Faculty Bibliography

BACKGROUND: Maintaining optimal coagulation is vital for successful microvascular tissue transfer. The viscoelastic thromboelastography (TEG) is a modern and dynamic method to assess a patient's coagulation status. The aim of this study was to evaluate its diagnostic capabilities of identifying microvascular complications. METHODS: A retrospective chart review was conducted for the most recent 100 cases of abdominal free flap breast reconstruction of a single surgeon. Patient demographics, medical history, clinical, and operative details were documented. Thrombocyte counts, prothrombin time (PT), activated partial thromboplastin time (aPTT), and various TEG parameters were gathered for preoperative, intraoperative, and two postoperative time points. RESULTS: = 0.049), while PT and aPTT failed to identify these patients. Of those, two resulted in flap loss (1.2%) that both occurred in patients with abdominal scars from previous surgery. CONCLUSION/CONCLUSIONS: The TEG is a useful adjunct for monitoring coagulation status in microsurgical breast reconstruction. When thrombosis at the anastomosis occurs, TEG correlates with a more rapid rebound from an intraoperative hypocoagulable state to a postoperative hypercoagulable state, when using the TEG. The TEG is a valuable tool for a more dynamic assessment of the patients' changing coagulation status.

Introduction: /UNASSIGNED:Gallstones are an etiological factor in 23%-54% of patients with acute pancreatitis. A small proportion of these patients will also have intestinal complications requiring necrosectomy with diverting loop ileostomy. Later, these patients require cholecystectomy and ileostomy reversal. Laparoscopic cholecystectomy is fraught with difficulty in these patients due to dense intra-abdominal adhesions, and many surgeons resort to an open approach. We describe a technique which takes advantage of the ileostomy site for initial access. Materials and Surgical Technique/UNASSIGNED:port. Additional ports are inserted and standard steps are followed for cholecystectomy. Conclusion/UNASSIGNED:port.

Facial fractures are a common source of emergency department consultations for the plastic surgeon. A working understanding of the evaluation, the assessment, the management, and the prevention of further injury when dealing with these fractures is vital. This second of a two-part series detailing the management of midfacial fractures serves as a guide for the appropriate workup and management of the wide variety of fracture patterns that are commonly encountered.

Facial fractures are a common source of emergency department consultations for the plastic surgeon. A working understanding of evaluation, assessment, management, and prevention of further injury when dealing with these fractures is vital. This two-part series detailing the management of midface fractures serves as a guide for the appropriate workup and management of the wide variety of fracture patterns that are commonly encountered.

The impact of specific patient comorbidities on outcomes in craniosynostosis surgical repair is not well defined. The aim of this retrospective review was to evaluate the short-term 30-day reoperation rate, unplanned readmission rate, and overall morbidity of craniosynostosis surgical repair using the 2012 through 2014 American College of Surgeons National Surgical Quality Improvement Program-Pediatrics (ACS NSQIP-Pediatric) database. Overall morbidity included pneumonia, wound occurrence, shock/sepsis, venous thromboembolism, cardiac complication, renal and urinary complications, or nerve injury. The authors identified patients undergoing craniosynostosis repair by CPT code resulting in 2,037 patients. A univariate and multivariate analysis was performed to identify risk factors for reoperation, readmission, and morbidity. The reoperation rate was 2.4%, the overall morbidity rate was 2.8%, and readmission rate was 3.4%.Regression analysis identified age, high American Society of Anesthesiologists (ASA) classification, and history of either neurologic or pulmonary disorders as associated with unplanned reoperations within 30 days. High ASA classification also demonstrated significant correlation with unplanned 30-day readmission, and a history of neurologic disorders was associated with overall morbidity. The most common reason for readmission was wound complications (n = 15) followed by respiratory complications (n = 7). Gender, gastrointestinal comorbidities, blood disorders, cardiac risk factors, and prior operation within 30 days did not show significant association with any outcome. Craniosynostosis surgical repair is safe and associated with low complication and readmission rates. Careful patient selection and preoperative optimization of these factors should be sought to reduce detrimental outcomes.

Despite the sheer number of pediatric tonsillectomies performed in the United States annually, there is no clear consensus as to which surgical technique is superior. One way to compare surgical techniques is to study the morbidity associated with each. We report postoperative hemorrhage rates, one of the frequently encountered major adverse events, as part of a retrospective chart review across four different surgical techniques. These surgeries involved either (1) Coblation, (2) Co-blation with partial suture closure of the tonsillar fossa, (3) diathermy, or (4) partial intracapsular tonsillectomy (PIT). Of the 7,024 children we evaluated, 99 (1.4%) experienced a postoperative hemorrhage that required a second surgery; hemorrhage occurred after 33 of the 3,177 Coblation-alone procedures (1.04%), 28 of the 1,633 Coblation with partial suture closure procedures (1.71%), 29 of the 1,850 diathermies (1.57%), and 9 of the 364 PIT procedures (2.47%). Statistical analysis of hemorrhage rates with each surgical technique yielded p values >0.05 in each case (Coblation alone and Coblation with partial suture closure: p = 0.29; diathermy: p = 0.47; PIT, p = 0.20). Based on these data, we conclude that none of these techniques is significantly superior in terms of decreasing the risk of post-tonsillectomy hemorrhage in children. Therefore, surgeons should continue to use the surgical procedure they are most familiar with to optimize recovery in the postoperative period.

BACKGROUND:The purpose of this study was to compare functional outcomes between nerve grafting and nerve transfer procedures in the setting of isolated, posttraumatic axillary nerve injuries. METHODS:A systematic review was performed using the PubMed, Scopus, and Cochrane databases to identify all cases of isolated, posttraumatic axillary nerve injuries in patients aged 18 years or older. Patients who underwent axillary nerve reconstruction were included and categorized by technique: graft or transfer. Demographics were recorded, including age, time to operation, and presence of concomitant injuries. Functional outcomes were evaluated, including British Medical Research Council strength and range of motion for shoulder abduction. RESULTS:Ten retrospective studies met criteria, for a total of 66 patients (20 nerve grafts and 46 nerve transfers). Median time from injury to operation was equivalent across the nerve graft and nerve transfer groups (8.0 months versus 7.0 months; p = 0.41). Postoperative follow-up was 24.0 months for nerve grafting versus 18.5 months for nerve transfer (p = 0.13). Clinically useful shoulder abduction, defined as British Medical Research Council grade M3 or greater, was obtained in 100 percent of nerve graft patients versus 87 percent of nerve transfer patients (p = 0.09). Grade M4 or better strength was obtained in 85 percent of nerve graft patients and 73.9 percent of nerve transfer patients (p = 0.32). CONCLUSIONS:Significant differences in functional outcomes between nerve graft and transfer procedures for posttraumatic axillary nerve injuries are not apparent at this time. Prospective outcomes studies are needed to better elucidate whether functional differences do exist. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.

A proper knowledge of noninvasive facial rejuvenation is integral to the practice of a cosmetic surgeon. Noninvasive facial rejuvenation can be divided into patient- versus physician-directed modalities. Patient-directed facial rejuvenation combines the use of facial products such as sunscreen, moisturizers, retinoids, α-hydroxy acids, and various antioxidants to both maintain youthful skin and rejuvenate damaged skin. Physicians may recommend and often prescribe certain products, but patients are in control with this type of facial rejuvenation. On the other hand, physician-directed facial rejuvenation entails modalities that require direct physician involvement, such as neuromodulators, filler injections, laser resurfacing, microdermabrasion, and chemical peels. With the successful integration of each of these modalities, a complete facial regimen can be established and patient satisfaction can be maximized. This article is the last in a three-part series describing noninvasive facial rejuvenation. Here the authors review the mechanism, indications, and possible complications of lasers, chemical peels, and other commonly used noninvasive modalities.

BACKGROUND:Microcystic lymphatic malformations (LM) are congenital birth defects that can cause severe functional or esthetic deformity. At this time, several treatment interventions are possible, but there is no ideal therapy. A recently published article noted a coincidental improvement in microcystic LMs with the use of sildenafil for pulmonary hypertension, but conclusive and reproducible data is lacking regarding its efficacy. METHODS AND RESULTS/RESULTS:A prospective study was conducted to examine the subjective and objective results associated with sildenafil use in the treatment of microcystic LMs. Patients under the age of 18 were enrolled, and after evaluation with pre-intervention magnetic resonance imaging (MRI) studies, each was given a 6-week course of sildenafil. Subjective outcomes were obtained, and postoperative MRIs were used to objectively quantify changes. Five patients between the ages of 4 and 11 were enrolled in the study. All patients had microcystic LMs of the head and neck. All patients had undergone previous treatment interventions utilizing various modalities, and each was now seeking treatment for functional and cosmetic purposes. All patients had minimal to no response from a subjective standpoint. Comparison of pre- and post-treatment MRIs also demonstrated minimal to no response. CONCLUSIONS:The use of sildenafil for the treatment of microcystic lymphatic malformations did not have any appreciable effect on our selected population of pediatric patients who had been resistant to previous therapies. Further studies would be necessary to determine if other cohorts may benefit.

Transhiatal herniation of abdominal organs after oesophageal resection and reconstruction is rare and sparsely described in the literature. The commonest organ to herniate is the colon. Pancreatic herniation has been reported twice before. We report a case of postoesophagectomy transhiatal pancreatic herniation in an asymptomatic patient.