Faculty Bibliography

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.

Postburn lip deformities pose a significant set of challenges to reconstructive burn surgeons because of the complex anatomy, diverse functions, and specialized nature of the lip tissues. There has been a paucity of literature on restoration of the vermillion to date. The authors report on two patients who suffered burn injuries resulting in significant lip deformities who underwent a novel method of vermillion reconstruction with a full thickness anal verge skin graft. Both patients tolerated the procedure well without complications. One patient had slight hyperpigmentation of the graft which was treated with a phenol peel to cause intentional lightening. Overall, both patients had a restored vermillion border and improved color match and contour of the lip. Histologic analysis of the anal verge demonstrates that it has a nonkeratinized, transitional epithelial architecture which is nearly identical to that of the vermillion tissue. Skin grafting remains one of the cornerstones of tissue replacement in acute burn care and burn reconstruction. The vermillion represents an area of specialized tissue that is not well reconstructed with simple skin grafts. Other methods for reconstruction involve lip switch operations or local flaps, like a ventral tongue flap. These procedures are not without limitation and can often cause microstomia among other issues. With no donor site morbidity, a full thickness anal verge skin graft represents the closest approximation of actual vermillion tissue found anywhere else in the body and should be considered a viable option in the reconstruction of these challenging patients.

BACKGROUND:Breast cancer is the most commonly diagnosed malignancy in women. Mastectomy and breast-conserving surgery (BCS) have equivalent survival for early stage breast cancer. However, each surgery has different benefits and harms that women may value differently. Women of lower socioeconomic status (SES) diagnosed with early stage breast cancer are more likely to experience poorer doctor-patient communication, lower satisfaction with surgery and decision-making, and higher decision regret compared to women of higher SES. They often play a more passive role in decision-making and are less likely to undergo BCS. Our aim is to understand how best to support women of lower SES in making decisions about early stage breast cancer treatments and to reduce disparities in decision quality across socioeconomic strata. METHODS:We will conduct a three-arm, multi-site randomized controlled superiority trial with stratification by SES and clinician-level randomization. At four large cancer centers in the United States, 1100 patients (half higher SES and half lower SES) will be randomized to: (1) Option Grid, (2) Picture Option Grid, or (3) usual care. Interviews, field-notes, and observations will be used to explore strategies that promote the interventions' sustained use and dissemination. Community-Based Participatory Research will be used throughout. We will include women aged at least 18 years of age with a confirmed diagnosis of early stage breast cancer (I to IIIA) from both higher and lower SES, provided they speak English, Spanish, or Mandarin Chinese. Our primary outcome measure is the 16-item validated Decision Quality Instrument. We will use a regression framework, mediation analyses, and multiple informants analysis. Heterogeneity of treatment effects analyses for SES, age, ethnicity, race, literacy, language, and study site will be performed. DISCUSSION:Currently, women of lower SES are more likely to make treatment decisions based on incomplete or uninformed preferences, potentially leading to poorer decision quality, quality of life, and decision regret. This study hopes to identify solutions that effectively improve patient-centered care across socioeconomic strata and reduce disparities in decision and care quality. TRIAL REGISTRATION:NCT03136367 at ClinicalTrials.gov Protocol version: Manuscript based on study protocol version 2.2, 7 November 2017.

BACKGROUND:Distal radius fractures treated with open reduction and internal fixation are commonly stabilized with a volar locking plate; however, more complex fracture patterns may require supplemental fixation with fragment-specific implants. The objective of this study was to evaluate the outcomes of distal radius fractures treated with radial column plates. METHODS:A consecutive series of 61 patients who sustained distal radius fractures underwent radial column plating alone or in conjunction with other implants between August 2006 and January 2014. Thirty-one patients returned for follow-up or returned a mailed questionnaire at an average of 4.1 years. The outcomes measures included Visual Analog Scale (VAS); Disabilities of the Arm, Shoulder and Hand (DASH); and Patient-Rated Wrist Evaluation (PRWE) scores. RESULTS:Sixty-one patients with a mean age of 55 years (range, 20-87) met inclusion criteria and were available for follow-up or chart review at an average of 5.2 years (range, 1.6-9.0 years). Seventeen of 61 (28%) underwent radial column plate removal. Twenty patients returned for final follow-up examination, and 11 completed questionnaires via mail. Subjective scores included a mean postoperative VAS of 0.72, DASH score of 17.2, and PRWE score of 15.7. Hardware sensitivity and wrist stiffness were the most common complications at final follow-up. CONCLUSIONS:Radial column plating of the distal radius is a safe treatment modality and a valuable adjunct in the setting of complex distal radius fractures, but patients should be counseled that there is a 28% chance that hardware removal may be required. Our retrospective review found evidence of few complications and objective scores consistent with return to normal function.

Background: Obesity and type 2 diabetes have not only been linked to fatty liver, but also to fatty kidney and chronic kidney disease. Since non-invasive tools are lacking to study fatty kidney in clinical studies, we explored agreement between proton magnetic resonance spectroscopy ( 1 H-MRS) and enzymatic assessment of renal triglyceride content (without and with dietary intervention). We further studied the correlation between fatty kidney and fatty liver. Methods: Triglyceride content in the renal cortex was measured by 1 H-MRS on a 7-Tesla scanner in 27 pigs, among which 15 minipigs had been randomized to a 7-month control diet, cafeteria diet (CAF) or CAF with low-dose streptozocin (CAF-S) to induce insulin-independent diabetes. Renal biopsies were taken from corresponding MRS-voxel locations. Additionally, liver biopsies were taken and triglyceride content in all biopsies was measured by enzymatic assay. Results: Renal triglyceride content measured by 1 H-MRS and enzymatic assay correlated positively ( r = 0.86, P < 0.0001). Compared with control diet-fed minipigs, renal triglyceride content was higher in CAF-S-fed minipigs (137 +/- 51 nmol/mg protein, mean +/- standard error of the mean, P < 0.05), but not in CAF-fed minipigs (60 +/- 10 nmol/mg protein) compared with controls (40 +/- 6 nmol/mg protein). Triglyceride contents in liver and kidney biopsies were strongly correlated ( r = 0.97, P < 0.001). Conclusions: Non-invasive measurement of renal triglyceride content by 1 H-MRS closely predicts triglyceride content as measured enzymatically in biopsies, and fatty kidney appears to develop parallel to fatty liver. 1 H-MRS may be a valuable tool to explore the role of fatty kidney in obesity and type 2 diabetic nephropathy in humans in vivo .

BACKGROUND: The septocutaneous tensor fasciae latae (sc-TFL) or lateral thigh perforator (LTP) flap was previously introduced by our group as an alternative flap for autologous breast reconstruction when the abdomen is not suitable as a donor site. The aim of this study was to analyze our experience with the LTP flap and to present the surgical refinements that were introduced. METHODS: A prospective study was conducted of all LTP flap breast reconstructions performed since September 2012. Patient demographics, operative details, complications and flap re-explorations were recorded. Preoperative imaging with MRA was performed in all patients. Surgical refinements that were introduced during this study included limitation of the flap width and the use of quilting sutures at the donor site. RESULTS: A total of 138 LTP flap breast reconstructions were performed in 86 consecutive patients. Median operation times were 277 minutes (range 196-561) for unilateral and 451 minutes (range 335-710) for bilateral procedures. Median flap weight was 348 grams (range 175-814). Two total flap losses (1.4%) were recorded and eleven flaps (8.0%) required re-exploration, which resulted in viable flaps. The incidence of donor-site complications reduced significantly after the surgical refinements were introduced. Wound problems decreased from 40.0% to 6.3%, seroma from 25.0% to 9.5%, and infection from 27.5% to 9.5%, respectively. CONCLUSIONS: The LTP flap is an excellent option for autologous breast reconstruction with minimal recipient-site complications. The surgical refinements resulted in a significant reduction of donor-site complications. Therefore, the LTP flap is currently our second choice after the DIEP flap.