J Plast Reconstr Aesthet Surg [journal]
- Sentinel lymph node biopsy and survival in Merkel cell carcinoma: A 10 year review. [LETTER]
- J Plast Reconstr Aesthet Surg 2016 Jul 30.
- Hand trauma: A prospective observational study reporting diagnostic concordance in emergency hand trauma which supports centralised service improvements. [JOURNAL ARTICLE]
- J Plast Reconstr Aesthet Surg 2016 Jul 9.
Hand injuries are common, contributing up to 30% of accident and emergency (A&E) attendances. The aim of this study was to prospectively analyse the pathological demographics of hand injuries in a level 1 trauma centre with a Hand Trauma Unit and direct A&E links, and compare clinical and intra-operative findings. The null hypothesis was that there would be no differences between clinical and intra-operative findings (100% diagnostic concordance).Data were prospectively collected for referrals during 2012. Referral diagnosis, additional pathologies found on clinical assessment and intra-operative findings were documented on a live database accessible from both the Hand Unit and associated operating theatres. Odds ratios were calculated using SAS.Injuries (1526) were identified in 1308 patients included in the study. Diagnostic concordance between Hand Unit clinical examination and intra-operative findings was 92.5% ± 2.85% (mean ± SEM); this was lower for flexor tendon injuries (56.3%) because a greater number of additional pathologies were found intra-operatively (2.25 ± 0.10). This 'trend' was noted across multiple referral pathologies including phalangeal fractures (1.28 ± 0.02; 82.9%), lacerations (1.33 ± 0.04; 79.1%), extensor tendon injuries (1.30 ± 0.05; 87.8%) and dislocations (1.18 ± 0.05; 87.8%). Odds ratio analysis indicated a relationship between primary referral diagnoses that were more or less likely to be associated with additional injuries (p < 0.05); referral diagnoses of flexor tendon injuries and lacerations were most likely to be associated with additional injuries.As hand injuries are a common presentation to A&E departments, greater emphasis should be placed on training clinicians in the management of hand trauma. Our findings, coupled with the presented relevant literature reports, lead us to advocate that A&E departments should move towards a system wherein links to specialist hand trauma services are in place; we hereby present useful data for hospitals implementing such services.
- Contralateral breast symmetrisation in unilateral DIEP flap breast reconstruction. [JOURNAL ARTICLE]
- J Plast Reconstr Aesthet Surg 2016 Jul 19.
Women undergoing unilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstruction may be offered a contralateral symmetrisation either at the time of reconstruction (simultaneous/immediate) or at a later stage (delayed). Simultaneous contralateral breast symmetrisation may be more beneficial to patients and healthcare institutions by avoiding staged surgery, although there is limited evidence on which to base practice. This deficit formed the rationale for our study. The primary outcome was the overall rate of revision surgery.Over a 6-year period, this prospective cohort study recorded the demographics, cancer treatments and operative outcomes of all consecutive unilateral DIEP flap breast reconstructions with or without contralateral symmetrising surgery. Patients were categorised into three groups: (1) simultaneous symmetrisation, 2) delayed symmetrisation and (3) no symmetrisation for comparative analysis.During the study period, 371 women underwent unilateral DIEP flap breast reconstruction 194 (52.3%) were not symmetrised, 155 (41.8%) were simultaneously symmetrised and 22 (5.9%) underwent delayed symmetrisation. Simultaneous symmetrisation of the contralateral breast and unilateral DIEP flap breast reconstruction increased the mean total operative time by 28 min. There were no differences in the rates of peri-operative complications. There were significantly higher rates of all-cause revision surgery (OR 3.97 [1.58, 9.94], p = 0.003) in women undergoing delayed symmetrisation, because of higher rates of revision lipomodelling, scar revision and revision contralateral symmetrisation.Simultaneous contralateral breast symmetrisation was associated with a lower risk of all-cause revision surgery. It is safe, beneficial and likely to be more cost-effective for women undergoing unilateral free DIEP flap breast reconstruction.
- Reconstruction following abdominoperineal resection (APR): Indications and complications from a single institution experience. [JOURNAL ARTICLE]
- J Plast Reconstr Aesthet Surg 2016 Jul 2.
Abdominoperineal resection (APR) is the surgical treatment of low-lying rectal cancers and other pelvic malignancies. Plastic surgery offers a means to close these complicated defects through obliterating dead space, providing tension-free closure, and introducing vascularized tissue into a radiated field. The indications for reconstructive surgery and choice of reconstruction are debatable. This study aims to identify when and which reconstruction is preferred.A retrospective comparative analysis was performed on all patients undergoing APR at Stanford Hospital between 2007 and 2013. Data points included demographics, disease, operative positioning, and postoperative complications. Univariate analysis and multivariate logistic regression analysis were performed to identify markers of flap reconstruction and complications.A total of 178 APRs were performed, of which 51 underwent flap reconstruction. The odds ratio of all complications between flap and primary closure was not significant at 1.36 (0.69-2.66). Independent predictors for flap reconstruction included prone positioning, anal squamous cell carcinoma (SCC), prior smoking, and neoadjuvant chemoradiation therapy. Univariate predictors of flap reconstruction included female gender and combined vaginectomy. Independent predictors of complications included current and prior smoking. Muscle flap closure had lower recipient site complications than V-to-Y advancement closure (20% vs. 50%, p = 0.039).Flap reconstruction following APR is associated with prone positioning, neoadjuvant chemoradiation, female gender, prior smoking, and anal SCC resections. Pedicled muscle flaps had a significantly lower rate of recipient site complications than V-to-Y advancement flaps and therefore should be the flap reconstruction of choice. The vertical rectus abdominis myocutaneous flap was superior to the gracilis flap in terms of the overall reduction of complications.
- Predictors and consequences of intraoperative microvascular problems in autologous breast reconstruction. [JOURNAL ARTICLE]
- J Plast Reconstr Aesthet Surg 2016 Jul 12.
Microvascular complications can have devastating consequences in breast reconstruction. Because of the relatively low rate of complications, it can be difficult to identify significant predictors of failure. This study explores the importance of intraoperative microvascular problems in the development of postoperative complications and seeks to identify risk factors that may predict such events.Three hundred and eighty-four patients undergoing 562 microvascular breast reconstructions were eligible for inclusion in this study. Bivariate and multivariate logistic regressions were performed to identify factors showing a significant association with intraoperative microvascular problems and postoperative microvascular complications.In multivariate logistic regression, intraoperative problems were an independent risk factor for the development of postoperative microvascular complications (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.1-6.6, p = 0.02). Smoking was the only independent predictor of intraoperative events (OR 2.4, 95% CI 1.1-5.3, p = 0.03). While intraoperative problems are predisposed to postoperative microvascular complications in general, those that were thrombotic in nature could be corrected by early recognition and intraoperative revision in the majority of cases.This study identifies intraoperative microvascular problems as significant predictors of postoperative complications in breast reconstruction. Smoking increases the rate of intraoperative problems, and although many can be corrected, preoperative smoking cessation may reduce the complexity of microsurgery and optimize postoperative outcomes.
- Supplement: Eyelid reconstruction using a hard palate mucoperiosteal graft combined with a V-Y subcutaneously pedicled flap. [LETTER]
- J Plast Reconstr Aesthet Surg 2016 Aug 4.
- Maximizing length and safety in gracilis free flap dissection. [LETTER]
- J Plast Reconstr Aesthet Surg 2016 Jul 30.
- Cracking the perfusion code?: Laser-assisted Indocyanine Green angiography and combined laser Doppler spectrophotometry for intraoperative evaluation of tissue perfusion in autologous breast reconstruction with DIEP or ms-TRAM flaps. [JOURNAL ARTICLE]
- J Plast Reconstr Aesthet Surg 2016 Aug 3.
The aim of this prospective study was to assess the correlation of flap perfusion analysis based on laser-assisted Indocyanine Green (ICG) angiography with combined laser Doppler spectrophotometry in autologous breast reconstruction using free DIEP/ms-TRAM flaps. Between February 2014 and July 2015, 35 free DIEP/ms-TRAM flaps were included in this study. Besides the clinical evaluation of flaps, intraoperative perfusion dynamics were assessed by means of laser-assisted ICG angiography and post-capillary oxygen saturation and relative haemoglobin content (rHb) using combined laser Doppler spectrophotometry. Correlation of the aforementioned parameters was analysed, as well as the impact on flap design and postoperative complications. Flap survival rate was 100%. There were no partial flap losses. In three cases, flap design was based on the angiography, contrary to clinical evaluation and spectrophotometry. The final decision on the inclusion of flap areas was based on the angiographic perfusion pattern. Angiography and spectrophotometry showed a correlation in most of the cases regarding tissue perfusion, post-capillary oxygen saturation and relative haemoglobin content. Laser-assisted ICG angiography is a useful tool for intraoperative evaluation of flap perfusion in autologous breast reconstruction with DIEP/ms-TRAM flaps, especially in decision making in cases where flap perfusion is not clearly assessable by clinical signs and exact determination of well-perfused flap margins is difficult to obtain. It provides an objective real-time analysis of flap perfusion, with high sensitivity for the detection of poorly perfused flap areas. Concerning the topographical mapping of well-perfused flap areas, laser-assisted angiography is superior to combined laser Doppler spectrophotometry.
- Response to comments by de Boer & Qiu on "Success of free flap anastomoses performed within the zone of trauma in acute lower limb reconstruction". [LETTER]
- J Plast Reconstr Aesthet Surg 2016 Jul 21.
- Auricular reconstruction using a novel three-flap technique improves the auriculocephalic angle. [JOURNAL ARTICLE]
- J Plast Reconstr Aesthet Surg 2016 Jul 12.
Skin grafting is needed for traditional auricular reconstruction. As the skin grafts contract, the postoperative framework is distorted. This leads to a decrease in the auriculocephalic angle. The objective of this study was to test a new method to cover the reconstructive framework by using three skin flaps and a larger tissue expander than that normally used. This may reduce the distortion of the reconstructed ear and create a well-shaped auriculocephalic angle.A large expander was inserted in the postauricular mastoid area. Three expanded flaps were then created to cover the anterior and posterior frameworks, with separate mastoid coverage. By measuring the height and angle at three different points on the reconstructed ear and comparing them with the contralateral normal ear, a system for measuring the auriculocephalic angle was established.The surface of the framework and the mastoid area were covered by three flaps developed from one large tissue expander. The appearance of the reconstructed ears was similar to that of the normal side by the patient's 6- to 12-month follow-up. The difference in the distance at the three points between the reconstructed and normal sides after the three-flap reconstruction was less than that following traditional reconstruction (p < 0.05). The variation in the angle measured at these three points in the three-flap group was also much smaller than that in the traditional group (p < 0.01).The three-flap technique not only improves the appearance of the reconstructed ear, but helps shape a perfect auriculocephalic angle.