Faculty Bibliography

BACKGROUND:Corticosteroid use continues to rise nationally. Studies have evaluated the impact of chronic steroid use on surgical outcomes in smaller populations. This study investigated the impact of chronic steroid use on perioperative surgical outcomes in a surgical cohort of more than 5 million surgical patients, using a statistically rigorous methodology. METHODS:and t test analysis, and then repeated after propensity score matching. Finally, a double-adjustment logistic regression was utilized, yielding odds ratios to assess the effect of chronic steroids on perioperative outcomes within the matched population. RESULTS:Between 2008 and 2016, a total of 5,244,588 patients met inclusion criteria, of whom 181,901 (3.5%) were taking steroids for a minimum of 30 days before surgery. Patients on chronic steroids had significantly more comorbidities compared with the remaining population. After propensity score matching and double-adjusted logistic regression, chronic steroid use was found to be associated with increased surgical complications and poorer surgical outcomes. Chronic steroid use significantly increased a patient's risk of having a hospital stay longer than 30 days by 19%, risk of readmission within 30 days by 58%, risk of reoperation by 21%, and risk of death by 32%. CONCLUSION/CONCLUSIONS:After controlling for differences in comorbidities and demographics, patients on chronic steroids have significantly poorer perioperative outcomes. Chronic steroid use should be evaluated and, if possible, addressed before surgery, given their significant impact on surgical outcomes.

PURPOSE/OBJECTIVE:Being one of the most common congenital hand malformations, syndactyly is repaired by orthopedic, plastic, and fellowship-trained general surgeons. Limited multi-institutional outcomes analyses regarding incidence, timing, and type of repair exist. METHODS:, Fisher exact, and t-test analysis. RESULTS:A total of 956 patients who underwent syndactyly repair were identified. Most cases were simple syndactyly with nearly even case distribution among plastic and orthopedic surgeons. Most patients were men and Caucasian. Mean age at the time of surgery was 2.6 years. Most cases were performed as outpatient surgery. Patients of plastic surgeons had significantly more airway abnormalities and shorter operative times. Patients with complex syndactyly had significantly more ventilator dependence, tracheostomy, and comorbidities when compared with those with simple syndactyly. Cases with complex syndactyly also had longer operative times and a higher rate of superficial surgical site infections. CONCLUSIONS:Syndactyly repair is a safe procedure with few major or minor reconstructive complications regardless of the surgical specialty or syndactyly type. Patients with complex syndactyly have significantly more preoperative comorbidities with comparable outcomes. orthopedic surgeons have significantly longer operative times than plastic surgeons, likely due to caring for increased number of patients with complex syndactyly.

G protein-coupled receptors (GPCRs) are the largest family of transmembrane signaling proteins. Within the gastrointestinal tract, GPCRs expressed by epithelial cells sense contents of the lumen, and GPCRs expressed by epithelial cells, myocytes, neurons, and immune cells participate in communication amongst cells. GPCRs control digestion, mediate digestive diseases, and coordinate repair and growth. GPCRs are the target of over one third of therapeutic drugs, including many drugs used to treat digestive diseases. Recent advances in structural, chemical, and cell biology research have revealed that GPCRs are not static binary switches that operate from the plasma membrane to control a defined set of intracellular signals. Rather, GPCRs are dynamic signaling proteins that adopt distinct conformations and subcellular distributions when associated with different ligands and intracellular effectors. An understanding of the dynamic nature of GPCRs has provided insights into the mechanism of activation and signaling of GPCRs, and has revealed opportunities for drug discovery. We review the allosteric modulation, biased agonism, oligomerization, and compartmentalized signaling of GPCRs that control digestion and digestive diseases. We highlight the implications of these concepts for the development of selective and effective drugs to treat diseases of the gastrointestinal tract.

BACKGROUND:Integrated plastic surgery residency applicants sometimes complete research fellowships before residency. The average productivity and the impact of these fellowships on subsequent application to residency are unknown. The purpose of this study was to provide objective data to better understand the utility and productivity of a research fellowship. METHODS:A national survey was conducted in which integrated plastic surgery residency applicants from 2013 to 2016 were surveyed regarding their experiences with research fellowships. American Council of Academic Plastic Surgeons members were also surveyed to elicit their perspectives on the value of these fellowships. RESULTS:Six hundred twenty-one integrated plastic surgery applicants from 2013 to 2016 were included in the study. Twenty-five percent of applicants participated in a research fellowship. Applicants who completed research fellowships were more likely to match into plastic surgery compared to those who did not (97 percent versus 81 percent, respectively; p < 0.05). Fellows were highly satisfied with their fellowship experience and produced an average of five publications and presentations per fellowship year. Sixty-three percent of research fellowships were performed to strengthen applications to categorical integrated plastic surgery residency. American Council of Academic Plastic Surgeons members considered three or four publications/presentations productive. Most do not recommend research fellowships to all medical students. CONCLUSIONS:Research fellowships can effectively prepare for categorical plastic surgery by improving publication and presentation experience. This is the first study to show that applicants who completed research fellowships were highly satisfied with their experience, accomplished higher than expected levels of productivity, and statistically significantly matched into an integrated plastic surgery residency more often than applicants without research fellowships.

BACKGROUND:The general teaching is that increased number of vein repairs in digit replantation leads to improved venous outflow, resulting in lower need for iatrogenic bleeding, lower postoperative transfusion requirements, and better survival rates. The purpose of this study was to determine whether the traditional teaching that emphasizes the repair of multiple veins per arterial anastomosis results in superior survival rates. METHODS:A retrospective review of a single urban replant center's single-digit replants distal to the mid-metacarpal level in adult patients from 2007 to 2017 was performed. Data on patient demographics, mechanism and level of injury, veins repaired, iatrogenic bleeding, postoperative transfusions, and replant survival were obtained. RESULTS:There were a total of 54 single-digit replants. The most common mechanism was lacerations (N = 38), and the most common injury level was at the proximal phalanx (N = 21). All digits were replanted with a single arterial anastomosis-44% via grafting. In all, 0 to 3 veins were repaired per digit (mean = 1.5 veins). The mean transfusion requirement was 1.7 units. The survival rate was 50%. Digits with 1 or 2 veins repaired had lower transfusion requirements (1.1-1.3 units) and higher survival rates (56%-61%) compared with those replanted with 0 or 3 veins repaired (2.9-3.5 transfused units, 25%-29% survival). There were no differences between those digits replanted with either 1 or 2 veins repaired for transfusion requirements or survival. CONCLUSIONS:More veins repaired do not necessarily improve survival or possibly venous outflow, calling into question the traditional teaching that 2 veins should be repaired for every arterial anastomosis.

BACKGROUND:The medial sural artery perforator flap offers thin, pliable tissue with a relatively long pedicle and low donor-site morbidity. This study explores the characteristics and uses of the medial sural artery perforator flap along with postoperative outcomes and complications. METHODS:A systematic literature review was performed using PubMed, Embase, and Cochrane Central Register of Controlled Trials to identify all cases of medial sural artery perforator flap reconstruction. Descriptive and meta-analyses were performed on pooled outcomes. Multivariate logistic regression identified factors associated with increased complication rates. RESULTS:Thirty-five studies encompassing 526 medial sural artery perforator flaps were included for analysis. The most common reasons for surgery were oncologic (47.6 percent) and traumatic injuries (31.8 percent). The oral cavity was the most common recipient location (45.5 percent). Average flap dimensions were 6.0 ± 2.3 cm × 9.8 ± 3.6 cm, with an average pedicle length of 10.1 ± 6.6 cm. Meta-analysis revealed an overall complication rate of 14.3 percent (Q value = 22.16; p = 0.877; I= -39.9). Use of chimeric medial sural artery perforator flaps was associated with significantly higher rates of complications (OR, 3.92; p = 0.039; 95 percent CI, 1.10 to 13.89). The majority of flap donor sites were closed primarily (68 percent) versus 32 percent that were covered with split-thickness skin grafts. A flap width greater than 5.75 cm had an odds ratio of 5.3 (95 percent CI, 1.3 to 21.8; p = 0.014) of having a donor-site complication if closed primarily. CONCLUSIONS:The medial sural artery perforator flap offers thin, pliable tissue with a relatively long pedicle and has minimal donor-site morbidity when the donor site is managed appropriately. As such, it should be considered a workhorse flap for both head and neck and extremity reconstruction.

LEARNING OBJECTIVES/OBJECTIVE:After studying this article, the participant should be able to: 1. Evaluate appropriate patients best suited for one- or two-stage alloplastic breast reconstruction. 2. Discuss and apply the unique advantages and disadvantages of scaffold use and different implant types in breast reconstruction to maximize outcomes. 3. Develop a plan for patients undergoing implant-based breast reconstruction requiring postmastectomy radiation therapy. 4. Analyze the evidence with regard to antibiotic prophylaxis in implant-based breast reconstruction. 5. Recognize and critique novel technical and device developments in the field of alloplastic breast reconstruction, enabling appropriate patient selection. SUMMARY/CONCLUSIONS:Implant-based, or alloplastic, breast reconstruction is the most common method of breast reconstruction in the United States. Within implant-based reconstruction, many techniques and reconstructive strategies exist that must be tailored for each individual patient to yield a successful reconstruction. Not unexpectedly, many hot topics and controversies in this field have emerged, including stages of reconstruction, use of scaffolds, permanent implant type, strategies for postmastectomy radiation therapy, and antibiotic prophylaxis. In addition, there has been an evolution in technical and device development in recent years. Therefore, plastic surgeons must be on the forefront of knowledge to approach implant-based breast reconstruction in an evidence-based fashion to best treat their patients.

OBJECTIVE:To evaluate the probability of survival of monolithic and porcelain veneered lithium disilicate crowns comprised by a conventional or modified core when loaded on marginal ridges. METHODS:Lithium disilicate molar crowns (n=30) were fabricated to be tested at mesial and distal marginal ridges and were divided as follows: (1) bilayered crowns with even-thickness 0.5mm framework (Bi-EV); (2) bilayered crowns with modified core design (Bi-M-lingual collar connected to proximal struts), and: (3) monolithic crowns (MON). After adhesively cemented onto composite-resin prepared replicas, mesial and distal marginal ridges of each crown (n=20) were individually cyclic loaded in water (30-300N) with a ceramic indenter at 2Hz until fracture. The 2-parameter Weibull was used to calculate the probability of survival (reliability) (90% 2-sided confidence bounds) at 1, 2, and 3 million cycles and mean life. RESULTS:The reliability at 1 and 2 million cycles was significantly higher for MON (47% and 19%) compared to Bi-EV (20% and 4%) and Bi-M (17% and 2%). No statistical difference was found between bilayered groups. Only the MON group presented crown survival (7%) at 3 million cycles. The mean life was highest for MON (1.73E+06), lowest for Bi-M (573,384) and intermediate for Bi-E (619,774). Fractographic analysis showed that the fracture originated at the occlusal surface. The highest reliability was found for MON crowns. The modified framework design did not improve the fatigue life of crowns. SIGNIFICANCE/CONCLUSIONS:Monolithic lithium disilicate crowns presented higher probability of survival and mean life than bilayered crowns with modified framework design when loaded at marginal ridges.

Restoration of the upper lip provides a reconstructive challenge because of its anatomical and aesthetic requirements. This article provides a "where is it on the lip" approach to reconstruct small to subtotal defects of the upper lip that are feasible to perform in the office setting. Emphasis is placed on adherence to core principles, attention to macroaesthetic and microaesthetic landmarks, and technical refinements of well-established reconstructive techniques. These tenets include algorithms for central and lateral defects, precise use of the Abbe flap, use of local tissue rearrangement and skin grafts, and appropriate management of scars. A strong understanding of the anatomical and aesthetic nuances of the upper lip will allow for enhancement of conventional reconstructive procedures to optimize functional and aesthetic outcomes.