Faculty Bibliography

BACKGROUND:Previous studies have provided recommendations for increasing female leadership in academic plastic surgery. This study quantifies the extent to which these recommendations have been met in plastic surgery residency programs and identifies remaining institutional barriers to the advancement of women in academic plastic surgery. METHODS:An electronic survey was designed to quantify select recommendations for promoting female leadership in academic plastic surgery. The survey was distributed to either a female faculty member or a male program director at each academic plastic surgery program. An optional phone interview discussing current barriers to women's advancement followed the survey. RESULTS:Forty-nine of 92 survey recipients participated (52.7 percent response rate). Women constituted 25 percent of faculty, 22 percent of program directors, and 20 percent of program leaders of participating programs. Programs on average provided three of 11 resources. Programs with female leaders provided 6.20 resources versus 2.28 resources at departments with male chairs (p = 0.015). Programs with female program directors provided 5.50 resources versus 2.18 resources at programs with male program directors (p = 0.008). Of the 49 survey respondents, nine completed the interview (18.4 percent completion rate). The most frequently identified barriers to aspiring women leaders were opaque promotion criteria (cited by 77.8 percent of interviewees), motherhood bias (77.8 percent), and unequal recruitment practices (55.6 percent). CONCLUSIONS:The presence of a female chair or program director is associated with a greater quantity of resources for promoting female leaders. Remaining barriers to women seeking academic leadership positions include compensation and promotion disparities, motherhood bias, and unequal recruitment practices.

BACKGROUND: Transversus abdominis plane (TAP) blocks have been shown to significantly reduce pain and narcotic consumption following major abdominal surgeries. This study investigates the literature on their use in microsurgical breast reconstruction. PATIENTS AND METHODS/METHODS: A systematic review of TAP blocks in autologous breast reconstruction was performed. RESULTS: = 0.13). CONCLUSION/CONCLUSIONS: While the current data support the use of TAP blocks in autologous breast reconstruction, additional studies with more standardized protocols should be performed to determine the most optimal practice.

BACKGROUND: There are many different variables to consider in lower extremity microvascular soft tissue reconstruction including flap choice. Our aim is to objectively evaluate recipient complications related to lower extremity donor flap laterality. METHODS: A total of 77 lower extremity soft tissue reconstructions utilizing microvascular free tissue transfers for Gustilo type III between 1979 and 2016 were collected. We compared complication rates between ipsilateral and contralateral donor sites relative to the injured leg. The following parameters were analyzed: overall complications, total flap failure, partial flap failure, major complications, operative takebacks, and salvage rates. RESULTS: = 0.006). CONCLUSION/CONCLUSIONS: Although there is a higher risk of anastomotic thrombosis, particularly venous thrombosis, associated with ipsilateral donor-site group, there were no significant differences in complications or flap survival. Flaps can be harvested from a traumatized leg with acceptable complication rates while avoiding the morbidity of operating on an uninjured limb.

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.

Osteocutaneous reconstruction can be challenging because of concomitant injuries and limited donor sites. There is a paucity of data on limb salvage outcomes following combined soft-tissue reconstruction and bone transport or Masquelet procedures. The authors reviewed a consecutive series of open tibia fracture patients undergoing soft-tissue reconstruction with either distraction osteogenesis or Masquelet technique. Endpoints were perioperative flap complications and bone union. Fourteen patients with Gustilo type IIIB open tibia fractures were included. Half of the group received muscle flaps and the remaining half received fasciocutaneous flaps. Ten patients (71.4 percent) underwent distraction osteogenesis and the remaining patients underwent Masquelet technique. Average bone gap length was 65.7 ± 31.3 mm (range, 20 to 120 mm). In the bone transport group, the average external fixation duration was 245 days (range, 47 to 686 days). In the Masquelet group, the average duration of the first stage of this two-stage procedure (i.e., time from cement spacer placement to bone grafting) was 95 days (range, 42 to 181 days). Bone union rate, as determined by radiographic evidence, was 85.7 percent. There was one complete flap failure (7.1 percent). One patient underwent below-knee amputation after failing bone transport and developing chronic osteomyelitis and subsequent infected nonunion. Our case series demonstrates that nonosteocutaneous flap methods of limb reconstruction are a viable option in patients with segmental long bone defects, with a bone union rate of 85 percent and a limb salvage rate over 90 percent in patients with Gustilo type IIIB fractures. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

BACKGROUND:Simultaneous ventral hernia repair and panniculectomy (SVHRP) is a procedure that is more commonly being offered to patients with excess skin and subcutaneous tissue in need of a ventral hernia repair; however, there are concerns about surgical-site complications and uncertainty regarding the durability of repair. SVHRP outcomes vary within the literature. This study assessed the durability, complication profile, and safety of SVHRP through a large data-driven repository of SVHRP cases.360 METHODS:: The current SVHRP literature was queried using the MEDLINE, PubMed, and Cochrane databases. Predefined selection criteria resulted in 76 relevant titles yielding 16 articles for analysis. Meta-analysis was used to analyze primary outcomes, identified as surgical-site occurrence and hernia recurrence. Secondary outcomes included review of techniques used and systemic complications, which were analyzed with pooled weighted mean analysis from the collected data. RESULTS:There were 917 patients who underwent an SVHRP (mean age, 52.2 ± 7.0 years; mean body mass index, 36.1 ± 5.8 kg/m; mean pannus weight, 3.2 kg). The mean surgical-site occurrence rate was 27.9 percent (95 percent CI, 15.6 to 40.2 percent; I = 70.9 percent) and the mean hernia recurrence rate was 4.9 percent (95 percent CI, 2.4 to 7.3 percent; I = 70.1 percent). Mean follow-up was 17.8 ± 7.7 months. The most common complications were superficial surgical-site infection (15.8 percent) and seroma formation (11.2 percent). Systemic complications were less common (7.8 percent), with a thromboembolic event rate of 1.2 percent. The overall mortality rate was 0.4 percent. CONCLUSIONS:SVHRP is associated with a high rate of surgical-site occurrence, but surgical-site infection seems to be less prominent than previously anticipated. The low hernia recurrence rate and the safety of this procedure support its current implementation in abdominal wall reconstruction.

BACKGROUND: The lateral femoral circumflex artery (LFCA) system, which supplies the anterolateral thigh (ALT) flap territory, offers a plethora of tissue types for composite, functional reconstruction. However, the ability to include a reliable and flexible osseous component is limited. Based on cadaveric dissections, we describe an isolated LFCA branch to the femur separate from the vastus intermedius that can be included in ALT flap harvest in cases requiring bony reconstruction. METHODS: Cadaveric dissection was undertaken to define the LFCA vascular system with specific dissection of the proximal branches of the descending branch of the LFCA (db-LFCA) to define any muscular, periosteal, and/or osseous branches to the femur. RESULTS: Six thighs in four cadavers were dissected. Consistent in all specimens, there was an isolated branch extending distally, medially, and posteriorly from the proximal LFCA and entering the periosteum of the femur. In five specimens, the identified branch to the femur was located approximately 1-cm distal to the rectus femoris branch of the LFCA and approximately 1-cm proximal to a separate branch entering and supplying the vastus intermedius. In one specimen, there was a common trunk. The length of this branch from the origin at the LFCA to insertion into the femoral periosteum was approximately 6 to 8 cm. CONCLUSION/CONCLUSIONS: There appears to be a consistent and reliable branch to the femur based on the proximal LFCA that may be included in ALT flap harvest, adding even more versatility, as another option in complex cases requiring composite reconstruction, including bone.

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.

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.