Faculty Bibliography

BACKGROUND:Free flap reconstruction after lower extremity trauma remains challenging with various factors affecting overall success. Increasing defect and flap size have been demonstrated to be a surrogate for overall injury severity and correlated with complications. In addition, larger free flaps that encompass more tissue theoretically possess high metabolic demand, and may be more susceptible to ischemic insult. Therefore, the purpose of our study was to determine how flap size affects microsurgical outcomes in the setting of lower extremity trauma reconstruction. METHODS:. Partial flap failure, total flap failure, takebacks, and overall major complications (defined as events involving flap compromise) were compared between these two groups. Multivariate logistic regression was performed to determine whether flap size independently predicts complications and flap failures, controlling for injury-related and operative factors. RESULTS:, use of muscle flaps was associated with significantly increased flap failure rates (p = .008) while for smaller flap size, there was no significant difference in complications between muscle and fasciocutaneous flaps. CONCLUSION/CONCLUSIONS:was associated with significantly increased flap failure and complications particularly among muscle-based flaps. Therefore, we suggest that fasciocutaneous flaps be utilized for injuries requiring large surface area of soft tissue reconstruction.

BACKGROUND:Microsurgical free tissue transfer is an important treatment option for nonhealing lower extremity diabetic wounds. The purpose of this study was to identify factors that affect flap survival and wound complications. METHODS:A retrospective review was conducted of 806 lower extremity free-flap reconstructions performed from 1979 to 2016. A total of 33 free flaps were used for coverage of nonhealing lower-extremity diabetic ulcers. Primary outcome measures were perioperative complications and long-term wound breakdown. RESULTS:The average age was 54 ± 12.3 y. 15.2% of patients were smokers, 12.1% had coronary artery disease and 12.1% had end-stage renal disease. Muscle flaps predominated (75.8%) compared to fasciocutaneous flaps (24.2%). There were 7 patients (21.2%) that underwent a revascularization procedure before (71.4%) or at the same time (28.6%) as the free flap. Immediate complications occurred in 7 flaps (21.2%) with 4 partial losses (12.1%) and 3 total flap failures (9.1%). Major wound complications occurred in 18.2% of patients. An end-to-side (E-S) anastomosis for the artery was used in 63.6% (n = 22) of flaps compared with an end-to-end (E-E) anastomosis. E-S anastomosis was associated with a significantly lower risk of wound complications compared with an arterial E-E anastomosis (0% versus 45.5%, P = 0.001). CONCLUSIONS:The use of microvascular free flaps can be used successfully to cover lower-extremity diabetic wounds. E-E arterial anastomosis should be avoided if possible as it is associated with higher rates of wound breakdown, likely by impairing perfusion to a distal limb with an already compromised vasculature. LEVEL OF EVIDENCE/METHODS:Level III.

BACKGROUND:The reverse sural artery flap (RSAF) is a popular option for patients with distal lower extremity defects who are not ideal candidates for free flap reconstruction. This is the first systematic review and pooled analysis of surgical characteristics, risk factors, and outcomes of the RSAF. METHODS:A systematic literature review was conducted. All studies reporting on patients undergoing RSAF reconstruction and their outcomes were included. Outcomes were pooled and analyzed using Fisher exact or χ test. RESULTS:Forty-three studies (479 patients, 481 flaps) were analyzed. The majority of patients were male (70.3%), and average ± SD age was 46.9 ± 16.7 years. Rates of smoking, diabetes mellitus (DM), and peripheral vascular disease (PVD) were 34.6%, 35.4%, and 12.3%, respectively. Defect etiologies were largely traumatic (60.4%). The most common defect location was the heel (40.8%). Flap modifications were reported in 123 flaps (25.6%). The most common modification was adipofascial extension (20.3%).Overall, the partial and total flap loss rates were 15.4% and 3.1%, respectively. Partial flap loss was significantly increased in smokers (28.9% vs 12.2% in nonsmokers, P = 0.0195). Technical modifications decreased the odds of partial necrosis by almost 3-fold compared with traditional RSAF reconstruction (7.2% vs 17.9%; odds ratio, 2.8 [1.4-5.8]; P = 0.0035). Patient age, DM, and PVD were not significantly associated with flap loss. CONCLUSIONS:The RSAF remains a safe salvage option for patients with DM or PVD but should be used with caution in smokers. Technical modifications to minimize pedicle compression significantly reduce rates of partial necrosis.

INTRODUCTION/BACKGROUND:Simulation is a standard component of residency training in many surgical subspecialties, yet its impact on knowledge and skills acquisition in plastic surgery training remains poorly defined. We evaluated the potential benefits of simulation-based cleft surgery learning in plastic surgery resident education through a prospective, randomized, blinded trial. METHODS:Thirteen plastic surgery residents were randomized to a digital simulator or textbook demonstrating unilateral cleft lip (UCL) repair. The following parameters were evaluated before (pre-intervention) and after (post-intervention) randomization: knowledge of surgical steps, procedural confidence, markings performance on a three-dimensional (3D) stone model, and surgical performance using a hands-on/high-fidelity 3D haptic model. Participant satisfaction with either educational tool was also assessed. Two expert reviewers blindly graded markings and surgical performance. Intra-class correlation coefficients (ICC) were calculated. Wilcoxon signed-rank and Mann-Whitney U tests were used. RESULTS:Interrater reliability was strong for pre-intervention and post-intervention grading of markings (ICC=0.97; p<0.001 and ICC=0.96; p<0.001) and surgical (ICC=0.83; p=0.002 and ICC=0.81; p=0.004) performance. Post-intervention surgical knowledge (40.3±4.4 vs. 33.5±3.7; p=0.03), procedural confidence (24.0±7.0 vs. 14.7±2.3; p=0.03), markings performance (8.0±2.5 vs. 2.9±3.1; p=0.03), and surgical performance (12.3±2.5 vs. 8.2±2.3; p=0.04) significantly improved in the digital simulation group compared to pre-intervention, but not in the textbook group. All participants were more satisfied with the digital simulator as an educational tool (27.7±2.5 vs. 14.4±4.4; p<0.001). CONCLUSIONS:We present evidence suggesting that digital cognitive simulators lead to significant improvement in surgical knowledge, procedural confidence, markings performance, as well as surgical performance.

PURPOSE/OBJECTIVE:There is a dearth of literature dedicated to specifically evaluating the use of free flap reconstruction in pediatric lower extremity traumas. This study aims to identify specific risk factors for flap failure in pediatric lower extremity trauma reconstruction. METHODS:Retrospective review of 53 free flaps in our lower extremity database (1979-2017) identified all free flaps performed for traumatic reconstruction in children <18 years of age at our institution. RESULTS:analysis (P = 0.041). CONCLUSION/CONCLUSIONS:Free flap reconstruction in the pediatric trauma population is safe with similar survival outcomes when compared to the adult population. Arterial injury and vessel size mismatch were associated with significantly higher flap failure rates in this population. LEVEL OF EVIDENCE/METHODS:Level III.

BACKGROUND: The distal lower extremity poses unique reconstructive challenges due to its requirements for durability of the load-bearing plantar surface and for thin, pliable contour in the dorsal foot and ankle region. This study compares outcomes between muscle and fasciocutaneous flaps in patients with foot and ankle defects. METHODS: A retrospective review of soft tissue free flaps used for traumatic foot and ankle defects was performed. Outcomes included takebacks, partial flap failure, total flap failure, and wound complications. RESULTS: = 0.004). CONCLUSION/CONCLUSIONS: Compared with fasciocutaneous flaps, muscle flaps demonstrated higher rates of wound complications. While the flap selection in foot and ankle reconstruction depends on the nature of the defect, our findings support the use of fasciocutaneous over muscle flaps in this region.

BACKGROUND:Gustilo type IIIC open tibia fractures are characterized by an ischemic limb requiring immediate arterial repair. In this patient population, the decision between primary amputation and limb salvage can be challenging. This study aims to evaluate the reconstructive outcomes of patients with Gustilo type IIIC injuries. METHODS:A single-center retrospective review of 806 lower extremity free flaps from 1976 to 2016 was performed. Flap loss and salvage rates for patients with Gustilo type IIIC injuries were determined. To determine the utility of performing salvage in this group, outcomes of the IIIC reconstructions were compared to those of similar patients with Gustilo I type IIB injuries with only a single patent vessel. RESULTS:A total of 32 patients with Gustilo type IIIC injuries underwent reconstruction after traumatic injury. Ten patients (31.3 percent) experienced a perioperative complication, including seven unplanned returns to the operating room (21.9 percent), three partial flap losses (9.4 percent), and five complete flap losses (15.6 percent). When type IIIC injuries were compared with single-vessel Gustilo type IIIB injuries, no statistically significant differences were noted with respect to major perioperative complications (p = 0.527), unplanned return to the operating room (p = 0.06), partial flap loss (p = 0.209), complete flap loss (p = 0.596), or salvage rate (p = 0.368). Although this result was not statistically significant, Gustilo type IIIC injuries trended toward lower take-back rates and higher salvage rates compared with single-vessel Gustilo type IIIB injuries. CONCLUSION/CONCLUSIONS:Patients with Gustilo type IIIC open tibia fractures should be considered candidates for limb salvage, as flap loss and reconstruction of these injuries are comparable to those of the routinely reconstructed single-vessel runoff type IIIB injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.

Background/Purpose: Knowledge of cleft lip (CL) surgical markings is essential prior to performing the repair. Work hours restrictions, increased patient care documentation time, and requests by patients not to have trainees involved in their care are limiting the acquisition of this skill in the operating room. Textbooks provide 2-dimensional illustrations of CL markings; while the cost of 3-dimensional (3D) printed CL models prohibit their widespread utilization for this purpose. We propose 3D stone models as simple and affordable tools to teach surgical trainees unilateral CL markings. Methods/Description: Polyvinyl siloxane (PVS) impression material was used to create a negative of a patient with unilateral CL. Snapstone mixed with water was poured into the PVS impression to create unilateral CL stone models. Eleven plastic surgery residents were prospectively recruited in the study. They were provided with a textbook chapter and online module detailing surgical markings for unilateral CL repair, and were given 15 minutes of study time, before providing them with a unilateral CL stone model for performing the CL markings within 10 minutes. The participants were then provided with a standardized patient photograph for the same purpose. Learner satisfaction with the stone model and patient photograph as educational tools for learning surgical markings were evaluated using a modified survey based on the Student Evaluation of Educational Quality (SEEQ) survey, a validated tool for measuring higher education student satisfaction. Learner satisfactions with each tool were compared using a Mann-Whitney U test.
Result(s): The total production time of one stone model, including the PVS impression, was 10 minutes. The cost of one PVS impression and one stone model were 64 and 83 cents respectively, for a total of $1.47. Participants reported that when compared to the standardized patient photograph, the stone model was more stimulating (4.72 +/- 0.47 vs 3.82+/-0.87; U = 25.5; P = .01), increased their interest in the subject (4.63 +/- 0.50 vs 3.45 +/- 1.29; U = 26.5; P = .02), allowed better learning of the subject matter (4.54 +/- 0.52 vs 2.91 +/- 0.83; U = 5.0; P < .001), had greater clarity (4.64 +/- 0.50 vs 3.00 +/- 0.89; U = 6.0; P < .001), and was a more effective means of teaching CL markings (4.73 +/- 0.47 vs 2.91 +/- 1.04; U = 6.0; P < .001). Participants were also more likely to recommend the stone model (4.82+/-0.40) over the standardized patient photograph (3.00 +/- 1.10; U = 5.0; P < .001).
Conclusion(s): 3D stone models of the unilateral cleft lip deformity are affordable and simple to produce. Plastic surgery residents report that these models are superior training tools to learn cleft lip markings compared to patient photographs. These educational tools have the potential to overcome significant financial, logistic, and time constraints in teaching cleft lip surgery markings

BACKGROUND:Marko Godina, in his landmark paper in 1986, established the principle of early flap coverage for reconstruction of traumatic lower extremity injuries. The aim of this study was to determine how timing influences outcomes in lower extremity traumatic free flap reconstruction based on Godina's original findings. METHODS:A retrospective review identified 358 soft-tissue free flaps from 1979 to 2016 for below knee trauma performed within 1 year of injury. Patients were stratified based on timing of coverage: 3 days or less (early), 4 to 90 days (delayed), and more than 90 days (late). The delayed group was further divided into two groups: 4 to 9 days and 10 to 90 days. Flap outcomes were examined based on timing of reconstruction. RESULTS:Flaps performed within 3 days after injury compared with between 4 to 90 days had decreased risk of major complications (OR, 0.40, p = 0.04). A receiver operating curve demonstrated day 10 to be the optimal day for predicting flap success. Flaps performed less than or equal to 3 days versus 4 to 9 days had no differences in any flap outcomes. In contrast, flaps performed within 4 to 9 days of injury compared to within 10 to 90 days were associated with significantly lower total flap failure rates (relative risk, 0.29, p = 0.025) and major complications (relative risk, 0.37, p = 0.002). CONCLUSIONS:Early free flap reconstruction performed within 3 days of injury had superior outcomes compared with the delayed (4 to 90 day) group, consistent with Godina's original findings. However, as an update to his paradigm, this ideal early period of reconstruction can be safely extended to within 10 days of injury without an adverse effect on outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

BACKGROUND:Facial transplantation introduced a paradigm shift in the reconstruction of extensive facial defects. Although the feasibility of the procedure is well established, new challenges face the field in its second decade. METHODS:The authors' team has successfully treated patients with extensive thermal and ballistic facial injuries with allotransplantation. The authors further validate facial transplantation as a reconstructive solution for irreparable facial injuries. Following informed consent and institutional review board approval, a partial face and double jaw transplantation was performed in a 25-year-old man who sustained ballistic facial trauma. Extensive team preparations, thorough patient evaluation, preoperative diagnostic imaging, three-dimensional printing technology, intraoperative surgical navigation, and the use of dual induction immunosuppression contributed to the success of the procedure. RESULTS:The procedure was performed on January 5 and 6, 2018, and lasted nearly 25 hours. The patient underwent hyoid and genioglossus advancement for floor-of-mouth dehiscence, and palate wound dehiscence repair on postoperative day 11. Open reduction and internal fixation of left mandibular nonunion were performed on postoperative day 108. Nearly 1 year postoperatively, the patient demonstrates excellent aesthetic outcomes, intelligible speech, and is tolerating an oral diet. He remains free from acute rejection. CONCLUSIONS:The authors validate facial transplantation as the modern answer to the classic reconstructive challenge imposed by extensive facial defects resulting from ballistic injury. Relying on a multidisciplinary collaborative approach, coupled with innovative emerging technologies and immunosuppression protocols, can overcome significant challenges in facial transplantation and reinforce its position as the highest rung on the reconstructive ladder. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, V.