Salvage of Nipple-Areolar Complex Ischemia With Dimethyl Sulfoxide: A Case Series.

BACKGROUND: Nipple-areolar complex (NAC) necrosis is a known risk of breast surgery, particularly mastectomy. Disruption of the underlying blood supply to the NAC can lead to ischemia and subsequent necrosis. Nitroglycerin paste is currently used to combat NAC ischemia but has limited efficacy and an unfavorable side effect profile. Topical dimethyl sulfoxide (DMSO) has been shown to increase tissue perfusion in microsurgery and various skin flaps, but its role in the treatment and prevention of NAC ischemia has not been reported. Through a prospective case series, this study aims to introduce DMSO as a safe treatment for NAC ischemia after breast surgery. METHODS: Patients treated by 2 breast surgeons and a single plastic surgeon who underwent nipple-sparing mastectomy or breast reduction and developed NAC ischemia were identified via a prospectively maintained database. Ischemic changes were diagnosed, and treatment to the affected NAC with DMSO was initiated at the conclusion of the procedure, or postoperative day 1 in most cases, and continued 4 times daily until ischemic changes had resolved clinically. Collected demographic, surgical, and outcome variables were analyzed using descriptive statistics. RESULTS: Eleven patients with a mean age of 47.8 ± 9.5 years (range, 35-61 years) and mean body mass index of 26.0 ± 4.4 kg/m2 (range, 20.7-33.4 kg/m2) were identified. The mean duration of time between surgery and the clinical diagnosis of NAC ischemia was 1.3 ± 2.8 days (range, 0-7 days). The average length of time from DMSO initiation to clinical improvement or resolution of NAC ischemia was 7.5 ± 2.5 days (range, 5-12 days). All patients demonstrated significant improvement or complete resolution of NAC ischemia following serial topical DMSO application. CONCLUSIONS: This study demonstrates DMSO is a safe treatment for threatened NACs. All patients in this series showed either dramatic improvement or resolution of NAC ischemia after DMSO application, and threatened NACs of all 11 patients were successfully salvaged. These promising results set the basis for ongoing randomized controlled studies to determine the efficacy of DMSO treatment for NAC ischemia.

The Effects of Adjunctive Pain Medications on Postoperative Inpatient Opioid Use in Abdominally Based Microsurgical Breast Reconstruction.

BACKGROUND: The purposes of this study were to quantify the amount of opioid medication used postoperatively in the hospital setting after abdominally based microsurgical breast reconstruction, to determine factors that are associated with increased opioid use, and to identify other adjunctive medications that may contribute to decreased opioid use. METHODS: An electronic medical record data pull was performed at the University of Pennsylvania from November 2016 to October 2018. Cases were identified using Current Procedural Terminology code 19364. Only traditional recovery after surgery protocol patients were included. Patient comorbidities, surgical details, and pain scores were captured. Postoperative medications including non-patient-controlled analgesia opioid use and adjunctive nonopioid pain medications were recorded. Non-patient-controlled analgesia total opioid use was calculated and converted to oral morphine milligram equivalents (mme). Statistical analysis was performed using t test analyses and linear regression. RESULTS: A total of 328 patients satisfied our inclusion criteria. Five hundred forty free flaps were performed (212 bilateral vs 116 unilateral, 239 immediate vs 89 delayed). Bilateral patients used on average 115.2 mme (95% confidence interval [CI], 103.4-127.0 mme) compared with 89.0 mme in unilateral patients (95% CI, 70.0-108.0 mme; P = 0.015). Patients with abdominal mesh placement (n = 249) required 113.0 mme (95% CI, 100.5-125.5 mme) compared with 83.8 mme (95% CI, 68.8-98.7 mme) for patients without mesh (n = 79; P = 0.016). Each additional hour of surgery increased postoperative mme by 9.4 (P < 0.01). Patients with a nonzero preoperative pain score required 100.3 mme (95% CI, 90.2-110.4 mme) compared with 141.1 mme (95% CI, 102.7-179.7 mme) for patients with preoperative pain score greater than 0/10 (P < 0.01). Patients with postoperative index pain score ≤5/10 required 89.2 mme (95% CI, 78.6-99.8 mme) compared with 141.1 mme (95% CI, 119.9-162.2 mme) for patients with postoperative index pain score >5/10 (P < 0.01). After regression analysis, a dose of intravenous acetaminophen 1000 mg was found to decrease postoperative mme by 11.7 (P = 0.024). A dose of oral ibuprofen 600 mg was found to decrease postoperative mme by 8.3 (P < 0.01). CONCLUSIONS: Bilateral reconstruction and longer surgery resulted in increased postoperative mme. Patients with no preoperative pain required less opioids than did patients with preexisting pain. Patients with good initial postoperative pain control required less opioids than did patients with poor initial postoperative pain control. Intravenous acetaminophen and oral ibuprofen were found to significantly decrease postoperative mme.

Delayed-immediate hybrid breast reconstruction-Increasing patient input and precision in breast reconstruction.

The benefits of breast reconstruction via free tissue transfer with simultaneous implant placement, that is, hybrid breast reconstruction, in select patients are well-known. Challenges exist, however, and are related to proper implant selection as well as postoperative mastectomy skin necrosis. Here, the authors present an approach that increases reconstructive precision while minimizing postoperative mastectomy skin necrosis. A retrospective analysis of patients who underwent immediate prepectoral tissue expander placement (stage 1) followed by delayed-immediate hybrid breast reconstruction (stage 2) was performed. Parameters of interest included patient demographics, postoperative complications, and revision rates. A total of 31 patients with a mean age of 48.7 years (range, 30-67 years) and a mean BMI of 26.3 kg/m2 (range, 21.0-35.3 kg/m2 ) who underwent bilateral breast reconstruction were included. Of the 62 free abdominal flaps, 45 (72.6%) and 17 (27.4%) were MS-TRAM and DIEP flaps, respectively. The most common implant volume was 240 cc (range, 140-445 cc). Following stage 1, minor and major complications were observed in nine (29%) and one (3.2%) patients, respectively. No major complications were noted after stage 2. Of note, no patient developed mastectomy skin necrosis or requested a change in implant size following stage 2. Delayed-immediate hybrid breast reconstruction improves the ability to more precisely match patient expectations related to breast size and is associated with a reduction in the rate of mastectomy skin necrosis following the critical second stage of reconstruction.

Sternal wound complications in patients undergoing orthotopic heart transplantation.

PURPOSE: The incidence and management of sternal wound complications in patients undergoing orthotopic heart transplantation (OHT) is not well studied. We report outcomes in heart transplant patients who developed sternal infections requiring reoperations. METHODS: From 2004 to 2013, 437 patients underwent OHT at a single institution. In a retrospective review, patients who developed sternal infections (Infection group, n = 27) were compared with those without (Control group, n = 410). RESULTS: Sternal infection rate was 6.2% (n = 27). Demographics were similar (Table 1). Infection group had higher rates of COPD 25% vs 13%, P = 0.03, and previous cardiac surgery via median sternotomy 28% vs 15%, P = 0.03. Infection group had a greater incidence of prolonged ventilation, 44% vs 31%, P = 0.2, renal failure 56% vs 24%, P = 0.001, dialysis requirement 30% vs 10%, P = 0.006, permanent stroke 11% vs 2%, P = 0.02, perioperative myocardial infarction 4% vs 0.2%, P = 0.09. The infection group had a longer ICU stay (524 + 410 vs 187 + 355 hours, P = 0.001) and hospitalization (59 + 28 vs 0.29 + 43 days, P = 0.001). In-hospital/30-day mortality was 30% vs 19%, P = 0.2. The mean time for sternal reoperation at 44 + 50 days. Deep wound infection (41%) and sternal dehiscence (22%) were common presentations. Causative organisms were Enterobacter (22%), Klebsiella (15%), and Pseudomonas (15%). Vancomycin (44%), 4th generation cephalosporin (37%), and fluoroquinolones (30%) were the most commonly used antibiotics. Surgical treatment included sternal debridement with pectoralis muscle flap (52%), primary closure (18%), and omental flap (11%). CONCLUSION: Sternal wound infections impart a significant burden on patients with OHT. Causative organisms are predominantly virulent gram-negative bacteria. Therefore, a high index of suspicion must be maintained for early detection and treatment.

Improved pocket control in immediate microsurgical breast reconstruction with simultaneous implant placement through the use of mesh.

BACKGROUND: Autologous breast reconstruction is associated with long-term patient satisfaction that is superior to implant-based approaches. Occasionally, however, patients who desire autologous reconstruction present with inadequate donor-site volume. A hybrid approach, combining free flap reconstruction with simultaneous implant placement, is a solution. We present our experience with the use of mesh for improved pocket control using this reconstructive modality. METHODS: A retrospective analysis of a prospectively maintained database of patients undergoing autologous breast reconstruction was performed. Patients who underwent bilateral immediate breast reconstruction with free microsurgical abdominal tissue transfer with simultaneous implant placement were included for analysis. RESULTS: A total of 19 patients (38 breasts) with a mean age of 42.7 years (range, 31-57 years) and mean BMI of 26.3 (range, 23.6-30.8) were included in the study. No flap loss or implant-related complications were encountered during a mean follow-up of 14.2 months. The most common implant volume was 150 cc (N = 15; [78.9%]). No patient requested an implant change due to malposition or insufficient volume. Secondary fat grafting was performed in 5 patients (26.3%), 4 of which had undergone adjuvant radiotherapy. Three cases of red breast syndrome were observed following acellular dermal matrix placement. This prompted a transition to using polyglactin mesh thereafter without any untoward sequelae. CONCLUSIONS: Abdominal flap transfer with simultaneous implant placement is a safe reconstructive option in select patients. Improved implant pocket control is achieved through the use of mesh, thus, minimizing problems related to implant malposition. Adjuvant radiotherapy does not appear to put the reconstruction at risk with the occasional flap volume loss being easily remedied by secondary fat grafting.

Autologous breast reconstruction in the postbariatric patient population.

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.

Creation of spliced vein conduit using microvascular anastomotic coupler.

The single-segment great saphenous vein continues to be a conduit of choice for lower extremity arterial bypass. In patients without an adequate continuous segment of great saphenous vein, a spliced vein graft may be used as an alternative. Creating a spliced vein conduit can be technically challenging and time consuming. We present a technique of creating a spliced vein conduit by using a microvascular anastomotic coupler.

Managing Groin Wounds after Infrainguinal Vascular Procedures: Examining the Reoperative Events and Complication Profile of Muscle Flap Reconstruction.

BACKGROUND: The literature has been void of large outcome studies detailing the efficacy and complication profile of muscle flap reconstruction of complex groin wounds. Furthermore, a first-line choice for muscle flap selection remains unclear. The aim of this study is 2-fold: (1) to examine the complication profile and associated risk factors following muscle flap coverage and (2) to provide a compared efficacy analysis of the sartorius muscle flap (SMF) versus the rectus femoris flap (RFF) in the treatment of wounds following an infrainguinal vascular procedure. METHODS: A retrospective review of records was performed on all patients undergoing complex groin wound reconstruction from January 2005 to September 2014. RESULTS: A total of 201 flaps were performed on 184 patients. There were no sentinel bleeding events through the course of graft salvage or perioperative morbidity beyond local wound complications. Coronary artery disease (P = 0.049), dyslipidemia (P < 0.001), diabetes (P = 0.047), and history of multiple prior infrainguinal procedures (P = 0.029) were associated with increased complications following groin wound reconstruction. There was no statistically significant difference in complications in comparing the RFF versus the SMF (27.9% vs. 38.9% respectively; P = 0.109). There was no significant difference in the rates of graft salvage in comparing the RFF versus the SMF (21.6% vs. 16.1%, respectively; P = 0.459). CONCLUSIONS: Muscle flap coverage can be safely employed for vascular graft salvage. Medical comorbidities and multiple prior infrainguinal procedures are predictive of perioperative complications. The SMF and RFF demonstrated equivocal rates of complications and graft salvage. Given that the RFF risks increased functional morbidity and necessitates a second donor site, the SMF may be considered as an effective first-line approach for reconstruction of complex groin wounds.

The Retroauricular Approach to the Facial Nerve Trunk.

BACKGROUND: Exposure of the common trunk of the facial nerve has traditionally been approached based on principles of parotidectomy, which is associated with high rates of facial nerve palsy and landmarks that may be unreliable. On the basis of experience gained with vascularized composite allotransplantation of the face, the authors propose a retroauricular approach that may be more time-effective and safe. METHODS: In the proposed retroauricular facial nerve approach, an incision is made posterior to the ear in the retroauricular sulcus, and dissection proceeds anteriorly to the mastoid fascia to the base of the conchal bowl. The anteroinferior edge of the external auditory canal is followed as a reference structure to locate the facial nerve trunk (FNT), coursing between the stylomastoid foramen (posteromedially) and entering the parotid gland (anteriorly). Twelve unilateral FNT dissections were performed in 6 fresh human cadaver heads. Six dissections were performed for illustration and proof of concept using full facial transplant, conventional, and limited retroauricular exposures; 6 additional dissections were performed by trainees to assess reliability and replicability of technique. RESULTS: The FNT was successfully identified in all 12 dissections. Trainees tended toward being more time efficient in exploring the anatomy when using the limited retroauricular technique than with the conventional approach, 7.8 ±â€Š0.78 minutes versus 13.0 ±â€Š3.3 minutes (P = 0.089). No intraoperative injury to any critical structure was noted with either technique. CONCLUSION: A retroauricular approach to the FNT based on liberating anterior tissues from the auditory canal provides expedient and aesthetic exposure of the FNT.

Treatment Options for Bilateral Autologous Breast Reconstruction in Patients with Inadequate Donor-Site Volume.

More than 250,000 women will be diagnosed with invasive breast cancer in the United States in 2017 alone. A large number of these patients will undergo mastectomy and will be candidates for immediate breast reconstruction. The most common reconstructive options are either implant-based or autologous tissue reconstruction, with the latter having been reported to have higher rates of long-term patient satisfaction, lower cost, and less postoperative pain. A subset of patients, however, may not be ideal candidates for autologous microsurgical reconstruction, for example, due to inadequate abdominal tissues, yet they may desire this reconstructive modality. This is particularly challenging in patients requiring bilateral reconstructions. In this article, the authors discuss the various reconstructive modalities that can be considered in patients who desire bilateral breast reconstruction, are not ideal candidates for autologous reconstruction, yet do not wish to rely solely on implant-based modalities.

Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction.

Background Microvascular anastomotic patency is fundamental to head and neck free flap reconstructive success. The aims of this study were to identify factors associated with intraoperative arterial anastomotic issues and analyze the impact on subsequent complications and cost in head and neck reconstruction. Methods A retrospective review was performed on all head and neck free flap reconstructions from 2005 to 2013. Patients with intraoperative, arterial anastomotic difficulties were compared with patients without. Postoperative outcomes and costs were analyzed to determine factors associated with microvascular arterial complications. A regression analysis was performed to control for confounders. Results Total 438 head and neck free flaps were performed, with 24 (5.5%) having intraoperative arterial complications. Patient groups and flap survival between the two groups were similar. Free flaps with arterial issues had higher rates of unplanned reoperations (p < 0.001), emergent take-backs (p = 0.034), and major surgical (p = 0.002) and respiratory (p = 0.036) complications. The overall cost of reconstruction was nearly double in patients with arterial issues (p = 0.001). Regression analysis revealed that African American race (OR = 5.5, p < 0.009), use of vasopressors (OR = 6.0, p = 0.024), end-to-side venous anastomosis (OR = 4.0, p = 0.009), and use of internal fixation hardware (OR =3.5, p = 0.013) were significantly associated with arterial complications. Conclusion Intraoperative arterial complications may impact complications and overall cost of free flap head and neck reconstruction. Although some factors are nonmodifiable or unavoidable, microsurgeons should nonetheless be aware of the risk association. We recommend optimizing preoperative comorbidities and avoiding use of vasopressors in head and neck free flap cases to the extent possible.

Increased Lower Extremity Venous Stasis May Contribute to Deep Venous Thrombosis Formation after Microsurgical Breast Reconstruction-An Ultrasonographic Study.

Background Despite guideline-compliant prophylaxis, an increased rate of deep venous thrombosis (DVT) formation has been reported following autologous versus implant-based breast reconstruction. We hypothesized that tight abdominal fascia closure might decrease lower extremity venous return and promote venous stasis. Methods An observational crossover study of patients who underwent autologous breast reconstruction using transverse rectus abdominis musculocutaneous/deep inferior epigastric artery perforator flaps was conducted. Ultrasonographic measurements of the left common femoral vein (CFV) and right internal jugular vein (IJV) were performed preoperatively, in the postanesthesia care unit, and on postoperative day (POD) 1. Parameters of interest included vessel diameter, circumference, area, and maximum flow velocity. Results Eighteen patients with a mean age and body mass index of 52.7 years (range, 29-76 years) and 31.3 kg/m2 (range, 21.9-43.4 kg/m2) were included, respectively. A 29.8% increase in CFV diameter was observed on POD 1 (p < 0.0001). Similarly, a 24.3 and 69.9% increase in CFV circumference (p = 0.0007) and area (p < 0.0001) were noted, respectively. These correlated with a 28.4% decrease in maximum flow velocity in the CFV (p = 0.0001). Of note, none of these parameters displayed significant changes for the IJV, thus indicating that observed changes in the CFV were not the result of changes in perioperative fluid status. Conclusion Postoperative changes observed in the CFV reflect increased lower extremity venous stasis after microsurgical breast reconstruction and may contribute to postoperative DVT formation.

Geographic Variation in Access to Plastic Surgeons.

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.

Feasibility of the internal mammary lymph node flap as a vascularized lymph node transfer: A cadaveric dissection study.

BACKGROUND: We performed cadaveric dissections to examine the feasibility of an internal mammary-based lymph node flap as a donor site for vascularized lymph node transfer. METHODS: Internal mammary vessels and adjacent nodes were dissected in ten fresh cadaver specimens. Surgeon inspection and palpation identified the number of nodes in the specimen. Specimens were examined macro- and microscopically by a pathologist for correlation of lymph node counts. Kappa statistic correlated surgeon- and pathologist-reported node counts. RESULTS: Surgeon- and pathologist-reported node counts were moderately correlated (kappa 0.57). Inspection and palpation correctly predicted node presence or absence in 80% of specimens. Sixty percent of flaps contained between 1 and 3 nodes, with a mean of 2.0 nodes when nodes were present. CONCLUSIONS: Inspection and palpation predicts the presence or absence of nodes in 80% of flaps. Nodes were present in 60% of internal mammary-based flaps, and one to three nodes can be transferred. © 2015 Wiley Periodicals, Inc. Microsurgery 36:485-490, 2016.

Do Prior Abdominal Surgeries Increase Complications in Abdominally Based Breast Reconstructions?

BACKGROUND: A large proportion of patients presenting for autologous breast reconstruction have a history of prior abdominal surgeries such as obstetric, gynecologic, or general surgical procedures. The impact of prior abdominal wall violation on the ability to perform free tissue transfer from the abdomen needs to be explored and characterized. The purpose of this study was to assess the impact of prior abdominal surgery on perfusion-related complications and donor-site morbidity in free tissue abdominal transfer. METHODS: All patients who underwent abdominally based free tissue transfer for breast reconstruction from 2005 to 2011 at the Hospital of the University of Pennsylvania were included. In addition to collecting data on standard patient past medical histories, comorbidities, and case characteristics, we also noted specific types of prior abdominal surgeries, number of prior surgeries, and if the rectus sheath was violated. Outcomes assessed included thrombotic complications, flap loss, major surgical complications, minor surgical complications, delayed wound healing, and subsequent hernia formation. RESULTS: Eight hundred twelve patients underwent 1257 free flap breast reconstructions during the study period. Four hundred seventeen (51.4%) women had undergone prior abdominal surgery. The most common prior abdominal surgeries included total abdominal hysterectomy and/or bilateral salpingo-oophorectomy (35.7%), cesarean delivery (33.8%), and appendectomy (12.7%). No significant differences were noted in the number of major intraoperative complications (P = 0.68), total thrombotic events (P = 0.339), or flap losses (P = 0.53). Patients who had undergone prior rectus sheath violation were found to experience a greater amount of delayed healing of the donor site (22.7% vs 16.5%, P = 0.03). Additionally, a higher rate of postoperative hernia formation was noted in patients who had undergone prior hernia repairs (13.6% vs 3.3%, P = 0.04). CONCLUSIONS: A significant portion of patients presenting for breast reconstruction have had prior abdominal surgeries. This study demonstrates that these prior procedures represent an acceptable level of risk; although this issue should still be addressed during preoperative patient counseling. In patients with prior hernia repairs, however, additional care should be given to the fascial closure as these patients may be at higher risk for subsequent hernia formation after abdominally based breast reconstruction.

Loupes-Only Microsurgery is a Safe Alternative to the Operating Microscope: An Analysis of 1,649 Consecutive Free Flap Breast Reconstructions.

BACKGROUND: Loupes-only microsurgery challenges the paradigm that free flap surgery requires an operating microscope. We describe our loupes-only microsurgery experience with an emphasis on rates of intraoperative anastomotic revision and total flap loss. METHODS: We identified all patients having breast reconstruction with muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) or deep inferior epigastric perforator (DIEP) flaps over 7 years. We examined rates of intraoperative anastomotic revision and total flap loss as markers of technical quality. For one high-volume surgeon who started loupes-only microsurgery while at our institution, we examined rates of intraoperative anastomotic revision and total flap loss rates over time to evaluate for a learning curve. RESULTS: We performed 1,649 ms-TRAM or DIEP flaps in 1,063 patients. For 1,649 flaps, the rate of artery anastomotic revision was 2.2% (36 arteries) and venous anastomotic revision was 2.2% (37 veins). Any microvascular revision was performed in 3.5% (58 flaps). Total flap loss rate was 1.2% (20 flaps).For the "learning curve" analysis, there were no clinically relevant differences in rates of any intraoperative anastomotic revision or total flap loss during the first 60 months after loupes-only microsurgery was adopted. Total flap loss during this surgeon's first 60 months of loupes-only microsurgery was 1.6% (10 of 638 flaps). CONCLUSIONS: Loupes-only microsurgery is a safe alternative to the operating microscope for free flap breast reconstruction using the deep inferior epigastric system. Our total flap loss rate of 1.2% in 1,649 flaps is at the low end of published flap loss rates.

Surgical Site Infections after Free Flap Breast Reconstruction: An Analysis of 2,899 Patients from the ACS-NSQIP Datasets.

BACKGROUND: Surgical site infections (SSIs) are a costly complication, resulting in lower patient satisfaction and higher health care expenditures. Incidence varies widely in the literature by surgery type, yet few studies focus exclusively on autologous breast reconstruction, an increasingly common surgery. The aim of this study is to identify risk factors for SSIs in free flap breast reconstruction using the National Surgical Quality Improvement Program Database (NSQIP). METHODS: Patients undergoing breast reconstruction with any flap type were identified by Current Procedural Terminology codes in the NSQIP database. Patients with superficial or deep SSIs within 30 days of surgery were compared with controls by univariate analysis and multivariate logistic regression across various characteristics. RESULTS: Overall, 2,899 patients undergoing autologous reconstruction were identified. Of these, 143 (4.9%) patients developed SSIs. Those who developed wound complications were more likely smokers (18.2 vs. 8.4%, p < 0.001) and diabetics (9.8 vs. 3.4%, p < 0.001) with hypertension (38.2 vs. 25.4%, p < 0.001) and pulmonary (4.5 vs. 1.3%, p = 0.01) history. SSIs occurred in patients with higher American Society of Anesthesiologists (p = 0.003) and the World Health Organization obesity (p < 0.001) classes. On multivariate regression, SSIs were significantly associated with smoking (odds ratio [OR] = 3.59, p < 0.001) and hypertension (OR = 1.86, p = 0.03). CONCLUSIONS: This study demonstrates that patients who are active smokers or have hypertension are at the highest risk for SSIs. Preoperative identification and tailored postoperative management of these patients may decrease the incidence of this complication.

Complex wound management in ventricular assist device (VAD) patients: the role of aggressive debridement and vascularized soft tissue coverage.

BACKGROUND: Infections and complex wounds after ventricular assist device (VAD) placement can result in significant morbidity and mortality. The purpose of this study was to evaluate complex wound management in the VAD patient, and to describe a treatment protocol for these challenging and potentially mortal complications. METHODS: A retrospective study was performed to examine all patients who underwent continuous flow, second-generation VAD placement at the Hospital of the University of Pennsylvania between March 2008 and April 2013. RESULTS: Overall, 150 VADs were placed, with 12 (8%) patients requiring 15 operative interventions by the plastic surgery services. The most common indication for operative intervention was a complicated wound with VAD exposure (5/12, 41.7%). All patients underwent aggressive operative debridement, and 11/12 (92%) underwent vascularized soft tissue coverage. Flaps commonly utilized included rectus abdominus myocutaneous (n = 4), rectus abdominus muscle (n = 4), pectoralis major (n = 3), and omentum (n = 3). Three patients experienced complications which required a return to the operating room, including 1 flap loss, 1 hematoma, and 1 wound dehiscence requiring further soft tissue coverage. Salvage was achieved, yet a 50% mortality rate in follow-up was noted. CONCLUSION: Complex wound management in VAD patients can be achieved with aggressive debridement and vascularized soft tissue coverage, most commonly utilizing well-vascularized rectus abdominus muscle or omental flaps. Plastic surgeons should be familiar with the armamentarium at their disposal when approaching these challenging cases as VAD wound complications stand to become an increasingly prevalent issue.