Faculty Bibliography

Background Higher body mass index (BMI) has been shown to increase postoperative complications in autologous breast reconstruction. However, the correlation with flap weight is unknown. Here, we explore the relationship of flap weights and complication rates in patients undergoing microvascular breast reconstruction. Methods Retrospective chart review identified all patients undergoing microvascular breast reconstruction with abdominally based flaps at a single institution between November 2007 and April 2013. Breasts with documented flap weight and 1-year follow-up were included. Patients undergoing stacked deep inferior epigastric perforator flaps were excluded. Breasts were divided into quartiles based on flap weight and examined by demographics, surgical characteristics, complications, and revisions. Results A total of 130 patients undergoing 225 flaps were identified. Patients had a mean age of 50.4 years, mean BMI of 27.1 kg/m2, and mean flap weight of 638.4 g (range: 70-1640 g). Flap weight and BMI were directly correlated. Flaps were divided into weight-based quartiles: first (70-396 g), second (397-615 g), third (616-870 g), and fourth (871-1640 g). There were no associations between flap weight and incidences of venous thrombosis, arterial thrombosis, hematoma, flap loss, fat necrosis, or donor site hernia. However, increased flap weight was associated with increased rate of donor site wound healing problems in both univariate and multivariate analysis. Conclusions Increased flap weight is not associated with added flap complications among patients undergoing microvascular breast reconstruction, however, patients with flaps of 667.5 g or more are more likely to have donor site healing problems. The success and evidence contrary to previous studies may be attributed to surgeon intraoperative flap choice.

BACKGROUND: Given the complexity of microsurgical breast reconstruction, there are many opportunities to improve both surgical efficiency and outcomes. The use of two operating surgeons has been employed, but the outcomes are unproven. In this study, the authors compare the outcomes of patients undergoing microsurgical breast reconstruction with one operating surgeon to those with two surgeons. METHODS: A retrospective review of all patients undergoing microsurgical breast reconstruction between July of 2011 and January of 2014 at a single academic institution was conducted. Patients were divided into two cohorts: those undergoing reconstruction with one surgeon and those having reconstruction with two surgeons. Once identified, patients were analyzed and outcomes were compared. RESULTS: A total of 157 patients underwent 248 microsurgical breast reconstructions during the study period. One hundred three patients (170 flaps) had two surgeons and 54 patients (78 flaps) had one surgeon. Patients undergoing unilateral and bilateral reconstructions with two surgeons had decreased mean operating room time by 60.1 minutes and 134 minutes (p < 0.001) and length of stay by 1.8 days and 1.3 days (p < 0.05), when compared to a single surgeon. Additionally, patients with one surgeon were more likely to have postoperative donor-site breakdown at 5.1 percent (n = 4) versus 0.6 percent (n = 1) (p = 0.0351). CONCLUSIONS: The use of two operating surgeons has demonstrable effects on the outcomes of microsurgical breast reconstruction. The addition of a second surgeon significantly decreases operating room time and shortens hospital length of stay in both unilateral and bilateral reconstruction. It also significantly decreases donor-site wound healing complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Forequarter amputation is a radical operation performed for treatment of malignant neoplasms of the shoulder girdle not amenable to limb salvage. Traditional approaches involve bone and soft tissue resection, followed by ligation of the axillary vessels. We describe a technique to minimize blood loss whereby control of the subclavian vessels is performed before amputation of a large tumor associated with extensive venous congestion. A 34-year-old man presented with proximal humeral osteosarcoma. Surgery involved claviculectomy to facilitate vascular control of the subclavian vessels, followed by guillotine amputation at the proximal upper arm level and completion of the amputation as conventionally described.

BACKGROUND: The aim of this study was to perform an updated systematic review of the literature over the last 10 years, analyzing and comparing the many published techniques with the hope of providing plastic surgeons with a new standard in creating the perfect umbilicus in the setting of both abdominoplasty and abdominally based free-flap breast reconstruction. METHODS: An initial search using the PubMed online database with the keyword "umbilicoplasty" was performed. These results were filtered to only include articles published within the last 10 years. The remaining articles were thoroughly reviewed by the authors and only those pertaining to techniques for umbilicoplasty in the setting of abdominoplasty and abdominally based free flap were included. RESULTS: Of the 10 unique techniques yielded by our search, 9/10 (90 %) initially incised the native umbilicus with a round, oval, or vertical ellipse pattern. Of the 9 techniques that initially perform a round incision, 4 of them (44.4 %) later modify the round umbilicus with either an inferior or superior excision to create either a "U"- or "inverted U"-shaped umbilicus. In terms of the shape of the incision made in the abdominal flap for umbilical reinsertion, the most common were either a round incision or an inverted "V" or "U," both of which accounted for 4/10 (40 %) and 3/10 (30 %), respectively. Almost all of the studies (8/10; 80 %) describe "defatting" or trimming of the subcutaneous adipose tissue around the incision to create a periumbilical concavity following inset of the umbilicus. 4/10 (40 %) of the techniques describe suturing the dermis of the umbilical skin to rectus fascia. Furthermore, 3/10 (30 %) advise that stalk plication is a necessary step to their technique. 7/9 techniques (77.8 %) preferred nondissolvable sutures for skin closure, with nylon being the most common suture material used. Only 2/9 (22.2 %) used dissolvable sutures. CONCLUSION: Although future studies are necessary, it is our hope that this systematic review better elucidates the techniques and provides some guidance to both aesthetic and reconstructive plastic surgeons in the pursuit of creating the perfect umbilicus following abdominoplasty and TRAM/DIEP breast reconstruction. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BACKGROUND: Venous outflow problems are the most common reasons for perioperative flap complications. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction and warrants further investigation. MATERIALS AND METHODS: Retrospective review of our institutional flap registry from 1979 to 2014 identified 464 free flaps performed for lower leg trauma reconstruction. Patient demographics, flap characteristics, and outcomes were examined. RESULTS: A total of 219 flaps were randomly selected for preliminary analysis. Single-vein outflow was more common (72.6%) than dual-vein (27.4%); most of the recipients were in deep venous system (83.6%) versus superficial (11.9%) or both (4.6%). Two-vein anastomoses were more likely in fasciocutaneous flaps than muscle flaps (P = 0.001) and in smaller (<300 cm(2)) flaps (P = 0.002). Complications occurred in 98 flaps (44.7%); with 54 partial flap losses (24.7%), and 11 complete flap losses (5.0%). Multivariable regression analysis controlling for age, sex, flap type, presence of bone gap, flap size, vein size mismatch, and time since injury demonstrated dual-vein outflow to be protective against complications (relative risk [RR] = 0.269, P = 0.001), partial flap failure (RR = 0.351, P = 0.031), and any flap failure (RR = 0.31, P = 0.010). No significant difference in operative time was found (P = 0.664). CONCLUSIONS: Dual-vein outflow demonstrated 73% reduction in overall complications and 69% reduction in flap failure rate compared to single-vein flaps. These results suggest a protective effect of a dual-vein outflow system, and when considered together with our findings of unchanged operative time, provide evidence for preferential use of two venous anastomoses when possible for free flap reconstruction of lower extremity trauma.

Background The internal mammary vessels are the most commonly used recipients for microsurgical breast reconstructions. Often, the costal cartilage is sacrificed to obtain improved vessel exposure. In an effort to reduce adverse effects associated with traditional rib sacrifice, recent studies have described less-invasive, rib-sparing strategies. Methods After obtaining institutional review board's approval, a retrospective review of all patients undergoing microsurgical breast reconstruction at a single institution between November 2007 and December 2013 was conducted. Patients were divided into two cohorts for comparison: rib-sacrificing and rib-sparing internal mammary vessel harvests. Results A total of 547 reconstructions (344 patients) met inclusion criteria for this study. A total of 64.9% (n = 355) underwent rib-sacrificing internal mammary vessel harvest. Cohorts were similar in baseline patient characteristics, indications for surgery, and cancer therapies. However, patients undergoing rib-sparing reconstructions had significantly shorter operative times (440 vs. 476 minutes; p < 0.01), and significantly less postoperative pain on postoperative day (POD) 1 (2.8/10 vs. 3.4/10; p = 0.033) and POD2 (2.4/10 vs. 3.0/10; p = 0.037). Furthermore, patients undergoing rib-sparing techniques had greater incidence of fat necrosis requiring excision (12.5 vs. 2.8%; p < 0.01) and a trend toward higher incidence of hematoma, venous thrombosis, and arterial thrombosis when compared with rib-sacrificing patients. Conclusions Rib-sparing harvest of internal mammary vessels is a feasible technique in microsurgical breast reconstruction. However, given the significant increase in fat necrosis requiring surgical excision, the trend toward increased postoperative complications, and no significant difference in postoperative revision rates, the purported benefits of this technique may fail to outweigh the possible risks.

RATIONALE AND OBJECTIVES: Cellulitis is a common cause for emergency department (ED) presentation and subsequent hospital admission. Underlying fracture, osteomyelitis, or foreign body is often considered in the clinical evaluation of these patients. Accordingly, plain radiographs (XRs) of the affected extremity are often ordered during the initial work-up. The utility of these imaging studies in the treatment of uncomplicated lower-extremity cellulitis, however, remains unclear. In an effort to treat this common problem more efficiently, we evaluated our imaging practices and results in a cohort of consecutive patients admitted to a large public city hospital for treatment of uncomplicated lower-extremity cellulitis. MATERIALS AND METHODS: Retrospective cohort study of 288 consecutive ED admissions for treatment of uncomplicated cellulitis, of which 214 met the inclusion criteria for this study. Patient demographics, history, vitals, laboratory values, and test results were evaluated with univariate and multivariate statistical analyses. RESULTS: XRs of the affected lower extremity were obtained in 158 patients (73.8%). Positive XR findings were present in 19 patients (12.0%) and positively correlated with a history of acute trauma to the extremity (P < .001) or the presence of a chronic wound (P < .01). Multivariable logistic regression analysis revealed a history of trauma (P < .001) or the presence of a chronic wound (P < .05) to be independent predictors of positive XR findings with relative risks of 6.24 and 2.98, respectively. CONCLUSIONS: The establishment of evidence-based guidelines for the treatment of lower-extremity cellulitis has potential to significantly improve clinical efficiency and reduce cost by eliminating unnecessary testing. Based on our results, patients without a recent history of trauma to the affected extremity or the presence of a chronic wound do not appear to warrant XRs. When applied to our cohort, only 48 of 158 patients had a history of trauma or chronic wound. This means that 110 patients unnecessarily had plain films taken as part of their initial work-up. In a largely uninsured inner city patient population such as this cohort, that extra cost falls on the public hospital system.