Faculty Bibliography

BACKGROUND: Patients increasingly rely on Internet resources for medical information. Well-informed patients are more likely to be active participants in their health care, contributing to higher satisfaction and better overall outcomes. Access to online patient material, however, can be limited by inadequate functional health literacy. The National Institutes of Health and the American Medical Association recommend that educational content be written at a sixth-grade reading level. This study aims to assess the readability of online patient resources for breast augmentation surgery. METHODS: A Web search for "breast implant surgery" was performed using the largest public search engine. After sponsored results were excluded, the 12 most accessed sites were identified. Patient-directed information from all relevant articles immediately linked from the main site was downloaded and formatted into plain text. The readability of 110 articles was evaluated using 10 established analyses, both overall and by Web site. RESULTS: The overall average readability of the 12 most popular Internet resources for breast augmentation was at a thirteenth-grade reading level (Coleman-Liau, 13.4; Flesch-Kincaid, 12.7; FORCAST, 11.3; Fry, 13; New Dale-Chall, 12.9; New Gunning Fog, 13.8; Raygor Estimate, 15; and Simple Mesaure of Gobbledygook Formula, 14.3). The Flesch Reading Ease index was 41, which falls into a "difficult" reading category. No individual article or Web site was at the recommended sixth-grade level. CONCLUSIONS: Online resources for breast augmentation are above recommended reading levels. This may potentially serve as a barrier to patients seeking this type of surgery. Plastic surgeons should be aware of potential gaps in understanding and direct patients toward more appropriate resources.

BACKGROUND: Use of the tumescent mastectomy technique has been reported to facilitate development of a hydrodissection plane, reduce blood loss, and provide adjunct analgesia. Previous studies suggest that tumescent dissection may contribute to adverse outcomes after immediate implant reconstruction; however, its effect on autologous microsurgical reconstruction has not been established. METHODS: A retrospective review was conducted of all immediate microsurgical breast reconstruction procedures at a single academic center between January 2004 and December 2013. Records were queried for age, body mass index, mastectomy weight, diabetes, hypertension, smoking, preoperative radiation, reconstruction flap type, and autologous flap weight. Outcomes of interest were mastectomy skin necrosis, complete and partial flap loss, return to the operating room, breast hematoma, seroma, and infection. RESULTS: There were 730 immediate autologous breast reconstructions performed during the study period; 46% with the tumescent dissection technique. Groups were similar with respect to baseline patient and procedural characteristics. Univariate analysis revealed no significant difference in the incidence of mastectomy skin necrosis, complete or partial flap loss, return to the operating room, operative time, estimated blood loss, recurrence, breast hematoma, seroma, or infection in patients undergoing tumescent mastectomy. Multivariate analysis also demonstrated no significant association between the use of tumescent technique and postoperative breast mastectomy skin necrosis (P = 0.980), hematoma (P = 0.759), or seroma (P = 0.340). CONCLUSIONS: Use of the tumescent dissection technique during mastectomy is not significantly associated with adverse outcomes after microsurgical breast reconstruction. Despite concern for its impact on implant reconstruction, our findings suggest that this method can be used safely preceding autologous procedures.

BACKGROUND: Wound re-epithelialization has been traditionally described to occur from the dermal appendages of the wound edges. As such, the role of the dermal wound bed in re-epithelialization has been questioned. In a patient undergoing breast reconstruction with free tissue transfer, the buried portions of the free flap skin paddle could be either de-epithelialized or deskinned. In case of mastectomy skin flap loss, the role of de-epithelialized skin in wound healing has not been described before. METHODS: We report a patient with bilateral mastectomies and bilateral deep inferior epigastric perforator flaps whose postoperative course was complicated by bilateral full-thickness mastectomy skin flap loss. Multiple debridements of nonviable skin resulted in exposure of previously buried de-epithelialized skin paddle of the deep inferior epigastric perforator flap. RESULTS: Our study demonstrates self re-epithelialization of the dermal wound bed from the dermal appendages. We noticed multiple noncontiguous neoepidermal islands in the dermal wound bed, which did not communicate with the wound edges. CONCLUSIONS: In case of full-thickness mastectomy skin flap loss, deep vascular plexus present in the dermal bed of the underlying de-epithelialized skin paddle of the free flap converts an otherwise full-thickness wound to a partial-thickness wound. Our study demonstrates the self-epithelialization potential of the de-epithelialized dermal wound bed from the dermal appendages when exposed to air and in the presence of wound healing elements.

Metastatic tumors are the most common cranial neoplasms in adults. Skull metastases from rare primary tumors, such as cholangiocarcinoma or pancreatic neuroendocrine tumor, are extremely uncommon and rarely reported. Given the scarcity and variation of these rare skull metastases, treatments and outcomes of such patients are of interest to treating surgeons. The authors describe the treatment algorithm, course, and outcomes of 2 patients with rare gastrointestinal skull metastases. The first patient had intrahepatic cholangiocarcinoma metastatic to the skull, while the second patient developed a solitary skull metastasis secondary to a pancreatic neuroendocrine tumor. As part of this report, the authors include a literature review of rare skull metastases as well as the treatment of these 2 patients. Both the patients ultimately underwent successful resection of the tumor for relief of their clinical symptoms. Wide resections in both patients necessitated reconstruction using a free latissimus dorsi muscle flap in both the patients. Preoperative embolization of the hypervascular cholangiocarcinoma skull metastasis was performed prior to resection in the first patient. To date, there have been only 4 such reports of skull metastases from intrahepatic cholangiocarcinoma and limited reported cases of isolated skull metastases from a pancreatic neuroendocrine tumor.In patients with large or numerous skull metastasis from rare primary tumors, surgical resection should be considered for symptomatic improvement. In cases of hypervascular lesions, preoperative embolization can be considered to decrease the intraoperative bleeding. Free tissue transfers using myocutaneous flaps such as latissimus dorsi help in obliterating dead space, and creating a healthy soft tissue envelope to withstand postoperative radiation treatment. In addition, a chimeric flap can be designed to include additional muscle or soft tissue to obliterate and exclude the sinus cavities.

Pneumosinus dilatans (PD) is a pathologic hyperaeration of the paranasal sinuses of unknown etiology. Although benign itself, PD has been associated with a number of serious concomitant conditions, including meningioma, optic nerve tumors, and visual loss. Patients with PD often present with cosmetic complaints, desiring recontouring of the facial bones to achieve an improved appearance of the face. The present case illustrates one of the first attempts at intraoperative surgical navigation to map the frontal sinus during correction of the facial deformity caused by PD. The navigation device was used to give the surgical team real-time information during the case to prevent violation of the posterior table of the frontal sinus, allowing for facial bone contouring to occur in a more efficient and safer manner by way of accurate osteotomy placement with no wasted bone for reconstruction and no accidental intracranial involvement.

BACKGROUND: Outcome studies of immediate implant-based breast reconstruction have focused largely on patient factors, whereas the relative impact of the surgeon as a contributing variable is not known. As the procedure requires collaboration of both a surgical oncologist and a plastic surgeon, the effect of the surgeon team interaction can have a significant impact on outcome. This study examines outcomes in implant-based breast reconstruction and the association with patient characteristics, surgeon, and surgeon team familiarity. METHODS: A retrospective review of 3142 consecutive implant-based breast reconstruction mastectomy procedures at one institution was performed. Infection and skin necrosis rates were measured. Predictors of outcomes were identified by unadjusted logistic regression followed by multivariate logistic regression. Surgeon teams were grouped according to number of cases performed together. RESULTS: Patient characteristics remain the most important predictors for outcomes in implant-based breast reconstruction, with odds ratios above those of surgeon variables. The authors observed significant differences in the rate of skin necrosis between surgical oncologists with an approximately two-fold difference between surgeons with the highest and lowest rates. Surgeon teams that worked together on fewer than 150 procedures had higher rates of infection. CONCLUSIONS: Patient characteristics are the most important predictors for surgical outcomes in implant-based breast reconstruction, but surgeons and surgeon teams are also important variables. High-volume surgeon teams achieve lower rates of infection. This study highlights the need to examine modifiable risk factors associated with optimum implant-based breast reconstruction outcomes, which include patient and provider characteristics and the surgical team treating the patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Background & Purpose: Given the great variability in perioperative management of craniosynostosis, a large-scale national survey of current practice patterns was conducted. Methods & Description: Using scaphocephaly as a test diagnosis, 115 craniofacial surgeons at all levels of career experience across the United States were invited to participate in an anonymous survey. Surgeons were asked about practices related to pre-operative evaluation and planning, intraoperative monitoring, operative team composition, and post-operative care. Results: Fifty-three surgeons (46%) completed the survey. The overwhelming majority of craniofacial surgeons work with pediatric neurosurgeons (100%), fellowship-trained pediatric anesthesiologists (95.8%), and use arterial lines (95.8%) and urinary catheters (97.9%). All respondents complete repair before 1 year of age with a majority operating between 4-8 months. Surgeons with greater than 10 years of experience were significantly more likely to perform open repair at extremes of age (<4 months and 8-12 months) (p=0.03) and reported shorter operative times (p=0.01) compared to their less experienced colleagues. More than two-thirds of surgeons (68.8%) obtain pre-operative imaging for every case; 83% of these prefer CT scans. Over a fourth of respondents (28%) routinely prescribe an extended course (>24 hours) of antibiotics. Overall transfusion rates remain high, with nearly two in three (65.2%) transfusing in 76-100% of operations. The overwhelming majority of respondents (93.6%) routinely send patients to an intensive care unit (ICU) post-operatively. Conclusions: We present the largest United States survey of craniosynostosis surgical practice patterns to date. General consensus exists regarding safety and emergency preparedness standards. Craniosynostosis repair remains a high-risk operation that can be performed safely. Additionally we identified several patterns that deviate from published evidence-based guidelines and impact on patient care and healthcare expenditures. Specifically, these practices relate to the routine use of high-dose radiation imaging, long-term antibiotics, blood transfusions, and intensive postoperative surveillance. For the first time, stratifying by surgeon experience revealed significant differences in clinical practice

Background & Purpose: Traditional neurosurgical access to tumors or vascular anomalies of the anterior cranial fossa and/or ethmoid sinus requires coronal incision and extensive frontal dissection. Here we detail a limited supra-brow approach, focusing on operative technique, anatomic exposure, and clinical considerations. Methods & Description: Operative Technique: After epineph-rine infiltration, a supra-brow incision is made. Intermuscular dissection separates preorbital orbicularis oculi from inferior frontalis. Frontal periosteum is identified and supraperiosteal exposure is obtained from glabella medially to deep temporalis fascia laterally. The periosteum surrounding the supraorbital nerve is incised and the nerve is reflected inferiorly with periorbita (making an osteotomy for true foramina). Next, a medially based pericranial flap is raised, exposing frontal bone for mini-craniotomy; this flap is kept protected beneath the medial frontalis muscle. After neurosurgical intervention and dural repair, cranial bone is rigidly restored. Overlying soft tissue is closed in layers. Anatomic Exposure: Before craniotomy, various maneuvers provide additional exposure. Subperiosteal dissection within the supero-medial orbit permits supraorbital craniotomy and access to the ethmoid sinus. Elevating anterior temporalis permits more lateral craniotomy and access to neurosurgical targets within the lateral anterior cranial fossa. Clinical Considerations: To prevent injury to the fronto-temporal branch of the facial nerve, dissection over the frontal bone is supraperiosteal and dissection over temporalis is just above deep muscle fascia. When the craniotomy includes lateral frontal sinus, mucosa is burred off the removed bone and in situ sinus; the nasofrontal outflow tract is obliterated with the pericranial flap and sealed with fibrin glue. The preserved pericranial flap can also be used to restore dural integrity. When bone is deficient, the removed cranium can be split for additional graft. Results: We used the supra-brow approach in 14 patients to provide sufficient access for definitive neurosurgical management of an anterior clinoid meningioma, three lateral frontal lobe meningioma, nine aneurysms of the anterior communicating artery, and an intra-ethmoidal arterio-venous malformation. Blood loss during exposure was minimal in all cases. There was no injury to the ophthalmic division of trigeminal nerve or frontal branch of facial nerve. Split calvarial grafts were used in nine of fourteen patients. At one year follow-up, all patients had excellent frontal contour, bony union, and an aesthetic scar. Conclusions: A supra-brow approach limits extensive dissection and permits sufficient neurosurgical exposure to tumors and vascular anomalies of the entire anterior cranial fossa and ethmoid sinus