Faculty Bibliography

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.

BACKGROUND:Diabetes affects a significant proportion of the population in the United States. Microsurgical procedures are common in this patient population, and despite many conflicting reports in the literature, there are no large studies evaluating the direct association between diabetes and outcomes, specifically failure, following free flap reconstruction. In this study, we sought to determine the impact of diabetes on postoperative outcomes following free flap reconstruction using a national multi-institutional database. METHODS:We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients undergoing free flap reconstruction from 2010 to 2015. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Univariate and multivariate analyses were performed to control for confounders. RESULTS:We identified 6030 eligible patients. No significant difference in flap failure rates was observed. However, diabetic patients presented significantly higher rates of wound complications, including deep incisional surgical site infection (SSI) (OR = 1.35; P = .01) and wound dehiscence (OR = 1.17; P = .03). Diabetic patients also presented a significantly longer hospital length of stay (LOS) (β = .62; P < .001). CONCLUSIONS:Our study evaluated the largest national cohort of free flap procedures. These results suggest that diabetes is not associated with increased rates of flap failure. However, diabetic patients are at significantly higher risk of postoperative deep incisional SSI, wound dehiscence, and longer LOS. Our findings provide the most concrete evidence to date in support of free flap reconstruction in diabetic patients, but highlight the need for heightened clinical vigilance and wound care for optimal outcomes.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:To determine if a long segment of trachea can be transplanted as a vascularized organ and to determine if a tracheal transplant is a potential surgical option for a long-segment circumferential tracheal defect. STUDY DESIGN/METHODS:Animal model. METHODS:Four (two donors and two recipients) adult domestic Yorkshire swine were used. Two sets of transplants were performed from a donor to recipient pig. The transplant was placed heterotopically (not in continuity with the airway), and the recipient animals were monitored for 14 days to ensure the transplants were well vascularized. Immunosuppressive therapies included methylprednisolone, cyclosporine, and azathioprine. Gross as well as histological examination of multiple tissues types including mucosa, cartilage, muscle, and blood vessels were performed postsacrifice on day 14. RESULTS:Recipient animal weights ranged from 40 to 42 kilograms. Both recipient pigs survived the full 14 days of study and exhibited normal activity and appetite. Ischemia time of transplanted grafts ranged from 63 to 72 minutes. Transplanted tracheas included a minimum of 15 cartilaginous rings and measured greater than 10 cm in length. Both grafts maintained a robust blood supply throughout the duration of study. CONCLUSIONS:The entire visceral compartment can be reliably transplanted, either as a single component (trachea) or as a chimeric flap with multiple components (trachea, esophagus, larynx, and pharynx). Further studies in the swine model should be considered to study the effects of transplanting the trachea orthotopically into the native airway. Further studies are needed into the reliability of this technique of transplantation in humans. LEVEL OF EVIDENCE/METHODS:NA Laryngoscope, 128:S1-S9, 2018.

BACKGROUND:Nipple-sparing mastectomy (NSM) allows for preservation of the entire nipple-areola complex utilizing various incision patterns. Reconstructive trends and overall risk associated with these diverse NSM incisions have yet to be fully elucidated. METHODS:All NSMs from 2006 to 2017 were identified; outcomes were stratified by type of mastectomy incision: lateral or vertical radial, inframammary fold, Wise pattern, previous, and periareolar. RESULTS:A total of 1212 NSMs were performed with 1207 NSMs included for final analysis. Of these, 638 (52.9%) utilized an inframammary fold incision, 294 (24.4%) utilized a lateral radial incision, 161 (13.3%) used a vertical radial incision, 60 (5.0) utilized a Wise pattern incision, 35 (2.9%) used a previous incision, and 19 (1.6%) utilized a periareolar incision.The groups were heterogeneous and differed significantly with regards to various factors including age (p<0.001), body-mass index (p<0.001), mastectomy indication (p<0.001), mastectomy laterality (p<0.001), pathologic cancer stage (p<0.001), reconstruction modality (p<0.001), and adjuvant chemoradiation (p=0.031; p=0.002), among others.In crude multivariate logistic regression analysis, vertical radial (16.1%) and inframammary fold incisions (21.0%) were associated with lower overall complication rates. In a reduced multivariate logistic regression model, inframammary fold incisions (p=0.001) emerged as significantly protective of overall complications after controlling all variables. Wise pattern incisions increased the odds of complications, although not quite significantly (p=0.051). CONCLUSIONS:NSM may be safely performed using various mastectomy incisions, each with unique advantages and limitations. Overall, inframammary fold incisions appear to be associated with lowest complications while Wise pattern incisions may increase risk.

OBJECTIVES/OBJECTIVE:To investigate how muscle and fasciocutaneous flaps influence the progression of bone healing in acute Gustilo IIIB tibia fractures. DESIGN/METHODS:Retrospective Chart Review. SETTING/METHODS:Urban Academic Level I Trauma Center. PATIENTS/PARTICIPANTS/METHODS:Between 2006 and 2016, 39 patients from a database of operatively treated long bone fractures met the inclusion criteria, which consisted of adults with acute Gustilo IIIB tibia shaft fracture requiring flap coverage and having at least 6 months of radiographic follow-up. INTERVENTION/METHODS:Soft tissue coverage for patients with Gustilo IIIB open tibia fractures was performed with either a muscle flap or fasciocutaneous flap. MAIN OUTCOME MEASUREMENTS/METHODS:A radiographic union score for tibia (RUST) fractures, used to evaluate fracture healing, was assigned to patients' radiographs postoperatively, at 3, 6, and 12 months from the initial fracture date. Mean RUST scores at these time points were compared between those of patients with muscle flaps and fasciocutaneous flaps. Union was defined as a RUST score of 10 or higher. RESULTS:There was a significant difference (P = 0.026) in the mean RUST score at 6 months between the muscle group (8.54 ± 1.81) and the fasciocutaneous group (6.92 ± 2.46). There was no significant difference in the mean RUST score at 3 months (P = 0.056) and at 12 months (P = 0.947) between the 2 groups. There was also significance in the number of fractures reaching union, favoring muscle flaps, at 6 months (P = 0.020). CONCLUSIONS:Patients with acute Gustilo IIIB tibia fractures who received muscle flaps have significantly faster radiographic progression of bone healing in the first 6 months than do patients who received fasciocutaneous flaps. Furthermore, according to radiographic evaluation, more Gustilo IIIB tibia fractures receiving muscle flaps reach union by 6 months than those flapped with fasciocutaneous tissue. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:The prevalence of Obesity along with bariatric surgery and massive weight loss requiring panniculectomy is increasing in the United States. The effect of Diabetes Mellitus (DM) on outcomes following panniculectomy remains poorly defined despite its prevalence. Our study aims to evaluate the impact of DM on complications following panniculectomy and determine risk factors for adverse events. METHODS:The American College of Surgeons National Surgical Quality Improvement (ACS NSQIP) database was used to identify patients undergoing panniculectomy between 2010 and 2015. Patients were stratified based on diabetic status. Multivariate regression was performed to control for confounders. RESULTS:Review of the database identified 7,035 eligible patients who underwent panniculectomy, out of which 770 (10.9%) were diabetic. Multivariate regression showed that DM was a significant risk factor for wound dehiscence (OR = 1.92; 95% CI: 1.41-3.15; p=0.02). Obesity was a significant risk factor for superficial (OR = 2.78; 95% CI: 1.53 - 3.69; p<0.001) and deep (OR = 1.52; 95% CI: 1.38 - 3.97; p=0.01) incisional surgical site infection (SSI). Smokers were also at an increased risk for superficial (OR = 1.42; 95% CI: 1.19 - 1.75; p=0.03) and deep (OR = 1.63; 95% CI: 1.31 - 2.22; p=0.02) incisional SSI. CONCLUSIONS:Our analysis shows that DM is an independent risk factor for wound dehiscence following panniculectomy. Obesity and smoking were significant risk factors for superficial and deep incisional SSI. These results underscore the importance of preoperative risk factor evaluation in patients undergoing panniculectomy for safe outcomes.

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:Free tissue transfer after lower extremity trauma is associated with notoriously high complication rates. Theoretically, the inclusion of a cutaneous paddle on muscle free flaps may improve clinical flap monitoring. The effect of skin paddle presence on muscle free flap salvage outcomes after take-back was examined. METHODS:Retrospective query of our institutional free-flap registry (1979-2016) identified 362 muscle-based flaps performed for soft tissue coverage after below-knee trauma. Primary outcome measures were perioperative complications, specifically take-back indications, timing, and flap salvage rates. Univariate and multivariate regression analyses were performed where appropriate. RESULTS:The most common flaps were latissimus dorsi (166; 45.9%), rectus abdominis (123; 34%), and gracilis (42; 11.6%) with 90 flaps (24.9%) including skin paddles. Take-backs for vascular compromise occurred in 44 flaps (12.2%), of which 39% contained a skin paddle while 61% did not. Overall salvage rate was 20.5%, with 31.8% partial failures and 47.7% total flap losses. Muscle flaps with skin paddles were more likely to return to the operating room within 48 hours postoperatively than those without (57.1% vs 18.2%, P = 0.036). After take-back, significantly more muscle flaps with skin paddles were salvaged compared with muscle flaps without paddles (35.7% vs 4.5%, P = 0.024). Similarly, more muscle-only flaps after take-back failed compared with their counterparts with skin paddles (95.5% vs 65.3%, P = 0.024). CONCLUSIONS:Muscle flaps with a cutaneous paddle were associated with earlier return to the operating room and more successful flap salvage after take-back compared with muscle-only flaps. These findings suggest that skin paddle presence may improve clinical flap monitoring and promote recognition and treatment of microvascular compromise in lower extremity reconstruction.

BACKGROUND:Considering that muscle has higher metabolic demand than fasciocutaneous tissue and can be more difficult to monitor clinically, the authors compared take-back salvage rates between fasciocutaneous and muscle free flaps for lower extremity trauma reconstruction. METHODS:The authors conducted a retrospective review of 806 free flaps (1979 to 2016); 481 soft-tissue flaps performed for below-knee trauma met inclusion criteria. Primary outcome measures were perioperative complications, specifically, take-backs and flap salvage rates. Univariate and multivariate regression analysis was performed where appropriate. RESULTS:Take-backs occurred in 71 flaps (muscle, n = 44; fasciocutaneous, n = 27) at an average of 3.7 ± 5.4 days postoperatively. Indications were venous (48 percent), arterial (31 percent), unknown (10 percent), and hematoma (10 percent). Overall outcomes were complete salvage (37 percent), partial failure (25 percent), and total failure (38 percent). Take-backs occurring within 48 hours postoperatively correlated with higher salvage rates (p = 0.022). Fasciocutaneous flaps demonstrated increased take-back rates compared with muscle flaps (p = 0.005) that more frequently occurred within 48 hours postoperatively (relative risk, 13.2; p = 0.012). Fasciocutaneous flaps were successfully salvaged more often than muscle-based flaps (p < 0.001). Multivariable regression strongly demonstrated higher risk of take-back failure for muscle flaps (relative risk, 9.42; p = 0.001), despite higher take-back rates among fasciocutaneous flaps (relative risk, 2.28; p = 0.004). CONCLUSIONS:Compared with muscle-based flaps, fasciocutaneous flaps demonstrated earlier and more frequent take-backs for suspected vascular compromise, with higher successful take-back salvage rates. Furthermore, muscle flaps with skin paddles also demonstrated better salvage outcomes than those without. These findings may reflect a combination of lower metabolic demand and easier visual recognition of vascular compromise in fasciocutaneous tissue. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

BACKGROUND:Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy (NSM) remains controversial. We therefore examined outcomes in NSM with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle. METHODS:Autologous free flap reconstructions with NSM performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring. RESULTS:221 free flaps for NSM reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. Most common flaps used were deep inferior epigastric perforator (DIEP) (64%), profunda artery perforator (PAP) (12.1%), and muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps (10.4%). Autologous reconstructions with a skin paddle had significantly greater BMI (p=0.006). Mastectomy weight (p = 0.017) and flap weight (p<0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0% vs. 2.3%, p=1.000) or percentage of flaps requiring return to the operating room (6.0% vs. 4.7%, p=0.715) between groups. Buried flaps had an absolute greater mean number of revisional procedures per NSM (0.82) compared to the skin paddle group (0.44), however rates of revision procedures per NSM were statistically equivalent between the groups (p=0.296). CONCLUSIONS:While buried free flap reconstruction in NSM has been shown to be safe and effective, our technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision.