Faculty Bibliography

Lymphedema is a debilitating disease that is commonly caused by cancer and it is treatments in the developed world. Surgery is an option for refractory disease. Lymphovenous bypass and vascularized lymph node transfer are newer modalities that show great promise. Further work is necessary to determine proper patient selection and ensure minimum donor site morbidity. Liposuction and direct excision still have a role, especially in advanced cases. Further investigations into prevention of iatrogenic lymphedema are underway. J. Surg. Oncol. 2016;113:932-939. (c) 2016 Wiley Periodicals, Inc.

OBJECTIVE: To report on the prevalence of voice disturbances in the pediatric craniofacial population and to prove that the pediatric Voice Handicap Index (pVHI) is a useful questionnaire for this unique population. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care center. SUBJECTS: Pediatric patients seen by a pediatric otolaryngologist in a craniofacial clinic. METHODS: Consecutive patients (N = 366) seen by a single pediatric otolaryngologist in a craniofacial clinic from July 2011 to September 2012 were included. Any patient specifically referred for airway problems or voice difficulties completed a pVHI questionnaire. Patients each underwent an evaluation including flexible fiberoptic laryngoscopy and videostroboscopy. Voice disturbance was further characterized into dysphonia, hypernasality, or hyponasality. RESULTS: Of all the patients evaluated, 280 (77%) were specifically referred for airway problems or voice disturbance. Of those referred, 39 (10.7%) were found to have an organic vocal fold pathology causing dysphonia, as seen on the videostroboscopic examination; 53.7% of these lesions were attributable to potential iatrogenic causes. Hypernasality and hyponasality were seen in 116 (31.7%) and 78 (21.3%) patients, respectively. The pVHI was 3.95, 26.3, 11.34, and 10.53 for those with no voice disturbance, dysphonia, hypernasality, and hyponasality, respectively. CONCLUSION: Pediatric patients with craniofacial disorders have a higher prevalence of dysphonia than the general pediatric population. The majority of causes of dysphonia in these patients are possibly iatrogenic in origin. The pVHI serves as a useful questionnaire in this unique patient cohort to quantify the disability from not only dysphonia but also hypernasality and hyponasality.

BACKGROUND: Refinements in microsurgical breast reconstruction have refined superficial inferior epigastric artery (SIEA) and superficial circumflex iliac artery (SCIA) flaps, yet technical difficulties and varied success rates limit widespread acceptance. The authors present the outcomes of their experience with 145 consecutive SIEA/SCIA flaps and suggest technical tips to improve success with this important flap. METHODS: An institutional review board-approved retrospective chart review of all SIEA/SCIA free flaps performed by the senior authors between January 1, 2006, and February 6, 2014, was conducted. Data on patient demographics, flap characteristics, and complications were collected. RESULTS: There were 145 flaps performed in 119 patients. Arterial donor and recipient mismatch occurred in 55 instances (38 percent). In these cases, 48 arteries (87 percent) were spatulated and seven (13 percent) were back-cut to improve size concordance. Nine flaps required operative return for flap viability concerns. Five were arterial, three were venous, and one flap had concomitant arterial and venous thrombosis. Total flap loss rate attributable to thrombotic events was 4.8 percent. No flaps with arterial thrombosis on reoperation were salvageable. Furthermore, 80 percent had arterial revisions at initial operation. No patients had an abdominal bulge or hernia, and the fat necrosis rate was 10.3 percent. CONCLUSIONS: SIEA/SCIA breast reconstruction can be reliably performed; however, flaps exhibiting postoperative arterial thrombosis with revision at initial surgery are unlikely salvageable on reoperation. Spatulation did not correlate with an increased thrombosis rate; in fact, the authors advocate for donor artery manipulation to manage size mismatch. CLINCAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Forequarter amputation is a radical operation performed for treatment of malignant neoplasms of the shoulder girdle not amenable to limb salvage. Traditional approaches involve bone and soft tissue resection, followed by ligation of the axillary vessels. We describe a technique to minimize blood loss whereby control of the subclavian vessels is performed before amputation of a large tumor associated with extensive venous congestion. A 34-year-old man presented with proximal humeral osteosarcoma. Surgery involved claviculectomy to facilitate vascular control of the subclavian vessels, followed by guillotine amputation at the proximal upper arm level and completion of the amputation as conventionally described.

PURPOSE: To compare the bone bonding capabilities of 2 different surface treatments at an early healing period. Titanium alloy (Ti6Al4V) custom-made rectangular plates (1.4 x 2.4 x 4 mm) were either dual acid etched (Ti6Al4V-DAE) or DAE/nanotextured blasted (Ti6Al4V-NTB). MATERIALS AND METHODS: Implants were placed in the distal femurs of 10 Wistar rats and were allowed to heal for 9 days. After euthanasia, the bone immediately proximal and distal to the implant was removed to test the bone bonding force with a universal testing machine. Ultrastructure of the bone/implant interface was assessed by scanning electron microscopy. RESULTS: Ti6Al4V-NTB samples exhibited significantly greater bond strength than Ti6Al4V-DAE samples. Morphologically, the Ti6Al4V-NTB surfaces presented intimate interaction with bone, whereas little interaction between the Ti6Al4V-DAE surface and bone was observed. CONCLUSION: The results of this study indicated a significant increase in bone bonding for the DAE/nanotextured blasted surface, which is suggested to be the outcome of the nanotexturing.

BACKGROUND: Recipient-site infection after oropharyngeal reconstruction is a potentially disastrous complication. Although studies suggest that perioperative antibiotics reduces infection rates in these patients from 87% to 20%, there is no consensus regarding what constitutes the most appropriate antibiotic regimen and duration of treatment. METHODS: A retrospective review of perioperative antibiotic administration was performed of all patients who underwent local, pedicled, or free flap oropharyngeal reconstruction after oncologic resection by a single surgeon at a single institution between 2007 and 2013 to assess for recipient-site complications. RESULTS: Ninety-seven patients underwent 100 reconstructions (61 free flap reconstructions, 39 pedicled/local flap reconstructions) and all received a combination of intravenous (IV) antibiotic agents designed to cover oral flora. There were 23 (23%) recipient-site complications, which included cellulitis (9%), mucocutaneous fistula (5%), abscess (5%), and wound dehiscence (4%). Duration of antibiotic prophylaxis, defined as less than 48 hours (short-course) or greater than 48 hours (long-course), was not a significant predictor of recipient-site complication. Significant risk factors for recipient-site complications were clindamycin prophylaxis (P < 0.008), increased duration of surgery (P < 0.047), and advanced age (P < 0.034). Recipient-site complication was found to be a significant predictor of both increased length of hospital stay (P < 0.001) and increased time to the resumption of enteral feeds (P < 0.035). CONCLUSIONS: These data suggest that extended courses of perioperative antibiotics do not confer additional benefits in patients undergoing oropharyngeal reconstruction. We recommend a limited 48-hour course of prophylactic antibiotics with sufficient aerobic and anaerobic coverage to help minimize the incidence of antibiotic-related morbidities.

Background The time to detection of vascular compromise is a significant predictor of free flap salvage outcomes as early reexploration improves salvage rates. Continuous transcutaneous near-infrared tissue oximetry is an objective, quantitative method of detecting flap vascular compromise and has been shown to allow earlier reexploration and higher salvage rates than clinical assessment alone. We designed a novel text messaging system to improve communication using tissue oximetry monitoring. Methods A retrospective review was performed of a prospectively collected database of all microsurgical breast reconstructions from 2008 to 2015. A novel text messaging system was introduced in 2013 and programmed to send text messages alert when the tissue oximetry readings suggested potential flap compromise based on established thresholds. Patient demographics and complications, including rate of reexploration and flap loss were assessed. Results There were 900 autologous microsurgical breast free flaps during the study period: 614 were monitored with standard clinical monitoring and tissue oximetry compared with 286 flaps with the additional text messaging system. There were 27 unplanned returns to the operating room in the tissue oximetry group and 5 in the text messaging group with 1 complete flap loss in each group. Reexploration occurred sooner as a result of these text message alerts (17.5 vs. 26.6 hours postoperatively), however, it did not achieve statistical significance. Conclusions We were able to demonstrate the use of a novel text messaging system for tissue oximetry. This alert system shows promise in identifying impending flap loss with rapid notification of the surgical team.

BACKGROUND: The aim of this study was to perform an updated systematic review of the literature over the last 10 years, analyzing and comparing the many published techniques with the hope of providing plastic surgeons with a new standard in creating the perfect umbilicus in the setting of both abdominoplasty and abdominally based free-flap breast reconstruction. METHODS: An initial search using the PubMed online database with the keyword "umbilicoplasty" was performed. These results were filtered to only include articles published within the last 10 years. The remaining articles were thoroughly reviewed by the authors and only those pertaining to techniques for umbilicoplasty in the setting of abdominoplasty and abdominally based free flap were included. RESULTS: Of the 10 unique techniques yielded by our search, 9/10 (90 %) initially incised the native umbilicus with a round, oval, or vertical ellipse pattern. Of the 9 techniques that initially perform a round incision, 4 of them (44.4 %) later modify the round umbilicus with either an inferior or superior excision to create either a "U"- or "inverted U"-shaped umbilicus. In terms of the shape of the incision made in the abdominal flap for umbilical reinsertion, the most common were either a round incision or an inverted "V" or "U," both of which accounted for 4/10 (40 %) and 3/10 (30 %), respectively. Almost all of the studies (8/10; 80 %) describe "defatting" or trimming of the subcutaneous adipose tissue around the incision to create a periumbilical concavity following inset of the umbilicus. 4/10 (40 %) of the techniques describe suturing the dermis of the umbilical skin to rectus fascia. Furthermore, 3/10 (30 %) advise that stalk plication is a necessary step to their technique. 7/9 techniques (77.8 %) preferred nondissolvable sutures for skin closure, with nylon being the most common suture material used. Only 2/9 (22.2 %) used dissolvable sutures. CONCLUSION: Although future studies are necessary, it is our hope that this systematic review better elucidates the techniques and provides some guidance to both aesthetic and reconstructive plastic surgeons in the pursuit of creating the perfect umbilicus following abdominoplasty and TRAM/DIEP breast reconstruction. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .