Faculty Bibliography

Innovative surgery is defined as a novel procedure, a significant modification of a standard technique, or a new application of an established technique. Although innovation is a crucial part of improving patient care in plastic surgery, there are various ethical considerations and dilemmas in performing unvalidated techniques and procedures, especially for non-life-threatening indications. The aim of this study was to gain a better understanding regarding the motivations and ethical considerations of plastic surgeons in their decision to perform innovative operations. An anonymous, institutional review board-approved, online survey was sent to members of the American Society of Plastic Surgeons and other international plastic surgeons worldwide. The survey asked respondents to rank various factors that influence their decisions to perform innovative plastic surgery, both reconstructive and aesthetic, on a five-point Likert scale. Seven hundred thirty-three of 26,028 plastic surgeons (response rate, 2.9 percent) responded to the survey. Although similar factors were considered to be important for both reconstructive and aesthetic operations, only approximately 50 percent of respondents considered institutional review board approval to be an important factor when considering innovation in both reconstructive (50 percent) and aesthetic surgery (51 percent), suggesting that respondents do not consider innovation a form of research that ought be subject to standard research protections. Overall, the authors' survey suggests that more effort must be extended to ethical training in plastic surgery to create a stronger professional atmosphere regarding innovation and, possibly, to the creation of a more formal group charged with oversight of innovation.

OBJECTIVE:Despite the presence of self-inflicted wounds (SIWs) across all of medicine, our current understanding of SIWs in surgery is limited. Here, we detail the pertinent aspects of the history, diagnosis, decision making, and management of SIWs as they relate to the field of surgery. In addition, we present the first comprehensive review of SIWs across the surgical literature. SUMMARY BACKGROUND DATA/BACKGROUND:Self-inflicted wounds have been recognized for much of recorded human history and span a wide spectrum of patient behaviors, motivations, and underlying psychiatric illnesses. METHODS:We performed a comprehensive literature review of SIWs in the surgical literature. In total, 189 articles were identified. RESULTS:The most common site of primary SIW was the upper extremity (36.2%), and the most common presenting injuries were lacerations (22.7%). Forty-two percent of patients had received prior surgical procedures for their SIWs, and the average length of time preceding treatment or diagnosis of an injury as an SIW was 2.29 years. Self-inflicted wounds resulting from foreign body insertions were most common (25.9%). Psychiatric factors accounted for most SIW production (35%), of which factitious disorder was the most common (12.7%). Other motivations for SIW production included autoeroticism (8.6%), substance related (6.6%), organic brain disease (5.0%), and self-therapy/surgery by patients (1.7%). Surgical management was ultimately required for nearly 75% of SIWs and was successful in most cases. CONCLUSIONS:Self-inflicted wounds are frequently encountered in all surgical specialties and encompass many anatomic locations, presentations, and patient-motivating factors. Surgical intervention is common, and successful outcomes are often achieved.

GENERAL PURPOSE/UNASSIGNED:To provide information about the pathophysiology, diagnosis, and treatment options for systemic sclerosis. TARGET AUDIENCE/BACKGROUND:This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES/UNASSIGNED:After participating in this educational activity, the participant should be better able to:1. Describe the pathophysiology, signs, symptoms, and diagnosis of systemic sclerosis.2. Outline the evidence-based medical and surgical management of systemic sclerosis. ABSTRACT/UNASSIGNED:OBJECTIVE:: To perform a targeted review of systemic sclerosis, including epidemiology, pathophysiology, diagnosis, signs and symptoms, and medical and surgical management of upper extremity manifestations. DATA SOURCES AND STUDY SELECTION/METHODS:An electronic literature review was conducted using PubMed for all publication dates through October 2017. Searches were performed using combinations of terms including "systemic sclerosis," "scleroderma," "management," "upper extremity," "hypercalcinosis," "Raynaud's phenomenon," "sympathectomy," and "digital ulcers." Only full-length articles written in English that discussed the management of upper extremity scleroderma were used. DATA EXTRACTION AND SYNTHESIS/METHODS:The epidemiology, pathophysiology, diagnosis, upper extremity manifestations, and medical and surgical management of systemic sclerosis were reviewed. The case described in this article reports the utility of microsurgical interventions in the treatment of medically refractory upper extremity systemic sclerosis. CONCLUSIONS:Systemic sclerosis is a rare rheumatologic disease that greatly impacts quality of life. Medical management is the mainstay of treatment, propelling an improvement in the dismal 10-year cumulative survival rate from 54% in the 1970s to 66% in the 1990s. However, the pathophysiology of this disease is still poorly understood, and when medical management fails and the disease inevitably progresses, surgical approaches are critical.

OBJECTIVE:Osteoarthritis (OA) is a leading cause of disability in the world. Mesenchymal stem cells (MSCs) have been studied to treat OA. This review was performed to systematically assess the quality of literature and compare the procedural specifics surrounding MSC therapy for osteoarthritis. DESIGN/METHODS:PubMed, CINAHL, EMBASE and Cochrane Central Register of Controlled Trials were searched for studies using MSCs for OA treatment (final search December 2017). Outcomes of interest included study evidence level, patient demographics, MSC protocol, treatment results and adverse events. Level I and II evidence articles were further analyzed. RESULTS:Sixty-one of 3,172 articles were identified. These studies treated 2,390 patients with osteoarthritis. Most used adipose-derived stem cells (ADSCs) (n=29) or bone marrow-derived stem cells (BMSCs) (n=30) though the preparation varied within group. 57% of the sixty-one studies were level IV evidence, leaving five level I and nine level II studies containing 288 patients to be further analyzed. Eight studies used BMSCs, five ADSCs and one peripheral blood stem cells (PBSCs). The risk of bias in these studies showed five level I studies at low risk with seven level II at moderate and two at high risk. CONCLUSION/CONCLUSIONS:While studies support the notion that MSC therapy has a positive effect on OA patients, there is limited high quality evidence and long-term follow-up. The present study summarizes the specifics of high level evidence studies and identifies a lack of consistency, including a diversity of MSC preparations, and thus a lack of reproducibility amongst these articles' methods.

BACKGROUND:Patients' satisfaction is an increasingly important indicator for successful ear reconstruction surgeries. However, there is no scientifically sound patient-based outcome instrument in this field. This study aims at developing a patient-reported outcome measure for microtia reconstruction for investigating patients' satisfaction and perception of reconstructed ear and clinical researches. METHODS:The development of questionnaire included 3 stages. Traditional psychometric tests were used for analysis. At first stage, a preliminary version of the questionnaire was developed using qualitative methods, including interviews with 10 patients. At second stage, the questionnaire was field tested by survey of 76 patients. Redundant items were deleted; acceptability, reliability, and responsiveness were examined. At third stage, survey was conducted to another 94 patients with the shortened questionnaire to further evaluate the acceptability, reliability, and validity. RESULTS:A questionnaire of 12 items for microtia reconstruction was developed. Results demonstrated the instrument satisfied the current criteria. The acceptability (missing data <1%, largest endorsement frequencies <60%), reliability (Cronbach alphas >0.80, item-total correlations >0.7, interitem correlation <0.8), validity (scale intercorrelations r = 0.59, low correlations with age and sex) of the questionnaire. CONCLUSIONS:The questionnaire is an acceptable, reliable, and validated outcome measure for evaluation of ear reconstruction esthetic outcomes in microtia patients. It could be used for further comparison studies and effectiveness studies.

BACKGROUND:Plantar foot reconstruction requires special consideration of both form and function. There are several fasciocutaneous flap options, each with indications and reservations. CASE STUDY/METHODS:This case presents a new application of the vertical profunda artery perforator flap for definitive closure of a neuropathic foot ulcer in a young woman with spina bifida. The postoperative course was uneventful, and the flap survived completely. The surgical and donor sites were without wound recurrence at 5-month follow-up. DISCUSSION/CONCLUSIONS:Understanding the variability of foot flap options is important because of unique cases such as the one presented where the wound was caused by specific and less commonly observed foot anatomy. The specific choice to use the vertical profunda artery perforator flap for this patient and her neuropathic wound type was made based on its excellent flexibility, durability, and donor site appeal. CONCLUSIONS:The vertical profunda artery perforator flap has adequate surface area and bulk and a favorable pedicle length and caliber, can be thinned, and leaves a donor scar in a less conspicuous area than other popular free flaps for lower-extremity reconstruction. For these reasons, it should be considered a first-line therapy for free flap coverage of selected foot wounds.

Wounds of the foot challenge reconstructive surgeons to manage multiple factors: sensibility, stability, and durability. In this article, we focus on the insensate foot, which poses challenges to wound prevention with its propensity to develop pressure ulceration. The authors present the innovative use of a pressure-sensing smart insole system (SurroSense Rx, Orpyx Medical Technologies Inc., Calgary, Canada) in the management of the insensate foot in a patient following foot reconstruction. The pressure-sensing smart insole system provided unique feedback to both patient and provider in ways that contributed to the prevention of pressure ulcer recurrence, as well as highlight the importance of prescribed footwear in both the affected and unaffected foot. Wearable real-time monitoring and feedback faces the challenge of patient adherence. Future studies are indicated to examine the specific behaviors that are associated with favorable outcomes and long-term behavior changes.

GENERAL PURPOSE: To provide information on risk factors for surgical site infections (SSIs) and actions to mitigate that risk. TARGET AUDIENCE: This continuing education activity is intended for surgeons, surgical teams, physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Identify modifiable risk factors associated with the development of SSIs.2. Select steps to mitigate the risks for and morbidity from SSIs. ABSTRACT: Given the current reimbursement structure, the avoidance of a surgical site infection (SSI) is crucial. Although many risk factors are associated with the formation of an SSI, a proactive and interprofessional approach can help modify some factors. Postoperative strategies also can be applied to help prevent an SSI. If an SSI becomes a chronic wound, there are recommended guidelines and strategies that can foster healing.

GENERAL PURPOSE: To provide information from a review of the literature about chronic ulcers associated with tophaceous gout. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Identify the pathophysiology of tophaceous gout, its presentation, phases, and common comorbidities.2. Evaluate the findings in this review regarding effectiveness of interventions for chronic tophaceous ulcers. ABSTRACT: OBJECTIVE: Treating chronic ulcers associated with tophaceous gout is an uncommon but important clinical challenge. However, treatments vary greatly from topical therapies, to debridements, to free flap wound coverage. To the authors' knowledge, this is the first study to assemble and compare these different approaches in order to guide effective treatment. DATA SOURCES: An electronic search of MEDLINE (PubMed) was conducted. Search terms included (gout and ulcer) not "peptic ulcer," and (gout, chronic wound) or (gout, nonhealing wound). STUDY SELECTION: Studies that discussed the presentation, characterization, or treatment of gout-associated wounds were included. The literature search yielded 9 case reports and case series; there were no randomized controlled studies or reviews. DATA EXTRACTION: Patient and wound characteristics, treatment approaches, and outcomes were noted. DATA SYNTHESIS: The 82% of 22 patients were male, aged 36 to 95 years. Three patients had not been previously diagnosed with gout, whereas others had received a diagnosis 2 to 35 years prior to presentation with an ulcer. Many patients had comorbidities including diabetes and peripheral vascular disease. Most of the 43 total ulcers occurred on the feet. Treatments included topical 3% citric acid in petroleum jelly, allogeneic culture dermal substitute, silver-containing dressing and heterologous lyophilized collagen, debridements, and free flap coverage. CONCLUSIONS: Chronic tophaceous wounds are a worldwide problem. Although physicians report some successes with different treatments, controlled studies are needed to determine the most effective approach and to identify risk factors and preventive strategies.