Faculty Bibliography

BACKGROUND: The ethical practice of medicine has always been of utmost importance, and plastic surgery is no exception. The literature is devoid of information on the teaching of ethics and professionalism in plastic surgery. In light of this, a survey was sent to ascertain the status of ethics training in plastic surgery residencies. METHODS: A 21-question survey was sent from the American Council of Academic Plastic Surgeons meeting to 180 plastic surgery program directors and coordinators via email. Survey questions inquired about practice environment, number of residents, presence of a formal ethics training program, among others. Binary regression was used to determine if any relationships existed between categorical variables, and Poisson linear regression was used to assess relationships between continuous variables. Statistical significance was set at a P value of 0.05. RESULTS: A total of 104 members responded to the survey (58% response rate). Sixty-three percent were program directors, and most (89%) practiced in academic settings. Sixty-two percent in academics reported having a formal training program, and 60% in private practice reported having one. Only 40% of programs with fewer than 10 residents had ethics training, whereas 78% of programs with more than 20 residents did. The odds of having a training program were slightly higher (odds ratio, 1.1) with more residents (P = 0.17). CONCLUSIONS: Despite the lack of information in the literature, formal ethics and professionalism training does exist in many plastic surgery residencies, although barriers to implementation do exist. Plastic surgery leadership should be involved in the development of standardized curricula to help overcome these barriers.

BACKGROUND: Iatrogenic pneumothorax is a serious intraoperative complication of immediate breast reconstruction with tissue expanders. However, there is paucity of literature regarding incidence or management of intraoperative pneumothorax in the breast reconstruction patient population. METHODS: We performed a retrospective chart review on prospectively collected data from all patients undergoing immediate breast reconstruction with tissue expanders from 1992 to 2012 to determine institutional incidence. We also searched the Nationwide Inpatient Sample database from 1998 to 2008 to determine national incidence. RESULTS: A total of 9653 tissue expanders were placed in 6955 patients at the Memorial Sloan Kettering Cancer Center between 1992 and 2012. There were 3 cases of pneumothorax during immediate breast reconstruction with tissue expanders. The incidence of pneumothorax is 0.03% per expander and 0.04% per patient. From the national database, there were 153 cases of pneumothorax during immediate breast reconstruction with tissue expanders in 27,612 patients. The overall national incidence of pneumothorax is 0.55% per patient. CONCLUSIONS: Our algorithm for management includes a thoracic surgery consultation intraoperatively. A chest tube should be placed at a site distal to the pleurotomy. The site of injury should be repaired primarily or patched as necessary. If the patient remains stable, it is safe to proceed with placement of the tissue expander.

BACKGROUND: Tendon gliding is key to optimal recovery of hand function after complex tendon injuries. Gliding is facilitated by a low-friction gliding surface that is normally provided by the periosteum of the underlying bone. However, significant injuries may damage the periosteum, which must be reconstructed to allow uninterrupted tendon excursion. The absence of the periosteum may compromise a tendon's ability to glide freely, thereby limiting the range of motion. METHODS: Six digits in 4 patients with complex, composite soft tissue defects involving tendon, periosteum, and skin of the hand underwent surgical repair. Each digit had disruption of the bony cortex underlying the tendon injury including periosteal loss. Through an incision on the dorsum of the ipsilateral wrist, an extensor retinaculum graft corresponding to the size of the periosteal defect was harvested. It was then sutured into place over the bare cortex to replace the lost periosteum. RESULTS: All the 6 digits in the 4 patients had complete return to function. Additionally, all patients had near normal strength in the repaired hand along with excellent tendon excursion in both flexion and extension. The average time of follow-up of this series of patients was 1.5 years. CONCLUSIONS: Extensor retinaculum grafting to replace lost periosteum is a technique that is easily used, uses locally available autogenous tissues, and produces excellent tendon function. Additionally, the histologic similarities between extensor retinaculum and periosteum add scientific merit to this novel approach. On the basis of our experience, we recommend the use of extensor retinaculum for periosteal reconstruction to provide an adequate gliding surface for a reconstructed tendon.

BACKGROUND: Limited data exist in the literature regarding the general incidence of secondary abdominal contour procedures and secondary abdominoplasty (excluding revisions) or specific recommendations for surgical management of these patients. METHODS: The authors performed a retrospective chart review of 562 patients who underwent abdominal contouring procedures (liposuction and/or modified or full abdominoplasty) performed by a single surgeon (A.M.) from January of 2004 until October of 2012. Nonsurgical primary cases, secondary surgery that was revisional in nature, and massive weight loss patients were excluded. RESULTS: Seventy-three patients (13.0 percent) underwent secondary abdominal contouring procedures. Forty-six of 73 patients had charts available to be examined in greater detail. Thirty-four of these patients underwent secondary liposuction, whereas 12 of these patients had secondary full abdominoplasty procedures. Secondary operations occurred an average of 4.98 years after the primary procedure (range, 6 months to 15 years). Patients underwent secondary liposuction (n = 34) on average 3.16 years after their initial procedure, significantly sooner than patients who underwent secondary abdominoplasty (n = 12) 8.35 years after their initial procedure (p = 0.002). Patients with a body mass index less than 25 kg/m (n = 26) had both secondary liposuction (n = 16) and secondary abdominoplasty (n = 10), whereas all patients who had a body mass index of 25 kg/m or greater (n = 20) underwent only secondary liposuction. CONCLUSIONS: True secondary abdominal contouring procedures represented 13.0 percent of all abdominal contouring procedures. The most common indication for a secondary procedure was an umbilical-site closure scar. Specific recommendations for surgical management of five common scenarios for secondary abdominal procedures are discussed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

BACKGROUND: The integrated model of plastic surgery education, shortly to become the standard for all 6-year programs, has set minimal but no maximal exposure to plastic surgery. The authors hypothesized that the first 3 years of integrated training will show variability among residency programs. METHODS: Rotation schedules for all 42 integrated programs were analyzed for plastic surgery versus 18 nonplastic surgery rotations for postgraduate years 1, 2, and 3 as well as cumulatively for the first 3 years. Rotations "strongly suggested" by the Residency Review Committee on Plastic Surgery and American Board of Plastic Surgery were also examined. RESULTS: Postgraduate years 1 through 3 spent a wide range of 3 to 19 months (SD +/- 4.9 months) on plastic surgery (mean, 9.1 months). General surgery also varied dramatically, with 8 to 21 months (SD +/- 4.0 months) of exposure (mean, 16.3 months). Surgical subspecialty rotations ranged substantially from 1 to 6 months (SD +/- 1.0 months). Plastic surgery exposure was greater in programs based within plastic surgery departments than within divisions (13.8 versus 8.3 months, p < 0.005). Eighteen programs (42.9 percent) had dedicated hand surgery rotations, while seven (16.7 percent) had time dedicated for research. There was also wide variability in the inclusion of 18 nonplastic surgery rotations as well as specific "strongly suggested" rotations. CONCLUSIONS: The plastic surgery experience in the first 3 years of residency training varies by a greater than 6-fold difference among integrated programs. This was also found in the 2.5-fold and 6-fold differences in general surgery and subspecialty surgery experiences. Since standardized residency training is an expectation by both accrediting bodies and the public, this variability may warrant closer attention.

ABSTRACT: Because of increased risk for nipple necrosis, many surgeons believe large ptotic breasts to be a relative contraindication to nipple-sparing mastectomy (NSM). A retrospective review was performed on 85 consecutive patients who underwent NSM with 141 immediate perforator free-flap breast reconstructions. We analyzed the subset of patients with large ptotic breasts, defined as cup size C or greater, sternal notch to nipple distance greater than 24 cm and grade 2 or 3 breast ptosis. Of the 85 patients, 19 fit the inclusion criteria. Breast cup size ranged from 34C to 38DDD. There was 1 case of nipple necrosis in the patient with previous breast radiation (5%), 1 hematoma (5%), and no flap losses. Five (26%) patients underwent subsequent mastopexy or breast reduction, a mean of 6.6 months after the primary procedure. We demonstrate that NSM and free-flap breast reconstruction can be safely and reliably performed in selected patients.

We present the deep femoral artery perforator (DFAP) flap, a new perforator flap for breast reconstruction, with a detailed description of operative technique and four clinical examples. The DFAP flap allows harvest of tissue from the lower buttock and lateral thigh with similar territory to an in-the-crease inferior gluteal artery perforator (IGAP) flap but based on a different perforator. When present, the DFAP is the largest vessel supplying this territory and is often septocutaneous, facilitating dissection when compared with the IGAP flap. We used preoperative imaging with magnetic resonance angiography to assist in accurate flap planning which also permitted precise determination of perforator origin. In patients with either a contraindication to abdominal wall-based perforator flaps or weight distribution below the waist, the DFAP flap provides an alternative to the IGAP flap with an excellent pedicle and a favorable location on the lateral thigh

BACKGROUND: : Autologous bone grafts, often harvested from the iliac crest, are the criterion standard for secondary alveolar cleft repair. The best technique for harvest remains controversial. Minimally invasive techniques have been used for bone graft harvest in cleft patients, but outcome studies have been limited by small numbers of patients. METHODS: : A total of 104 patients undergoing bone grafting for alveolar cleft were reviewed. Fifty-five consecutive patients underwent minimally invasive iliac bone graft harvest using the Acumed power-driven trephine system performed by the same surgeon. These patients were compared with 49 control patients undergoing a similar procedure in which the traditional method of open iliac bone harvest with an osteotome was used. RESULTS: : Operative time for the bone graft harvest was significantly shorter with the Acumed device when compared with the osteotome (2.37 hours versus 3.26 hours, p < 0.001). Patients who underwent minimally invasive Acumed bone harvest required significantly less postoperative analgesia than did patients who underwent osteotome harvest, for both narcotic (0.31 mg/kg versus 1.64 mg/kg, p < 0.001) and nonnarcotic (15.1 mg/kg versus 27.2 mg/kg, p < 0.01) pain medication. Acumed patients had significantly less pain on discharge (0.26 versus 3.1 pain scores on a scale from 0 to 10, p < 0.001) and left the hospital more quickly (23.3 hours versus 30.1 hours, p < 0.001). CONCLUSION: : Minimally invasive bone graft harvest technique using the trephine system offers a superior alternative to the conventional open iliac bone harvest method for patients undergoing secondary alveolar cleft repair, with shorter operative time, decreased requirement for pain medications, less pain on discharge, and a shorter hospital stay. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, III.(Figure is included in full-text article.)

Hemangiopericytoma (HPC) is a rare vascular tumor arising from contractile cells around blood vessels, with the potential for malignant degeneration. Up to 10% of HPC occurs in children. Standard therapy for this tumor is surgical excision. We report the case of a 6-month-old infant with giant HPC involving the hand. Chemotherapy resulted in a decrease in tumor size, allowing for salvage of most of the hand and fingers. Preoperative chemotherapy should be considered in the care of HPC tumors involving the upper extremity in children