Faculty Bibliography

SUMMARY: Surgical manipulation of the groin can result in lymphatic injury in a significant number of patients leading to poor wound healing or infectious complications. Surgical repair of lymphatic injury is greatly aided by the precise and prompt intraoperative localization of the injured lymphatic vessels. We assessed and identified lymphatic leaks in 2 cases of surgical wound lymphorrhea occurring after instrumentation of the groin using laser-assisted indocyanine green lymphography paired with isosulfan blue injection. Both cases healed without complication, and no lymphatic leak recurrence was observed during postoperative follow-up. Laser-assisted indocyanine green lymphography is a useful adjunct in the management of lymphatic leaks after surgery of the groin and may have potential for prophylactic evaluation of high-risk groin wounds.

BACKGROUND: Fingertip injuries are extremely common in children, and severe trauma with pulp loss requires soft-tissue reconstruction to restore length, bulk, and sensibility. The thenar flap is a well-described technique but there are few reports of its use in pediatric patients. METHODS: Pediatric thenar flap reconstructions were retrospectively identified from October 2000 to October 2010 at a single institution. RESULTS: Sixteen pediatric patients (eleven male, five female) underwent thenar flap procedures. The average age was 10.8years (1.1-17.8years). The average defect size was 1.5cmx1.5cm (1cm(2)-2cm(2)). Division and inset occurred on average 16days later (12-24days). Average follow-up was 6.8months (4.1-9.6months). The average total active range of motion (TAM) in flexion was 248 degrees (235 degrees -260 degrees ) [normal maximum: 260 degrees ]. All patients had 85 degrees metacarpophalangeal joint (MCPJ) range of motion (ROM) [normal maximum: 85 degrees ]. The average proximal interphalangeal joint (PIPJ) ROM was 103 degrees (95 degrees -110 degrees ) [normal maximum: 110 degrees ] in flexion, and an average 60 degrees distal interphalangeal (DIPJ) ROM (55 degrees -65 degrees ) [normal maximum: 65 degrees ] in flexion. Objective sensibility in the flap was ascertained as an average static two-point discrimination of 7mm (6mm-10mm) in 10 compliant patients and was grossly intact in all other patients. There were no complications. CONCLUSIONS: The thenar flap is a safe and effective option for pediatric fingertip amputation injuries requiring soft-tissue reconstruction.

BACKGROUND: Scapular position and size deficiency is evident in obstetric brachial plexus paralysis (OBPP) patients due to the absence of balanced muscular forces acting on the scapula. Scapula stabilization (SS) procedures aim to restore a balanced musculature and anatomic position and to augment shoulder function and enhance developmental potential. METHODS: Retrospective chart review of 106 patients with OBPP between March 1979 and March 2007 was performed. Forty-one female and 27 male were included in the study. In 38 patients, the paralysis was global, 13 had Erb's paralysis with C7 root involvement; in 18 patients, the lesion was limited to C5 and C6. X-rays were evaluated, and scapula dimensions were manually measured at several stages. Shoulder abduction (SA) and external rotation (SER) outcomes were also recorded. RESULTS: Mean improvement was 85.68 degrees in shoulder abduction and 36.74 degrees in shoulder external rotation. SA and SER improvement was significantly better in those who underwent SS procedures compared to those who did not (mean improvement was increased by 9.15 degrees and 8.54 degrees , respectively). Improvement was noted in all scapular dimensions, in all groups, postoperatively. However, the mean improvement in scapular height, big width, small width, and oblique axis discrepancies was 4.92, 14.04, 12.66, and 13.89 %, respectively, higher in patients who underwent SS procedures compared to those who did not. CONCLUSION: Dimensional discrepancies and functional outcomes are improved by SS procedures. Maximal results are attained in patients who have undergone both primary and secondary shoulder reconstruction before age 2.

I do not pretend to understand the moral universe. The arc is a long one. My eye reaches but little ways. I cannot calculate the curve and complete the figure by experience of sight. I can divine it by conscience. And from what I see I am sure it bends toward justice. -Theodore Parker, 19th century abolitionist and Unitarian minister Four years ago, I wrote a chapter for a volume since published titled, "The Search for the Legacy of the USPHS Syphilis Study at Tuskegee: Reflective Essays Based Upon Findings From the Tuskegee Legacy Project."1 (Am J Public Health. Published online ahead of print July 17, 2014: e1-e3. doi:10.2105/AJPH.2014.302127).

PURPOSE: Numerous techniques have been described for repair of myelomeningoceles, but outcome data is scarce. PATIENTS AND METHODS: A retrospective review was performed in 32 consecutive patients who underwent neonatal myelomeningocele repair and extra-dural closure to determine the influence of repair type on outcome. All procedures for myelomeningocele closure were classified into one of three groups, which included primary closure, myocutaneous flaps, and fasciocutaneous flaps. RESULTS: Defect size ranged from 1 to 48 cm(2). Primary skin closure was performed in 3 patients, fasciocutaneous flaps in 13 patients, and myocutaneous flaps in 16 patients. The overall complication rate was 18%. No difference in the complication rates among the primary closure, myocutaneous, and fasciocutaneous flap groups was observed in our analysis. While not statistically significant, our data documents an association of fasciocutaneous flaps with postoperative complications that were not evident with primary skin closure or myocutaneous flaps (odds ratio 3.8; p = 0.15). The occurrence of one or more complications was associated with a longer hospital stay. CONCLUSIONS: Myocutaneous flaps provide a secure repair and should be considered for smaller myelomeningocele defects in addition to the larger defects where they are more traditionally used. We propose a tissue-based classification of closure techniques strictly for multi-institution outcome comparison that may ultimately inform clinical decision-making.

Neurosurgical craniotomy, craniectomy, or other trans-galeal interventions are performed for a variety of indications, including the resection of benign or malignant tumors, hematoma evacuation, and for the management of intractable seizure disorders. Despite an overall low complication rate of intervention, wound healing complications such as dehiscence, surgical site infection, and cerebrospinal fluid leak are not uncommon. A retrospective review was performed of all patients who underwent scalp incision closure at a single institution by a single plastic surgeon between 2006 and 2013. Sixty patients (83 procedures) were included in the study. Fifty-seven patients (95.0 %) underwent previous craniotomy, craniectomy, or other trans-galeal procedure. Of the total 60 patients, 35 patients received preoperative radiation. Sixteen patients received bevacizumab prior to their index case, while 12 received bevacizumab postoperatively. Ten patients (16.7 %) required additional plastic surgical intervention for wound complications after their index plastic surgery procedure. Plastic surgery was consulted prophylactically in 34 patients (38 procedures). When plastic surgery was consulted prophylactically, 4 patients (11.8 %) required further wound revision. None of the 14 patients who underwent prophylactic plastic surgery closure for previous scalp incision, preoperative bevacizumab, and XRT administration required re-intervention. Plastic surgery closure of complex scalp incisions reduces the incidence of wound complications among patients who underwent previous neurosurgical intervention, XRT administration, and preoperative bevacizumab administration. This is particularly true when plastic surgery closure is performed "prophylactically." Further collaboration between the neurosurgical and plastic surgery teams is therefore warranted, particularly in the setting of these high-risk cases.

BACKGROUND: Surgical education is in a period of significant change. Assessment of surgical competency is imprecise compared with cognitive knowledge and judgment. A surgical competency measurement tool may be useful for plastic surgery training programs and certification societies. We present a validation study of a novel measurement instrument for arch bar placement and dental wire handling. METHODS: An Arch Bar Placement Assessment Scale (ABPAS) was created via consensus by 2 craniofacial and 2 maxillofacial surgeons. Residents and faculty members of plastic and maxillofacial surgery (n = 20) then placed an arch bar on the lower jaw of a skull model. Performances were video recorded without revealing identities. Two study groups were created based on subjects experience level: group 1 (n = 10) previously placed fewer than 25 arch bars; group 2 (n = 10) previously placed more than 25 arch bars. Two craniofacial surgeons used the ABPAS to blindly grade surgical performance. RESULTS: The ABPAS consisted of a 48-point rating scale that included a 23-point task-specific work list and a 25-point global rating scale. Pearson coefficient showed limited intraobserver (P = 0.97) and interobserver (P = 0.95) variance of test scores. The ABPAS demonstrated superior performance in group 2 in the task-specific work list [12.6 (5.5) vs 17.6 (1.5), P = 0.02], global rating scale [17.4 (4.4) vs 22 (2.1), P = 0.01], and ABPAS score [30 (9.8) and 39.6 (3.2), P = 0.01]. CONCLUSIONS: The ABPAS is a novel measurement tool which assesses technical surgical skill and can identify surgical competency in arch bar placement and dental wire handling. This tool may have future use in residency training and continuing education.

BACKGROUND: A large amount of interindividual variability exists in the occurrence of symptoms in patients receiving chemotherapy (CTX). The purposes of the current study, which was performed in a sample of 582 oncology outpatients who were receiving CTX, were to identify subgroups of patients based on their distinct experiences with 25 commonly occurring symptoms and to identify demographic and clinical characteristics associated with subgroup membership. In addition, differences in quality of life outcomes were evaluated. METHODS: Oncology outpatients with breast, gastrointestinal, gynecological, or lung cancer completed the Memorial Symptom Assessment Scale before their next cycle of CTX. Latent class analysis was used to identify subgroups of patients with distinct symptom experiences. RESULTS: Three distinct subgroups of patients were identified (ie, 36.1% in Low class; 50.0% in Moderate class, and 13.9% in All High class). Patients in the All High class were significantly younger and more likely to be female and nonwhite, and had lower levels of social support, lower socioeconomic status, poorer functional status, and a higher level of comorbidity. CONCLUSIONS: Findings from the current study support the clinical observation that some oncology patients experience a differentially higher symptom burden during CTX. These high-risk patients experience significant decrements in quality of life. Cancer 2014. (c) 2014 American Cancer Society.

BACKGROUND: Reconstruction in the setting of prior breast irradiation is conventionally considered a higher-risk procedure. Limited data exist regarding nipple-sparing mastectomy in irradiated breasts, a higher-risk procedure in higher-risk patients. METHODS: The authors identified and reviewed the records of 501 nipple-sparing mastectomy breasts at their institution from 2006 to 2013. RESULTS: Of 501 nipple-sparing mastectomy breasts, 26 were irradiated. The average time between radiation and mastectomy was 12 years. Reconstruction methods in the 26 breasts included tissue expander (n = 14), microvascular free flap (n = 8), direct implant (n = 2), latissimus dorsi flap with implant (n = 1), and rotational perforator flap (n = 1). Rate of return to the operating room for mastectomy flap necrosis was 11.5 percent (three of 26). Nipple-areola complex complications included one complete necrosis (3.8 percent) and one partial necrosis (3.8 percent). Complications were compared between this subset of previously irradiated patients and the larger nipple-sparing mastectomy cohort. There was no significant difference in body mass index, but the irradiated group was significantly older (51 years versus 47.2 years; p = 0.05). There was no statistically significant difference with regard to mastectomy flap necrosis (p = 0.46), partial nipple-areola complex necrosis (p = 1.00), complete nipple-areola complex necrosis (p = 0.47), implant explantation (p = 0.06), hematoma (p = 1.00), seroma (p = 1.00), or capsular contracture (p = 1.00). CONCLUSION: In the largest study to date of nipple-sparing mastectomy in irradiated breasts, the authors demonstrate that implant-based and autologous reconstruction can be performed with complications comparable to those of the rest of their nipple-sparing mastectomy patients.