocktails. Various studies throughout the surgical literature have demonstrated the efficacy of these aspects and their relevance to the overall goal of decreasing patient pain, both in plastic surgery and other surgical fields. In addition to the individual ERAS phases, ERAS protocols have shown promise in both the inpatient and outpatient sectors of plastic surgery of the breast. Conclusion: ERAS protocols have repeatedly been shown to provide improved patient pain control, decreased hospital or PACU length of stay, decreased opioid use, and cost savings. Although protocols have most commonly been utilized in inpatient plastic surgery procedures of the breast, emerging evidence points towards similar efficacy when used in outpatient procedures. Furthermore, this review demonstrates the efficacy of local anesthetic blocks in controlling patient pain.