Faculty Bibliography

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.

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.

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: Recipient vessels proximal to the zone of injury have traditionally been preferred for lower extremity reconstruction. However, more recent data have shown mixed outcomes when performing anastomoses distal to the zone of injury. We investigated the impact of recipient vessel location on free flap outcomes. METHODS: Retrospective review (1979-2016); 312 soft tissue free flaps for open tibia fractures met inclusion criteria. Flap characteristics and perioperative outcomes were examined. Systematic review identified articles evaluating anastomosis location and flap outcomes; pooled data analysis was performed. RESULTS: = 0.39) found no difference in flap failure rates between proximal and distal groups. CONCLUSION/CONCLUSIONS: Our results are congruent with the current lower extremity literature and demonstrate no difference in perioperative complication rates between anastomoses performed proximal or distal to the zone of injury. These findings suggest that anastomotic location choice should be based primarily on recipient vessel quality/flow and ease of access/exposure rather than orientation relative to the zone of injury.

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.

PURPOSE/OBJECTIVE:Mandibular defects involving the condyle represent a complex reconstructive challenge for restoring proper function of the temporomandibular joint (TMJ) because it requires precise bone graft alignment for full restoration of joint function. The use of computer-aided design and manufacturing (CAD/CAM) technology can aid in accurate reconstruction of mandibular condyle defects with a vascularized free fibula flap without the need for additional adjuncts. The purpose of this study was to analyze clinical and functional outcomes after reconstruction of mandibular condyle defects using only a free fibula graft with the help of virtual surgery techniques. MATERIALS AND METHODS/METHODS:A retrospective review was performed to identify all patients who underwent mandibular reconstruction with only a free fibula flap without any TMJ adjuncts after a total condylectomy. Three-dimensional modeling software was used to plan and execute reconstruction for all patients. RESULTS/RESULTS:From 2009 through 2014, 14 patients underwent reconstruction of mandibular defects involving the condyle with the aid of virtual surgery technology. The average age was 38.7 years (range, 11 to 77 yr). The average follow-up period was 2.6 years (range, 0.8 to 4.2 yr). Flap survival was 100% (N = 14). All patients reported improved facial symmetry, adequate jaw opening, and normal dental occlusion. In addition, they achieved good functional outcomes, including normal intelligible speech and the tolerance of a regular diet with solid foods. Maximal interincisal opening range for all patients was 25 to 38 mm with no lateral deviation or subjective joint pain. No patient had progressive joint hypomobility or condylar migration. One patient had ankylosis, which required release. CONCLUSION/CONCLUSIONS:TMJ reconstruction poses considerable challenges in bone graft alignment for full restoration of joint function. The use of CAD/CAM technology can aid in accurate reconstruction of mandibular condyle defects with a vascularized free fibula flap through precise planning and intraoperative manipulation with optimal functional outcomes.

A retrospective Institutional Review Board-approved review was performed at the Institute of Reconstructive Plastic Surgery, NYU Langone Medical Center, of patients undergoing craniofacial distraction osteogenesis procedures using the rigid external distractor device between 2000 and 2010. Three particularly challenging cases were identified and are presented here.

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.

OBJECTIVE:Driveline infection is a common complication of durable left ventricular assist device support. The majority involve the driveline exit site and can be treated with antibiotics and local wound care. Less frequently, these infections extend into deeper tissues and surgical debridement is necessary. Few studies have described the surgical strategy for treatment of deep driveline infection or have reported long-term outcomes. With a growing population of patients being implanted as destination therapy, there is an obvious need to evaluate and optimize treatment for complex driveline infections. METHODS:Outcomes of patients undergoing durable left ventricular assist device implantation at a single center between 2011 and 2017 were reviewed retrospectively. Data including occurrence of driveline infection, pathogen, time to driveline infection, and treatment strategy were abstracted from the electronic medical record. RESULTS:Driveline infection occurred in 10 (16.4%) of 61 patients at a median of 362 days (Q1 = 99, Q3 = 694) after primary left ventricular assist device implantation. Three (30.0%) of 10 driveline infections were categorized as deep and did not resolve with intravenous antibiotic therapy. In these cases, a multistage approach that included initial debridement and exteriorization of the infected driveline, followed by delayed surgical relocation of the driveline in a clean vascularized soft tissue bed, was used. Long-term device salvage was achieved in all cases. CONCLUSIONS:An aggressive surgical strategy, including debridement and formal relocation of the driveline exit site, can result in long-term device salvage after deep driveline infection. This approach is a less invasive alternative to device exchange for refractory driveline infections.

BACKGROUND: Left ventricular assist devices (LVADs) have become useful adjuncts in the treatment of patients with end-stage heart failure. LVAD implantation is associated with a unique set of problems; one such problem is device infection. We report our experience with flap salvage of infected and/or exposed LVAD hardware. METHODS: Between 2011 and 2016, 49 patients underwent LVAD implantation at our institution. Patients were then categorized by infectious status: systemic infection not directly involving the LVAD device, hardware infection responsive to antibiotics, and exposure of LVAD hardware or device infection refractory to antibiotics requiring debridement and flap coverage. RESULTS: Approximately 50% of device-related infections resolved with either oral or intravenous antibiotics while the other 50% necessitated debridement and coverage with healthy tissue. In total, 12 patients (24%) developed a device-related infection ranging from superficial driveline cellulitis to purulent pocket infections. Seven patients (14%) required extensive debridement and/or flap coverage. CONCLUSION: Early debridement and coverage of exposed hardware are crucial to successfully treating these LVAD infections.