Faculty Bibliography

BACKGROUND:The Gustilo classification serves as a proxy for injury severity, but recent data suggest rising complications with decreasing arterial runoff. This study aims to compare different microsurgical anastomosis options based on the number of patent vessels in the lower extremity. METHODS:A single-center retrospective review of 806 lower extremity free flaps performed from 1976 to 2016 was performed. Patients with Gustilo type IIIB injuries were grouped based on the number of patent vessels in the leg (three, two, or one). Patients were compared based on the type of anastomosis performed, evaluating for perioperative complications and flap failures. RESULTS:Perioperative complications occurred in 111 flaps (27 percent): 71 take-backs (17 percent), 45 partial losses (11 percent), and 37 complete losses (9 percent). Among patients with three-vessel runoff (61.8 percent), there was no difference in take-backs or flap loss between those with end-to-end versus end-to-side anastomoses. In 68 patients (18.7 percent) with two-vessel runoff, no difference between take-backs or flap loss was noted when comparing any anastomosis (i.e., end-to-end into an injured vessel, end-to-end into an uninjured vessel, or end-to-side into an uninjured vessel), although vein grafts were required more often in the end-to-side groups (p < 0.01). Finally, in 39 patients (10.7 percent) with single-vessel runoff, no difference was seen between end-to-end anastomosis into an injured vessel or end-to-side anastomosis into an uninjured vessel in terms of take-backs or flap loss. CONCLUSION:Higher rates of flap failure correlated with decreasing numbers of patent vessels in the leg, but neither type of microvascular anastomosis nor vessel selection demonstrated any impact on reconstructive outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.

INTRODUCTION/BACKGROUND:Interpositional grafts (IG) can be used to reconstruct the digital artery during revascularization and replantation when primary repair is not possible. The purpose of this study is to determine the effect of using interpositional graft on rates of digit survival. METHODS:A retrospective review of all patients from 2007 to 2016 that required revascularization and/or replantation of one or more digits was performed. RESULTS:127 patients were identified with 171 affected digits (118 digital revascularizations, 53 digital replantation). A graft was used to repair the digital artery in 50% (59 of 118) of revascularizations and in 49% (26 of 53) of replantations. There was no difference in digit survival with use of an IG for arterial repair vs. primary repair in revascularization (91.5% in both groups) or replantation (48.1% vs. 46.2%, p = 0.88). Regression analysis demonstrated no association between use of IG and digit survival. The source of IG did not have any effect on digit survival (p=0.97). IG was more likely to be used in crush (62.5%) and avulsion injuries (72.2%) compared to sharp laceration injuries (11.1 %) with RR = 5.6 (p=0.01) and RR = 6.5 (p=0.006) respectively. CONCLUSION/CONCLUSIONS:There was no difference in the survival rate of amputated digits that required IG for arterial repair. The need for an IG in a large zone of injury should not be considered a contraindication to performing revascularization or replantation. Furthermore, hand surgeons should have a low threshold for using IG especially in crush or avulsion injuries.

BACKGROUND:The general teaching is that increased number of vein repairs in digit replantation leads to improved venous outflow, resulting in lower need for iatrogenic bleeding, lower postoperative transfusion requirements, and better survival rates. The purpose of this study was to determine whether the traditional teaching that emphasizes the repair of multiple veins per arterial anastomosis results in superior survival rates. METHODS:A retrospective review of a single urban replant center's single-digit replants distal to the mid-metacarpal level in adult patients from 2007 to 2017 was performed. Data on patient demographics, mechanism and level of injury, veins repaired, iatrogenic bleeding, postoperative transfusions, and replant survival were obtained. RESULTS:There were a total of 54 single-digit replants. The most common mechanism was lacerations (N = 38), and the most common injury level was at the proximal phalanx (N = 21). All digits were replanted with a single arterial anastomosis-44% via grafting. In all, 0 to 3 veins were repaired per digit (mean = 1.5 veins). The mean transfusion requirement was 1.7 units. The survival rate was 50%. Digits with 1 or 2 veins repaired had lower transfusion requirements (1.1-1.3 units) and higher survival rates (56%-61%) compared with those replanted with 0 or 3 veins repaired (2.9-3.5 transfused units, 25%-29% survival). There were no differences between those digits replanted with either 1 or 2 veins repaired for transfusion requirements or survival. CONCLUSIONS:More veins repaired do not necessarily improve survival or possibly venous outflow, calling into question the traditional teaching that 2 veins should be repaired for every arterial anastomosis.

BACKGROUND:Integrated plastic surgery residency applicants sometimes complete research fellowships before residency. The average productivity and the impact of these fellowships on subsequent application to residency are unknown. The purpose of this study was to provide objective data to better understand the utility and productivity of a research fellowship. METHODS:A national survey was conducted in which integrated plastic surgery residency applicants from 2013 to 2016 were surveyed regarding their experiences with research fellowships. American Council of Academic Plastic Surgeons members were also surveyed to elicit their perspectives on the value of these fellowships. RESULTS:Six hundred twenty-one integrated plastic surgery applicants from 2013 to 2016 were included in the study. Twenty-five percent of applicants participated in a research fellowship. Applicants who completed research fellowships were more likely to match into plastic surgery compared to those who did not (97 percent versus 81 percent, respectively; p < 0.05). Fellows were highly satisfied with their fellowship experience and produced an average of five publications and presentations per fellowship year. Sixty-three percent of research fellowships were performed to strengthen applications to categorical integrated plastic surgery residency. American Council of Academic Plastic Surgeons members considered three or four publications/presentations productive. Most do not recommend research fellowships to all medical students. CONCLUSIONS:Research fellowships can effectively prepare for categorical plastic surgery by improving publication and presentation experience. This is the first study to show that applicants who completed research fellowships were highly satisfied with their experience, accomplished higher than expected levels of productivity, and statistically significantly matched into an integrated plastic surgery residency more often than applicants without research fellowships.

We retrospectively reviewed 201 digit replantations or revascularizations that were performed between August 2007 and June 2015. Leeching therapy was used in 48 digits and was more commonly required in replanted digits. In revascularized digits, leeching was used significantly more frequently in avulsion injuries and injuries associated with fractures. Digits that were leeched for more than 4.5 days had significantly higher rates of survival of digits after replantation or revascularization. Leeching was associated with higher incidence of transfusion, higher mean number of transfusions, and longer length of stay. We conclude from this study that leeching is used more frequently after digital replantation than revascularizaion, and in revascularized digits, leeching is used more often in avulsion injury and in patients with fractures. In patients requiring leeching therapy, leaching for more than 4.5 days leads to higher rate of digital survival. Level of evidence: IV.

BACKGROUND: Microvascular reconstruction of the lower extremity has the highest reported complication and flap failure rates of any anatomical region. Despite widespread adoption of the mechanical anastomotic venous coupler and encouraging results in other anatomical regions, there are limited reports examining its use in the lower extremity. This study compares outcomes between coupled and hand-sewn venous anastomoses in traumatic lower extremity reconstruction. METHODS:-tests. RESULTS: = 0.004). CONCLUSION/CONCLUSIONS: Complication and flap failure rates were similar between reconstructions performed with a venous coupler and those performed with hand-sewn venous anastomoses. These findings suggest that use of the venous anastomotic coupler is safe and effective in lower extremity reconstruction, with comparable outcomes to conventional sutured anastomoses.

PURPOSE: The dependent nature of the lower extremity predisposes to venous congestion, especially following significant trauma. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction. This study investigated the effect of an additional venous anastomosis on flap outcomes in lower extremity trauma reconstruction. METHODS: Retrospective review between 1979 and 2016 identified 361 soft tissue flaps performed for Gustilo IIIB/C coverage meeting inclusion criteria. Muscle flaps were performed in 287 cases (79.9%) and fasciocutaneous flaps in 72 cases (20.1%). Single-vein anastomosis was performed in 76% of cases and dual-vein anastmoses in 24% of cases. Patient demographics, flap characteristics, and outcomes were examined. RESULTS: Fasciocutaneous flaps were more likely to have two veins performed (P < .001). Complications occurred in 143 flaps (39.8%): 45 take-backs (12.4%), 37 partial losses (10.3%), 31 complete losses (8.6%). Compared to single-vein flaps, two veins reduced major complications (P = .005), partial flap failures (P = .008), and any flap failure (P = .018). Multivariable regression analysis demonstrated two veins to be protective against complications (RR = 2.58, P = .009). Subset regression analysis by flap type demonstrated an even more significant reduction in complications among muscle flaps (RR = 3.92, P = .005). Additionally, a >1 mm vein size mismatch was predictive of total flap failure (RR = 3.02, P = .038). CONCLUSION: Lower extremity trauma free flaps with two venous anastomoses demonstrated a fourfold reduction in complication rates compared to single-vein flaps. Additionally, venous size mismatch >1 mm was an independent predictor of total flap failure, suggesting beneficial effects of both two-vein outflow and matched vessel diameter.

BACKGROUND:As the United States' population diversifies, eliminating disparities in health and healthcare has become increasingly important across all disciplines of medicine, including plastic and reconstructive surgery. This is evidenced by the growing body of literature in recent years focusing on disparities in postmastectomy breast reconstruction. No study to date has evaluated whether this research is progressing appropriately to promote tangible evidence-based interventions to reduce these disparities. METHODS:A systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was performed to identify studies focusing on disparities in postmastectomy breast reconstruction. A previously established public health framework for advancing health disparities research was used to inform analysis of the quality and progression of the included studies. This triphasic framework categorizes disparities research as follows: detecting (identifies and measures disparities in vulnerable populations), understanding (establishes determinants of disparities), or reducing (proposes and evaluates interventions for eliminating disparities). RESULTS:Ninety-five studies were identified between 1979 and 2016, with 61 (64.2%) published after 2010. The majority of studies (51.6%) were retrospective cohort or case-control studies (American Society of Plastic Surgery level III evidence). Fifty-eight (63.7%), 31 (34.1%), and 2 (2.2%) studies provided detecting-, understanding- and reducing-phase disparities research, respectively. Non-plastic and reconstructive surgery journals accounted for 70.5% of all articles and for most higher phase research articles, publishing 83.9% and 100% of second and third phase studies, respectively. Disparity categories investigated included race/ethnicity, age, income, insurance status/type, geography, and education level, with race/ethnicity being the most common (73.7%). The most commonly measured outcome was percent of subpopulation receiving reconstruction (63, 66.3%), followed by reconstruction type (14, 16.7%). Patient-, provider-, system-, and research-level factors were all identified as potential targets for interventions to reduce disparities. CONCLUSIONS:Despite a recent increase in literature focusing on postmastectomy breast reconstruction disparities, the majority focuses on identifying vulnerable populations with inadequate progression to second (understanding) and third (reducing) phases. Increasing research funding, availability of language-concordant and culturally concordant educational materials, and advocacy and sociopolitical awareness within the plastic surgery community is necessary to advance research on postmastectomy breast reconstruction and, ultimately, eliminate it.

PURPOSE/OBJECTIVE:Phalangeal fractures represent a significant portion of upper extremity injuries but are not well studied as a single entity. We define our approach at a level 1 trauma center and determine whether plating or lag screws (ie, rigid fixation) have superior functional outcomes compared with Kirschner wire fixation for phalangeal or metacarpal fractures. METHODS:We performed a systematic review of all surgically managed hand fracture cases at Bellevue Hospital during 2012 and 2013. Demographics, type of fixation, length of operation, period of immobilization, range of motion, time to return to work, and complications including reoperation were noted. Comparisons were assessed for significance using Student t tests and Fisher exact test (P < 0.05 considered significant). RESULTS:One hundred ninety-two fractures (158 patients) were treated and followed for an average of 113 days. Rigid fixation was used for 17 (19%) of 90 metacarpal fractures and 5 (5%) of 102 phalangeal fractures. Operative times were significantly shorter (59 vs 135 minutes, 84 vs 149 minutes), and period of immobilization was longer (37 vs 15 days, 34 vs 18 days) when Kirschner wires were used for metacarpal and phalangeal fractures, respectively (P > 0.05). Total active motion and return to work were similar regardless of type of intervention in both fracture types. No patients treated with rigid fixation required reoperation. CONCLUSIONS:To our best knowledge, this is the first review to study phalangeal fractures concurrently but also separately from metacarpal fractures. Despite shorter periods of immobilization, rigid fixation does not appear to lead to improved total active motion or time to return to work.

BACKGROUND:Transversus abdominis plane blocks are increasingly being used in microvascular breast reconstruction. The implications of these blocks on specific reconstructive, patient, and institutional outcomes remain to be fully elucidated. METHODS:Patients undergoing abdominally based microvascular breast reconstruction from 2015 to 2017 were reviewed. Length of stay, complications, narcotic consumption, donor-site pain, and hospital expenses were compared between patients who did and did not receive transversus abdominis plane blocks with liposomal bupivacaine. Outcomes were subsequently compared in patients with elevated body mass index. RESULTS:Fifty patients (43.9 percent) received blocks [27 (54.0 percent) under ultrasound guidance] and 64 patients (56.1 percent) did not. Patients with the blocks had significantly decreased oral and total narcotic consumption (p = 0.0001 and p < 0.0001, respectively) and significantly less donor-site pain (3.3 versus 4.3; p < 0.0001). There was no significant difference in hospital expenses between the two cohorts ($21,531.53 versus $22,050.15 per patient; p = 0.5659). Patients with a body mass index of 25 kg/m or greater who received a block had a significantly decreased length of stay (3.8 days versus 4.4 days; p = 0.0345) and decreased narcotic consumption and postoperative pain compared with patients without blocks. Patients with a body mass index less than 25 kg/m did not have a significant difference in postoperative pain, narcotic consumption, or length of stay between groups. CONCLUSIONS:Transversus abdominis plane blocks with liposomal bupivacaine significantly reduce oral and total postoperative narcotic consumption and donor-site pain in all patients after abdominally based microvascular breast reconstruction without increasing hospital expenses. The blocks also significantly decrease length of stay in patients with a body mass index greater than or equal to 25 kg/m. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.