BACKGROUND::

A number of microvascular free-flap tissue transfer techniques exist for reconstruction of head and neck defects. The scapular free-flap is a versatile option that can be used for a wide variety of defects in this complex region.

METHODS::

A series of 42 free-flaps from 41 patients was retrospectively identified from the senior author's database between 2006 and 2012. Information regarding patient demographics, indication for surgery, type of flap, reconstructive methods, complications and prosthodontic outcome were reviewed and have been described.

RESULT:

: A wide range of defects were reconstructed using the scapular free-flap. Of the 42 reconstructions, twenty-four were for mandibular, thirteen for maxillary, and five for calvarial reconstruction. The patients' age ranged from 28-82 years with a median age of 70. Dental restoration was achieved in eight patients with maxillary reconstruction and two patients with mandibular reconstruction. There were eleven major complications including two total flap failures.

CONCLUSIONS::

We have found the scapular free-flap to be a reliable, robust, and versatile flap, which provides an unparalleled range of reconstructive options, with minimal donor site morbidity. Hence, we believe that the scapular free-flap is a valuable reconstructive option for patients with complex head and neck defects and in patients in whom comorbid disease contraindicates the use of the fibular free-flap.

BACKGROUND::

Secondary open rhinoplasty is a complex topic with many hazards. While there has been much discussion in the literature about what transcolumellar scar design creates the best aesthetic result, placement of the scar in a previously opened nose has not been widely discussed. In light of the outstanding blood supply to the nose, and often desire to reposition the transcolumellar scar, the senior surgeon has ignored prior incisions in the columella and has chosen to place the incision in the best location for the current operative plan.

METHODS::

This paper retrospectively reviewed 100 secondary rhinoplasty patients that have undergone two open procedures with different transcolumellar incisions by the senior surgeon from 2000 to 2010. Scar quality was graded pre and post operatively by three reviewers on a 4-point scale from Imperceptible to Poor Scar.

RESULTS::

Scar quality averaged 1.68 preoperatively and 1.61 postoperatively, indicating scar quality between "imperceptible" and "barely perceptible". There was no skin bridge necrosis in the series, no infections, and no wound breakdowns. Patient satisfaction was noted to be high overall.

CONCLUSION:

: Anatomic studies have previously shown the safety of the transcolumellar incision in rhinoplasty. This paper has shown the safety of ignoring prior incisions in the columella and basing the new scar location solely on where the surgeon feels is ideal. While caution should always be used when creating possibly devitalized skin bridges, this study lends weight to the argument that one can safely ignore prior incision patterns in this highly aesthetically important and well-vascularized area.

LEVEL OF EVIDENCE:

: IV.

BACKGROUND::

We aimed to study residency applicant attitudes towards rank list creation, communication with programs, and the impact of these factors on their performance in the Match.

METHODS::

An anonymous, 26-question, multiple-choice, online survey was distributed to the Program Coordinators of every ACGME-accredited program participating in the NRMP match for whom e-mail addresses were available. The survey addressed five areas: (1) demographics and interview characteristics, (2) pre-interview and interview factors, (3) post-interview contact, (4) importance of various factors in rank list creation, and (5) Match outcome. Survey responses were analyzed with Microsoft Excel.

RESULTS::

1179 responses were received. It was not possible to calculate a response rate, since the number of residents receiving the survey was not known. The majority of respondents (78%) reported post-interview contact with a program. A large portion of respondents (42%) considered such contact to be important in the creation of their rank lists. Half of all respondents admitted to exaggerating their interest in a program during or after an interview. The majority of respondents (87%) received no assistance in covering the costs of "second look" visits to programs.

CONCLUSIONS::

Applicants may be modifying their rank lists in response to post-interview contact from programs, and further, they usually have no assistance in paying for the cost of second looks. In order to level the playing field for students and programs alike, we propose that the NRMP modify residency interview rules to (1) disallow any post-interview contact between programs and students, and (2) disallow second looks.

BACKGROUND::

The purpose of this study was to evaluate the long-term outcomes following modified Furlow palatoplasty over a 30-year experience at a single institution.

METHODS::

A retrospective review was performed of all nonsyndromic patients undergoing primary modified Furlow palatoplasty at The Children's Hospital of Philadelphia between 1980 and 2011. Surgical success was evaluated by the rate of postoperative oronasal fistula, speech outcomes assessed at a minimum of age 5, and the need for secondary surgery for velopharyngeal dysfunction (VPD). Results were analyzed by surgeon, Veau cleft type, age at repair, and over time.

RESULTS::

869 patients who underwent modified Furlow repair were included in this study. The mean age at palatoplasty was 1.1 years, and the mean length of follow-up was 6.7 years. Repairs were performed by 11 surgeons with 44.3% by a single surgeon. The overall oronasal fistula rate was 5.2%, and this improved significantly over the 30 year period (p=.003). Speech results at age 5 or older were available for 559 patients. Of these 559 patients, 72.4% had a competent velopharyngeal mechanism, and 21.5% a borderline mechanism consistent with socially acceptable speech. Secondary pharyngeal surgery was indicated in 8.1% of patients. Speech results were stable (p=.10), and rates of secondary surgery for VPD declined significantly over the study time period (p=.005).

CONCLUSION:

: 30 year experience with the modified Furlow palatoplasty shows stable speech results, decreasing rates of secondary surgery, and an acceptable rate of post-operative oronasal fistula. CLINICAL QUESTION/

LEVEL OF EVIDENCE:

: Therapeutic, IV.

BACKGROUND::

The recommendations on the timing of microsurgical extremity reconstruction are as variable and numerous as the flaps described for such reconstruction. Original articles suggested reconstruction should take place within 72 hours of injury. However, significant changes in perioperative and intraoperative management have occurred in this field, which may allow for more flexibility in the timing of reconstruction. This article aims to review current literature on timing of upper extremity reconstruction to provide the microsurgeon with up-to-date recommendations.

METHODS::

A structured literature search including Spanish and English articles published between January 1995 and December 2011 was performed using MEDLINE and Scopus databases. The search strategy was conducted using groups of key words and articles were subsequently reviewed for relevance. Bibliographies of selected articles were further reviewed for additional relevant publications. Rates of total flap loss, infection, hospital stay and bony nonunion were recorded and analyzed according to Emergent (<24 hours), Early (<5 days), Primary (6-21 days) or Delayed (>21 days) reconstruction.

RESULTS::

Fifteen articles met inclusion criteria. There was no significant association between timing of reconstruction and rates of flap loss, infection or bony nonunion. Linear regression analysis displayed a significant association between length of hospital stay and timing of reconstruction.

CONCLUSIONS::

No conclusive evidence exists to suggest that emergent, early, primary or delayed reconstruction will eliminate or decrease complications associated with post-traumatic upper extremity reconstruction. Earlier reconstruction may decrease length of hospital stay and limit associated medical costs.

LEVEL OF EVIDENCE:

: Not gradable.

INTRODUCTION:

: The foot and ankle area has a tenuous blood supply that can easily be damaged with trauma or open exposures. The navicular and talus are susceptible to avascular necrosis (AVN) making arthrodesis difficult. In addition, in this region, large bone gaps occur as result of avascular necrosis, trauma or infection. Often vascularized bone flaps are required for reconstruction or salvage.

MATERIAL AND METHODS:

: A retrospective review of all vascularized bone flaps to the foot and ankle by the senior surgeon from July 2006 to July 2012 was performed. Twelve cases were identified (seven fibula flaps and five medial femoral condyle flaps). Indications included talus AVN with tibiatalar and subtalar arthritis (eight), talus AVN with tibiotalar arthritis (one), navicular AVN (one), talus persistent nonunion (one), and a traumatic bone defect (one).

RESULTS::

There were no flap failures or thrombotic events. Ankle stabilization was performed with plates (five), compression screws (two), external fixator (four) and a cast (one). There were three complications requiring return to the operating room. All patients ultimately obtained union and full-weight bearing was allowed at 18.7 ± 13.6 weeks following surgery.

DISCUSSION:

: We have successfully used the MFC flap and fibula flap for tibiotalar arthrodesis, pantalar arthrodesis, navicular revascularization, and persistent nonunion of the talus. The MFC is ideal when a small segment of vascularized bone is required but when structural support is necessary, the fibula offers a larger cortical surface area providing more rigidity. Both flaps are valid options for foot and ankle reconstruction and salvage. LEVEL OF CLINICAL

EVIDENCE:

: Level 4.

BACKGROUND::

External volume expansion (EVE) by suction has been proposed to improve the survival of fat grafting by preparing the recipient site. In previous experimental work, EVE demonstrated the capacity to stimulate cell proliferation, vessel remodeling and adipogenesis. This study investigated possible mechanisms underlying these observed changes.

METHODS::

A miniaturized EVE device was applied to the dorsum of mice for 2 hours. Hypoxia during stimulation was assessed with pimonidazole hydrochloride, and tissue perfusion was measured for up to 2 days via hyperspectral imaging. Treated tissues were evaluated by microscopy for the presence of edema, inflammation, the effects on cell proliferation and vessel remodeling.

RESULTS::

EVE-treated tissues were grossly expanded with 2 hours of stimulation, developing a macroscopic swelling that slowly regressed over the course of hours following stimulus cessation. This gross swelling was reflective of histological signs of intense edema, persistent for at least 1 hour post-EVE. Tissues were hypoxic during stimulation, and hyperspectral imaging demonstrated decreased tissue content of both oxygenated- and deoxygenated-hemoglobin in the first hour after EVE release. The onset of inflammation was already apparent by the end of stimulation, and remained elevated through two days post-EVE. At this time point epidermal and dermal cell proliferation, as well as vascular density, were significantly increased.

CONCLUSIONS::

EVE sets in motion various mechanisms including mechanical stimulation, edema, ischemia and inflammation that over distinct time periods maintain an environment conducive to cell proliferation and angiogenesis, which can be elicited even by a single 2 hour EVE cycle.

: Readmissions following surgical procedures can be common and extremely costly for healthcare systems. As healthcare reform evolves, 30-day, unplanned readmission rates may be closely scrutinized as an area of needed improvement. Efforts to minimize the incidence of readmission, through a deeper understanding of associated risk factors may permit a more efficient delivery of care. In this work we delineate several key independent risk factors for readmission, including perioperative complications and obesity.

PURPOSE:

: To assess the incidence and predictors of surgical readmissions following plastic surgery procedures.

BACKGROUND::

Readmission following surgical procedures can be common and extremely costly for healthcare systems. Efforts which minimize the incidence of readmission may provide significant cost savings and enhance patient care. This study explores factors associated with readmission following plastic surgery using a prospective, validated, national database.

METHODS::

Patients who underwent primary plastic surgery procedures (N = 10,669) were identified from the 2011 ACS-NSQIP databases. Two cohorts were compared: those who were readmitted and those who were not. Preoperative patient co-morbidities, laboratory values, and intraoperative details derived from the 2011 ACS-NSQIP dataset were analyzed to determine associations with readmission. A multivariate regression analysis was used to identify predictors of readmission.

RESULTS::

A total of 10,669 patients were included with a 4.5% readmission rate. The study cohort was on average 49.5 years of age, 32.2% were obese, and 15.2% were smokers. The majority of patients were female (81.7%). Cases were predominantly outpatient procedures (65.6%). The most commonly performed procedures included: elective/cosmetic breast (23.4%), implant breast reconstruction (16.5%), revision breast procedures (14.9%), hand operations (9.7%), and body contouring (5.9%).The incidence of wound complications was 4.6% and the incidence of medical complications was 4.9%. The overall incidence of any postoperative complication was 10.9%, of which 4.8% were defined as major surgical complication. The average length of stay was 2.0 days. A multivariate regression analysis demonstrated several independent risk factors associated with readmission: procedure type (OR=1.0, P=0.029), WHO obesity (OR=1.2, P=0.011), anemia (OR=1.8, P=0.003), and medical (OR=2.3, P<0.001), major surgical (OR=6.3, P<0.001), and wound (OR=5.3, P<0.001) complications.

CONCLUSION:

: Identifiable preoperative patient characteristics associated with readmission included procedure type, obesity, and anemia. Interestingly, the most significant predictor of readmission was postoperative complications - either surgical or medical. Patients experiencing postoperative surgical complications were 6 times more likely to be readmitted. These findings can assist surgeons and health systems better tailor preoperative counseling, resource allocation, and postoperative discharge services.

LEVEL OF EVIDENCE:

: prognostic/risk category, level II.

OBJECTIVES:

: The recent challenge in immediate two-stage prosthetic breast reconstruction has been the broadening of the indications for post-mastectomy adjuvant radiotherapy. We performed a systematic review of the literature on the outcome of therapy (loss of prosthesis, capsular contracture and cosmesis) for patients with breast cancer who underwent adjuvant radiotherapy after an immediate two-stage prosthetic breast reconstruction. We included patients who underwent radiation therapy either following tissue expansion (Stage 1) or after removal of the tissue expander and insertion of a final breast implant (Stage 2) and compared their outcome to patients who had reconstruction without post-mastectomy irradiation. DATA SOURCES &

REVIEW METHODS:

: Electronic database searches were supplemented by a full-text review of possible relevant articles on two-stage prosthetic immediate breast reconstruction and radiotherapy. Delayed or one-stage prosthetic or non-prosthetic breast reconstructions studies were excluded. The primary outcome measured is the reconstruction failure rate with prosthesis loss. The secondary endpoints are capsular contracture and aesthetic outcome.

RESULTS::

No randomised control trials were identified and only one prospective, non-randomised multi-centre trial was found. Reports that contain more than 15 patients were included. These included 12 studies with a total of 1467 patients (715 irradiated and 1138 non-irradiated) patients.This meta-analysis showed that adjuvant radiotherapy resulted in a significantly higher reconstruction failure rates in immediate two-stage prosthetic breast reconstructions compared to controls (18.6% vs 3.1%, p<0.00001). Radiotherapy particularly increased the failure rate when given after stage 1 (expander) (29.7% vs 5%, p<0.00001) but also stage 2 (permanent implant) (7.7% vs 1.5%, p=0.0003) of the IBR. There is also an increase in severe capsular contractures and an inferior cosmetic result in the irradiated patients.

CONCLUSION:

: Non-randomised studies suggest that adjuvant radiotherapy results in a higher risk of reconstruction failure. Improvements in surgery, radiotherapy planning and dose delivery will reduce this complication.