Faculty Bibliography

BACKGROUND:Microsurgical free tissue transfer is an important treatment option for nonhealing lower extremity diabetic wounds. The purpose of this study was to identify factors that affect flap survival and wound complications. METHODS:A retrospective review was conducted of 806 lower extremity free-flap reconstructions performed from 1979 to 2016. A total of 33 free flaps were used for coverage of nonhealing lower-extremity diabetic ulcers. Primary outcome measures were perioperative complications and long-term wound breakdown. RESULTS:The average age was 54 ± 12.3 y. 15.2% of patients were smokers, 12.1% had coronary artery disease and 12.1% had end-stage renal disease. Muscle flaps predominated (75.8%) compared to fasciocutaneous flaps (24.2%). There were 7 patients (21.2%) that underwent a revascularization procedure before (71.4%) or at the same time (28.6%) as the free flap. Immediate complications occurred in 7 flaps (21.2%) with 4 partial losses (12.1%) and 3 total flap failures (9.1%). Major wound complications occurred in 18.2% of patients. An end-to-side (E-S) anastomosis for the artery was used in 63.6% (n = 22) of flaps compared with an end-to-end (E-E) anastomosis. E-S anastomosis was associated with a significantly lower risk of wound complications compared with an arterial E-E anastomosis (0% versus 45.5%, P = 0.001). CONCLUSIONS:The use of microvascular free flaps can be used successfully to cover lower-extremity diabetic wounds. E-E arterial anastomosis should be avoided if possible as it is associated with higher rates of wound breakdown, likely by impairing perfusion to a distal limb with an already compromised vasculature. LEVEL OF EVIDENCE/METHODS:Level III.

Introduction: There has been a growing interest in hyperbaric oxygen therapy (HBOT) in recent years across multiple disciplines. In the field of ophthalmology, the implications of increased HBOT use may include expanded applications in treating ocular vascular pathologies as well as a greater incidence of HBOT-induced visual complications. Areas covered: The authors review recent studies on HBOT usage in the treatment of ocular conditions. In addition to providing updates on the ophthalmic indications of HBOT, adverse visual effects of HBOT are also investigated. Expert opinion: Further evidence substantiating HBOT as an effective treatment modality for ocular vascular pathologies, such as central retinal artery occlusion and diabetic retinopathy, have been published in recent years. With the identification of more prognostic factors, increased success in HBOT has been reported. However, studies also show that adverse ocular effects associated with hyperbaric oxygen exposure include myopia and cataracts. It is important to recognize the risks of iatrogenic changes in visual acuity when considering patients for HBOT.

INTRODUCTION/BACKGROUND:Simulation is a standard component of residency training in many surgical subspecialties, yet its impact on knowledge and skills acquisition in plastic surgery training remains poorly defined. We evaluated the potential benefits of simulation-based cleft surgery learning in plastic surgery resident education through a prospective, randomized, blinded trial. METHODS:Thirteen plastic surgery residents were randomized to a digital simulator or textbook demonstrating unilateral cleft lip (UCL) repair. The following parameters were evaluated before (pre-intervention) and after (post-intervention) randomization: knowledge of surgical steps, procedural confidence, markings performance on a three-dimensional (3D) stone model, and surgical performance using a hands-on/high-fidelity 3D haptic model. Participant satisfaction with either educational tool was also assessed. Two expert reviewers blindly graded markings and surgical performance. Intra-class correlation coefficients (ICC) were calculated. Wilcoxon signed-rank and Mann-Whitney U tests were used. RESULTS:Interrater reliability was strong for pre-intervention and post-intervention grading of markings (ICC=0.97; p<0.001 and ICC=0.96; p<0.001) and surgical (ICC=0.83; p=0.002 and ICC=0.81; p=0.004) performance. Post-intervention surgical knowledge (40.3±4.4 vs. 33.5±3.7; p=0.03), procedural confidence (24.0±7.0 vs. 14.7±2.3; p=0.03), markings performance (8.0±2.5 vs. 2.9±3.1; p=0.03), and surgical performance (12.3±2.5 vs. 8.2±2.3; p=0.04) significantly improved in the digital simulation group compared to pre-intervention, but not in the textbook group. All participants were more satisfied with the digital simulator as an educational tool (27.7±2.5 vs. 14.4±4.4; p<0.001). CONCLUSIONS:We present evidence suggesting that digital cognitive simulators lead to significant improvement in surgical knowledge, procedural confidence, markings performance, as well as surgical performance.

PURPOSE/OBJECTIVE:There is a dearth of literature dedicated to specifically evaluating the use of free flap reconstruction in pediatric lower extremity traumas. This study aims to identify specific risk factors for flap failure in pediatric lower extremity trauma reconstruction. METHODS:Retrospective review of 53 free flaps in our lower extremity database (1979-2017) identified all free flaps performed for traumatic reconstruction in children <18 years of age at our institution. RESULTS:analysis (P = 0.041). CONCLUSION/CONCLUSIONS:Free flap reconstruction in the pediatric trauma population is safe with similar survival outcomes when compared to the adult population. Arterial injury and vessel size mismatch were associated with significantly higher flap failure rates in this population. LEVEL OF EVIDENCE/METHODS:Level III.

BACKGROUND:De novo or rare transmitted mutations in the SMAD6 gene affect 7 percent of midline nonsyndromic synostosis patients. This study aimed to determine the neurocognitive sequelae of SMAD6 synostosis. METHODS:Nonsyndromic synostosis patients 6 years or older with SMAD6 mutations and non-SMAD6 nonsyndromic synostosis controls were recruited. All patients completed a double-blinded neurodevelopmental battery (i.e., Wechsler Fundamentals, Wechsler Abbreviated Scale of Intelligence, Beery-Buktenica Developmental test), and parents/guardians completed behavioral surveys (Behavior Rating Inventory of Executive Function and Behavior Rating System for Children). RESULTS:Twenty-eight patients participated: 10 known SMAD6 patients (average age, 10 years; 1 female; eight metopic and two sagittal; nine treated with cranial vault remodeling and one treated with strip craniectomy) and 18 non-SMAD6 controls (age, 9.5 years; three female; 12 metopic and six sagittal; 17 treated with cranial vault remodeling and one treated with strip craniectomy). There were no differences between any demographics. Testing age, surgical age, parental education, and household income correlated with cognition (p < 0.05). After controlling for these factors, SMAD6 patients performed worse on numerical operations (p = 0.046), performance intelligence quotient (p = 0.018), full-scale intelligence quotient (p = 0.010), and motor coordination (p = 0.043) compared to age/race/gender/synostosis/operation-matched controls. On behavioral surveys, SMAD6 patients scored worse on 14 assessments, including aggression, communication, and behavior. CONCLUSIONS:This prospective double-blinded study revealed that neuropsychiatric development of nonsyndromic synostosis may be under genetic control. SMAD6 mutations led to poorer mathematics, performance intelligence quotient, full-scale intelligence quotient, and motor coordination, even after controlling for exogenous factors. Genetic testing may be critical for advocating early adjunctive neurodevelopmental therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Risk, II.

BACKGROUND:The impact of insurance and socioeconomic status on breast reconstruction modalities when access to care is controlled is unknown. METHODS:Records for patients who underwent breast reconstruction at an academic medical center between 2013 and 2017 were reviewed and analyzed using chi-square analysis and logistic regression. RESULTS:One thousand six hundred eighty-three breast reconstructions were analyzed. The commercially insured were more likely to undergo microvascular autologous breast reconstruction (44.4 percent versus 31.3 percent; p < 0.001), with an odds ratio of 2.22, whereas patients with Medicare and Medicaid were significantly more likely to receive tissue expander/implant breast reconstruction, with an odds ratio of 1.42 (41.7 percent versus 47.7 percent; p = 0.013). Comparing all patients with microvascular reconstruction, the commercially insured were more likely to receive a perforator flap (79.7 percent versus 55.3 percent versus 43.9 percent), with an odds ratio of 4.23 (p < 0.001). When stratifying patients by median household income, those in the highest income quartile were most likely to receive a perforator flap (82.1 percent) (p < 0.001), whereas those in the lowest income quartile were most likely to receive a muscle-sparing transverse rectus abdominis myocutaneous flap (36.4 percent) (p < 0.001). CONCLUSIONS:Patients at the same academic medical center had significantly different breast reconstruction modalities when stratified by insurance and household income. Despite similar access to care, differences in insurance types may favor higher rates of perforator flap breast reconstruction among the commercially insured. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Risk, II.

OBJECTIVES/OBJECTIVE:The purpose of this retrospective study is to present our results with peroneal nerve lesions, to examine the relative significance of various factors, to assess their effect on outcome, and to establish guidelines of treatment for the microsurgical management of these difficult lesions. METHODS:Over a 33-year period, a total of 62 patients were treated at McGill University and the Microsurgical Research Center, Eastern Virginia Medical School. The clinical records of all patients treated for peroneal nerve lesions were reviewed for retrospective analysis. RESULTS:Of 62 patients, 35 had microneurolysis and nerve decompression of the common peroneal nerve (CPn) as the only surgical procedure while 27 required reconstruction with nerve grafting. Postoperatively muscle power was graded from M + 4 to M - 5 in 27 patients, from M - 4 to M4 in 26 patients, from M - 3 to M + 3 in 8 patients, and from M - 2 to M + 2 in 1 patient. The behavioral video data showed a mean preoperative ankle dorsiflexion of 6.79° ± 5.6 and postoperative ankle dorsiflexion of 37.9° ± 9.3. Overall, excellent functional results were achieved in 27 of 62 patients (43%) with peroneal palsy who underwent microsurgical reconstruction, and good results were observed in 25 patients (40%). CONCLUSIONS:Despite previous widespread pessimism, the surgical repair of CPn lesion is worthwhile, yielding good to excellent results in the majority of patients, after a careful preoperative consultation, establishment of a sound strategy of reconstruction and using aggressive and atraumatic microsurgery.